Class _ Book_ COPYRIGHT DEPOSIT PLATE I. Tubercular Meningitis. (Page 426.) P E D I AT R I C S THE HYGIENIC AND MEDICAL TREATMENT OF CHILDREN BY THOMAS MORGAN ROTCH, M.D, M PROFESSOR OF THE DISEASES OF CHILDREN, HARVARD UNIVERSITY THIRD EDITION, REARRANGED AND REWRITTEN ILLUSTRATED BY NUMEROUS ENGRAVINGS IN THE TEXT AND BY COLORED PLATES PHILADELPHIA AND LONDON J. B. L I P P I N C O T T COMPANY i 9 o i THE LIBRARY OF . CONGRESS, Two Copies Received SEP. 7 1901 Copyright entry CLASS <^XXc, N». 99 9& copy a Copyright, 1895, by J. B. Lippincott Company. Copyright, 1901, by J. B. Lippincott Company. ELECTROTYPEO AND PRINTED BY J. B. LIPPINCOTT COMPANY, PHILADELPHI, <- TO $C> ABRAHAM JACOBI, M.D., LL.D., PROFESSOR OF DISEASES OF CHILDREN IN COLUMBIA UNIVERSITY NEW YORK, THE MOST DISTINGUISHED STUDENT AND TEACHER OF PEDIATRICS IN AMERICA. PREFACE. When another edition of this work was called for it was found neces- sary to rewrite it in order to bring it into accord with the advances which have been made in the subject of Pediatrics during the past six years. It is. therefore, offered to the Profession as practically a new book. The order in which the different subjects have been treated, and the relative space assigned to them, have in many instances been radically changed. The endeavor has been made to emphasize the practical character of the work by thoroughly systematizing the etiology, the symptomatology, the diagnosis, and the treatment of the various diseases. Much attention has been devoted to the anatomy and physiology of early life and to the ad- vances which have been made in the subjects of infant feeding, of bac- teriology, and of the blood. Several new colored plates and a number of radiographs have been added to the illustrations. In acknowledging the aid which I have received I owe special recogni- tion to my assistant and friend, Dr. Maynarcl Lacld, for his help in the preparation of the entire book. His interest and enthusiasm have been unflagging and invaluable. My thanks are also offered to those who have by their advice enabled me to remodel the book, and I would particularly acknowledge the information connected with the pathology which has been given so freely by Professor William T. Councilman. I am also under much obligation to Dr. John H. McCollum, Dr. Robert W. Lovett, Dr. John L. Morse, Dr. Algernon Coolidge, Jr., Dr. John Dane, and Dr. John T. Bowen. Dr. William P. Northrup supplied for the previous edition a number of valuable plates illustrating gastro-enteric diseases, and these plates are now retained. Dr. Franklin W. White has been of great ser- vice in the preparation of the article on the blood. Dr. Ernest A. Cod- man kindly furnished the plates of the radiographs. The publishers have shown unfailing courtesy and much liberality. Finally, I am greatly indebted to my medical associates throughout the country for their encouragement, which has both stimulated me in my work and greatly aided me in its completion. T. M. Rotch. 197 Commonwealth Avenue, Boston, Massachusetts. 1 CONTENTS. DIVISION I. THE NORMAL INFANT. PAGE I. — Introduction 2 II. — The Fcetal Circulation „ 19 III.— The Infant at Term 21-39 Vernix Caseosa ; Skin ; Cord ; Spine ; Neck ; Head ; Thorax ; Abdo- men ; Bladder ; Pelvis ; Uterus ; Temperature ; Pulse ; Respiration ; Height ; Weight ; Vitality ; Hands ; Feet ; Bone Marrow ; Functions ; Blood ; Lymphatic System ; Urine ; Intestinal Discharges. IV.— Normal Development 39-111 Cord ; Spine ; Neck ; Head ; Thorax ; Abdomen ; Temperature ; Pulse ; Respiration ; Height ; Weight ; Feet ; Bone Marrow ; Skin ; Functions ; Lymphatic System ; Thyroid Body ; Urine ; Intestinal Discharges ; In- fantile Skeletons ; Normal Infants ; Topographical Anatomy of Early Life ; Nursery ; Bathing ; Clothing ; Feet ; Shoes ; Sleep ; When to go out ; Nursery-Maids ; Mouth ; School ; Defects of Posture. DIVISION n. FEEDING. G-eneral Principles 112 Mammary Gland 114 First Nutritive Period 116-241 I. — Maternal Feeding 116 II.— Direct Substitute Feeding 160 Wet-Nurses ; Animals. III. — Indirect Substitute Feeding 164 Cows ; Chemistry of Cow's Milk ; Bacteriology of Cow's Milk ; Milk-Laboratories and Percentage Feeding ; Home Modification ; Oat-Jelly ; Barley-Water ; Wheat ; Artificial Foods ; Matzoon ; Kumyss ; Peptonized Milk ; Malted Foods. Second Nutritive Period 241 Third Nutritive Period 24-3 DIVISION HI. GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT. Method of examining a Child 246-236 Lumbar Puncture ; Rontgen Light ; Treatment : Prophylaxis. DIVISION rv. PREMATURE INFANTS. Determination of Age 237 Normal Development 2-39 Appearance at Birth 264 Weight 2(1-3 Incubator (Brooder) 266 Food 273 vii Viii CONTENTS. DIVISION V. DISEASES OF THE NEW-BORN. PAGE Inheritance. Malformation. Traumatism 282 Maternal Impressions 285 Diseases of the Head 286-295 Caput Succedaneum ; Cephalhematoma ; Meningocele ; Encephalocele ; Anen- cephalia ; Congenital Hydrocephalus ; Harelip ; Cleft Palate ; Tongue-Tie ; Kanula ; Protrusion of Ears ; Ophthalmia Neonatorum. Diseases of the Neck 295-296 Hematoma of the Sterno-cleido-mastoid Muscle ; Branchial Fistulse. Diseases of the Trunk , 296-310 Mastitis ; Depressed Sternum : Prominent Sternum ; Spina Bifida ; Rhachis- chisis ; Phlebitis and Arteritis Umbilicalis ; Congenital Umbilical Hernia into the Cord ; Fungus of the Umbilicus ; Meckel's Diverticulum ; Umbilical Hernia ; Inguinal Hernia ; Femoral Hernia ; Hydrocele ; Undescended Testi- cle ; Tumors of the Testis ; Malformations about the Bectum ; Occlusion of the Vagina ; Hypospadias ; Epispadias ; Congenital Obliteration of the Intes- tine ; Congenital Malformations of the (Esophagus and Stomach. Diseases of the Extremities 310-312 Fingers ; Toes ; Club-Hand and Foot ; Congenital Dislocation of the Hip ; Congenital Dislocation of the Knee; Birth (Obstetrical) Paralysis. General Diseases 312-325 Asphyxia; Acute Fatty Degeneration of the N"ew-Born (Buhl's Disease); Infectious Hasmoglobinsemia of the New-Born ; Hemorrhage in Early Life ; Sclerema Neonatorum ; (Edema Neonatorum ; Icterus Neonatorum ; Erythema Neonatorum. DIVISION VI. DISEASES OF NUTRITION. Rhachitis (Pickets) 326-343 Congenital or Foetal Bhachitis. Osteomalacia 343 Scorbutus ( Scurvy ) 344 Infantile Atrophy 348 DIVISION vn. DISEASES OF THE SKIN. Scabies 355 Pediculosis 357 Impetigo Contagiosa . 357 Furunculosis 358 Molluscum Contagiosum 358 Seborrhea Capitis of Infants 359 Tinea Tricophytina 359 Tinea Favosa 360 Tinea Versicolor 360 Alopecia Areata 361 Pemphigus Neonatorum 361 Pemphigus 361 Epidemic Pemphigus Infantilis 362 Dermititis Exfoliativa Neonatorum (Ritter's Disease) 362 Dermatitis 363 Sudamina 365 Erythema 366 Erythema Intertrigo 367 CONTENTS. ix PAGE Erythema Nodosum 307 Erythema Urticatum ^ Urticaria) 367 Eczema 369 Psoriasis 372 Prurigo 373 Herpes Zoster 374 Pityriasis 375 Verrttcje (Warts) 375 Lentigo 376 Melanoderma Lentictjlaris Progressiva 376 Lichen 377 Ichthyosis 377 Scleroderma 379 Acute Circumscribed (Edema ( Angio-Neurotic (Edema) 379 division vni. SPECIFIC INFECTIOUS DISEASES. Tuberculosis 381-432 Acute Miliary Tuberculosis ; Chronic General Tuberculosis ; Tuberculosis of Lymph-Nodes, of Larynx, of Trachea, of Lungs, of Pleura, of Gastro-Enteric Tract, of Peritoneum, of Brain ; Tubercular Meningitis ; Tubercular Dactyl- itis ; Tuberculosis of Thyroid Gland, of Thymus Gland, of Pancreas, of Spleen, of Liver, of Kidney, of Bladder, of Testicle, of Skin. Epidemic Cerebro-Spinal Meningitis 432 Typhoid Fever 447 Diphtheria 459-476 Influenza (La Grippe) 476 Malaria 481 Erysipelas 497 Amcebic Ileo-Colitis 501 Cholera Infantum 502 Cholera Asiatica . „ 505 Pertussis 505 Acute Infectious Osteomyelitis 511 Rheumatic Fever (Acute Articular Eheumatism). . .' 514 Syphilis , 520-542 The Exanthemata 542-613 Scarlet Fever ; Measles ; Rubella ; Variola ; Vaccinia ; Varicella. Parotitis (Mumps) 613 DIVISION IX. DISEASES OF THE MOUTH, NOSE, EAR, NASO-PHARYNX, AND PHARYNX. Diseases of the Mouth 615-640 Nomenclature ; Stomatitis Catarrhalis ; Stomatitis Herpetica ; Stomatitis Ulcerosa; Stomatitis Mycetogenetica ; Stomatitis Hyphomycetica (Thrush); Stomatitis Pseudo-Membranosa ; Stomatitis Gangrenosa (Noma; Cancrum Oris) Glossitis; Lingua Geographica ; Microglossia; Macroglossia ; Difficult Dentition. Diseases of the Nose , 640-644 Rhinitis ; Mucous Polypus ; Epistaxis. Diseases of the Ear 644 Diseases of the Naso-Pharynx 643-649 Hypertrophy of the Pharyngeal Tonsil (Adenoid Growths). Diseases of the Pharynx 649-659 Tonsillitis; Peritonsillar Abscess ; Pharyngitis ; Elongation of Uvula; Retro- pharyngeal Abscess. x CONTEXTS. DIVISION X. DISEASES OF THE LARYNX, TRACHEA, BRONCHI, LUNGS, AND PLEURA. PAGE Diseases of the Larynx 660-665 Laryngospasmus ; New Growths ; Foreign Bodies ; (Edema ; Laryngitis. Diseases of the Trachea 665 Diseases of the Bronchi and Lungs 665-707 Acute Bronchitis ; Chronic Bronchitis ; Fibrinous Bronchitis ; Bronchial Asthma ; Pneumonia ; Pneumococcus Lobar Pneumonia ; Lobar Pneumonia due to other Causes ; Acute Broncho-Pneumonia ; Chronic Broncho-Pneu- monia ; Hypostatic Pneumonia; Atelectasis; Emphysema; Gangrene and Abscess of the Lung. Diseases of the Pleura 707-718 Acute Pleurisy, Dry, Sero-Fibrinous, Purulent (Empyema) ; Chronic Pleu- risy ; Hydrothorax ; Pneumothorax. DIVISION XI. DISEASES OF THE HEART AND PERICARDIUM. Diseases of the Heart 719-753 Congenital Diseases 720-730 Open Foramen Ovale ; Defect of the Ventricular Septum ; Lesions of the Pulmonary Orifice ; Persistence of the Ductus Arteriosus ; Transposition of the Large Arteries ; Lesions of the Tricuspid Orifice ; Lesions of the Mitral and Aortic Orifices. Acquired Diseases 730-748 Cardiac Hypertrophy ; Cardiac Dilatation ; Myocai'ditis ; Endocarditis, Acute, Chronic ; Mitral Insufficiency ; Mitral Stenosis ; Aortic Insuffi- ciency ; Aortic Stenosis ; Tricuspid Insufficiency ; Tricuspid Stenosis ; Pulmonary Insufficiency and Stenosis. Functional Diseases 748 Diseases of the Pericardium 754 Acute Pericarditis ; Chronic Adhesive Pericarditis. division xn. DISEASES OF THE (ESOPHAGUS, STOMACH, AND INTESTINE. The (Esophagus 767 The Stomach 769-783 Developmental 774 Functional 774 Acute Nervous Vomiting 774 Cyclic or Persistent Vomiting ; Gastralgia ; Acute Gastric Indigestion (Acute Dyspepsia) ; Chronic Gastric Indigestion (Chronic Dyspepsia) ; Eliminative. Organic 783 Contraction ; Dilatation ; Ulcers ; New Growths ; Acute Gastritis ; Chronic Gastritis. The Intestine 793 Developmental 795 Functional . . • 795 Acute Nervous ; " Acute Indigestion ; Chronic Nervous ; Tubular ; Chronic Duodenal Indigestion ; Chronic Intestinal Indigestion ; Incon- tinence of Fasces ; Constipation ; Eliminative. Organic 805 Acute Fermental ; Chronic Fermental ; Dilatation of Colon ; Volvulus : Intussusception ; Hernia ; Fissures ; Prolapse ; Polypi ; Hemorrhoids ; Fistuhe ; New Growths ; Proctitis ; Appendicitis ; Ileo-Colitis ; Animal Parasites. CONTENTS. x i DIVISION xm. DISEASES OF THE LIVER. PANCREAS, SPLEEN, AND PERITONEUM. PAGK The Liver 824 Icterus : Acute Yellow Atrophy ; Congestion ; Fatty Infiltration ; Suppura- tive Hepatitis (Abscess); Hydatids; Biliary Calculi; New Growths; Amy- loid; Interstitial Hepatitis (Cirrhosis). The Pancreas 840 The Spleen 840 The Peritoneum _ 840 Acute Peritonitis ; Peritonitis of the New-Born; Acute Pneumococcus Peri- tonitis ; Chronic Peritonitis. DIVISION xrv. DISEASES OF THE KIDNEYS, BLADDER, AND GENITAL ORGANS. The Kidney 844 Congenital: Acquired: Anuria; Physiological Albuminuria; Albuminuria of Adolescence: Hematuria and Hemoglobinuria ; Chyluria ; Glycosuria; Active Hyperemia ; Passive Hyperemia ; Acute Diffuse Nephritis ; Subacute Glomerular Nephritis ; Chronic Interstitial Nephritis (Chronic Bright's Dis- ease) ; Amyloid Infiltration; Acute Pyelitis and Pyelonephritis; Chronic Pyelitis; Perinephritis; Hydronephrosis; Malignant Growths and Enlarge- ment. The Bladder and Genitals 867 Acute Cystitis ; Chronic Cystitis ; Yulvo-Vaginitis ; Orchitis ; Epididymitis ; Tumors of the Testicle ; Phimosis ; Enuresis (Incontinence) ; Masturbation. , DIVISION XV. THE BLOOD. THE LYMPH-NODES. THE DUCTLESS GLANDS. The Blood 874-897 Nomenclature : . . , 874 Normal Conditions 875 Abnormal Conditions , 879 Leukemia 882 Pseudo-Leukemic Anemia of Infancy 887 Primary Anemias 890 Pernicious Anemia , 890 Chlorosis 892 Secondary Anemias 894 The Lymph-Nodes 897-898 Simple Acute Adenitis 897 Simple Chronic Adenitis 898 The Ductless Glands 899-909 Diseases of the Thyroid Gland 899 Goitre ( Bronchocele ) 899 Myxedema ; Cretinism 901 Exophthalmic Goitre 905 Acute Thyroiditis 907 Tumors of the Thyroid Gland 907 Diseases of the Thymus Gland 907 Diseases of the Adrenal Glands 908 Addison 's Disease 908 xii CONTENTS. DIVISION XVI. DISEASES OF THE NERVOUS SYSTEM. PAGE Convulsions 910 Chorea 911 Epilepsy 916 Insanity 925 Idiocy 930 Microcephalia 932 Mirror Writing 932 Hysteria 932 Hypnotic State 935 Catalepsy 935 Simulated Diseases 935 Insolation 935 Concussion 937 Temporary Amnesia 937 Temporary Aphasia 937 Arrested Psychical Development 938 Eetarded Speech 938 Headaches 939 Vertigo 940 Payor Nocturnus (Night-Terrors ) 941 Tremor 942 Tetany 942 Dental Reflexes 943 Nystagmus , 944 Gyrospasm and Spasmus Nutans 944 Reflex Symptoms of the Ear 944 Reflex Symptoms of the Larynx 944 Paroxysmal Gasping 946 Reflex Symptoms of the Lung , 940 Reflex Cough 947 Reflex Symptoms of the Heart 948 Reflex Symptoms of the Stomach 948 Reflex Symptoms of the Bladder 948 Reflex Symptoms of the Vagina 948 Reflex Symptoms of the Rectum 949 Cerebral Abscess 949 Cerebral Paralysis (Infantile Cerebral Palsies) 950 Myelitis 958 Infantile Spinal Paralysis (Poliomyelitis Anterior Acuta) 958 Paralysis caused by Caries of the Spine 967 Obstetrical Paralysis 968 Neuralgia 970 Epiphyseal Hyperemia (Growing Pains) 970 Hydrocephalus 970 Thrombosis of the Cerebral Sinuses 975 Athetosis 976 Intra-Cranial Tumors 978 Cerebral Syphilis 980 Meningitis 981 Acute Encephalitis 984 Bulbar Paralysis 985 Multiple Neuritis 985 Insular or Disseminated Sclerosis 987 Hereditary Ataxia (Friedrich's Disease) 988 Locomotor Ataxia 989 CONTENTS. xiii PAGE Syringomyelia 989 Hereditary Spastic Paralysis 989 Progressive Central Muscular Atrophy 989 Progressive Neural Musculae Atrophy. 991 Progressive Muscular Dystrophies 998 DIVISION XVII. UNCLASSIFIED DISEASES. haemophilia 997 Purpura 998 Status Lymph aticus (Lymphatism) 1000 Muscular Rheumatism (Myalgia) 1001 Arthritis Deformans 1003 Chronic Rheumatism 1003 Diabetes Insipidus 1003 Diabetes Mellitus 1004 LIST OF TABLES. TABLE PAGE 1. Relation of weight to vitality 37 2. Length of spine to sacrum 40 8. Relation of cricoid to sternum . 43 4. Circumferences of head and thorax from birth to thirteen years 45 5. Proportions of face to cranium 45 6. Height of posterior nares 47 7. Temporary teeth. Fh'st dentition 50 8. Permanent teeth. Second dentition 51 P. Post-natal changes of foetal conditions 55 10. Weights of the heart during its development 55 11. Amounts of food in an especial case , . . . 67 12. Three hundred and forty-one infants fed at the milk-laboratory (38 13. Temperature of infant at term 70 14. Townsend's temperature observations 71 15. Pulse-rate for males , 71 16. Townsend's pulse observations 72 17. Respirations in infancy and childhood 72 18. Respirations in infants awake, asleep, and crying 72 19. Pate of growth in girls and boys and the relation between growth and disease ... 74 20. General figures of weight 79 21. Average height and weights from birth to five years 81 22. Average analysis of urine in infancy and childhood 86 23. Temperature of the bath for different ages 97 24. Average analysis of five specimens of human colostrum milk 123 25. General average of twenty-six analyses of human colostrum milk 123 26. Average analysis of human milk 127 27. Analyses of fore-milk, middle-milk, and strippings 133 28. Human breast-milk analyses 134 29. Intervals and number of day and night feedings. 136 30. Analysis of typical normal, poor, over-rich, and bad milk 140 31. Analyses of human milk 148 32. Analyses of human milk 148 33. Analyses of human milk 144 34. Analyses of human milk 144 35. Analyses of human milk 144 36. Analyses of human milk 145 37. Analyses of human milk 145 38. Analyses of human milk , 146 39. Alkalinity of cream mixtures con*esponding to that of human milk 175 40. Cow's milk as compared with human milk 180 41. General rules for feeding during the first year 1 88 42. Practical limits of laboratory modification 199 43. Practical limits of laboratory modification 199 44. Table of whey-cream mixtures 201 45. Showing the management of the food and the increase in weight of a healthy infant during the first fifty-two weeks of its life 207 xv xv j LIST OF TABLES. TABLE PAGE 40. Showing the management of the food and the increase in weight of a healthy infant during the first fifty-two weeks of its life 209 47 Showing lowest possible proteids with creams of different strengths 219 48. Showing lowest possible proteid mixtures of two, three, four, and four and one- half per cent, of fat made from ten per cent, cream 220 49. Showing lowest possible proteid.- in mixtures of two, three, four, and four and one- half per cent, of fat made from twelve per cent, creams 220 50. Showing variation of fat percentage in milk of different herds 221 51. For the calculation of home modifications 230 52. Showing fat percentages obtained by diluting twenty per cent, cream with whole milk .* 231 53. Showing dilutions of milk with sugar solutions 232 54. Showing dilutions of whole milk with sugar solution 232 •35. Showing dilutions of eight per cent, cream with sugar solution 232 56. Showing dilution of twelve per cent, cream with sugar solution 232 57. Showing dilution of sixteen per cent, cream with sugar solution 233 58. Showing combination ot fats and proteids obtained with creams of different strengths and whey 234 59. Weight for sixty-one days of infant premature at thirty-two weeks 276 60. Showing details of sixty-four days of life in the incubator of an infant prema- ture at thirty weeks facing 281 61. Differential diagnosis of cerebral meningitis 415 62. Statistics of tuberculosis of the joints in the Children's Hospital 427 63. The doses of tincture of digitalis, strychnine, nitroglycerin, and atropine at dif- ferent ages 470 64. The principal combinations of paroxysms caused by the plasmodium malaria? .... 486 65. One thousand cases of scarlet fever, by ages, with the deaths 545 66. Individuals living in houses invaded by variola 602 67. Differential diagnosis between varicella and variola 609 68. Differential diagnosis of the exanthemata 612 69. Classification of the diseases of the mouth, 616 70. Amount of chlorate of potassium at different ages 624 71. Differential diagnosis between a dilated heart and a pericardial exudation 761 72. Classification of diseases of the gastric enteric tract 773 73. Normal average number of blood-corpuscles at different ages in cases in which there was a loss of weight in the first forty-eight hours 878 74. Percentages of leucocytes in the normal blood of infants and adults 879 75. Average percentages of the different elements of the blood in the splenic myelo- genous and lymphatic leukaemias 884 7'i. Differential diagnosis between cerebral paralysis and poliomyelitis anterior 962 LIST OF ILLUSTRATIONS. COLORED PLATES AND RADIOGRAPHS. PLATE PAGE I. Tubercular meningitis, convexity of the brain Frontispiece. II. Icterus neonatorum. Ked bone-marrow. Yellow bone-marrow. Erythema neonatorum .' 80 III. Intertrigo. Seborrhoea capitis. Umbilical cords. Napkins 84 IV. Radiograph of the chest and abdomen 254 V. Radiographs of the femora, tibiae, and fibulae in rhachitis, and of the tibhe and fibulae in syphilis 336 VI. Tubercular meningitis, base of the brain 424 VII. Radiographs of osteomyelitis of the lower end of the femur, and of tuberculo- sis of the knee-joint 512 VIII. Scarlet fever. Measles 564 IX. Vaccination 604 X. Varicella. Erysipelas. Syphilis 610 IX. Mouth and throat in thrush, varicella, stomatitis herpetica, stomatitis ulcerosa, follicular tonsillitis, diphtheria 620 XII. Blood-corpuscles. Mosquitoes, genus anopheles ; genus culex 874 FIGURES. FIG. 1. Fcetal circulation 19 2. Heart, natural size, at two days 20 3. Spinal curves 23 4. Skull of infant at term, natural size 25 5. Section of foetal lung at five months 32 6. Section of infant's lung at ten months 32 7. Lobulated kidney, natural size 34 8. Stomach, natural size. Infant, three hours old 34 9. Respiration at birth, illustrative diagram 36 10. Relative circumference of head, thorax, and abdomen 44 11. Infant skull, natural size 46 12. Skulls showing development of ramus at birth, and at three years 49 13. Eive periods of development in the first dentition 50 14. Eight periods of development in the second dentition 52 15. Respirations for one-half minute in a healthy infant nine months old 53 16. Frozen section, child of three years 54 17. Heart, showing Eustachian valve and foramen ovale 55 18. Heart, showing ductus arteriosus 55 19. Stomach, spleen, and pancreas at ten months . . 57 20. I., II. , III., and IV. Gastric capacity in the first five months of life 60 21. Stomach of infant two and one-half days old, natural size 64 22. Stomach of infant five days old, natural size 64 23. Stomach of infant seven days old, natural size 65 24. Stomach of infant twelve days old, distended to hold eighty c.c 65 25. Stomach of infant five months old, distended to hold two hundred and twenty- five c.c 66 B xvii xv iil LIST OF ILLUSTRATIONS. FIG PAGE 26 Stomach of infant seven months old, natural size 66 27. Stomach of infant nineteen months old, natural size . 67 28. Skeleton of infant at term , . . . . 87 29. Skeleton of infant at nineteen months 87 30 and 31. Normal infant seven months old 89 32 and 33. Normal development at six years 90 34 and 35. Normal development at twelve years 92 36. Infant's "bed, Infants" Hospital , 94 37. A, B, C, D, E. Long clothes for infants 100 38. F, G-, H, I, J. Short clothes for infants and children 103 39. Shape of soles for a child's shoe 105 40. Posterior spinal curvature from sitting too soon 110 41 and 42. Lateral curvature of the spine. Child, four and one-half years old Ill 43. Breast-pump • 120 44. Colostrum milk from cow (photomicrograph) 152 45. Colostrum milk from women (photomicrograph) 152 46. Stomach from infant five days' old and glass cylinder of same capacity 187 47. Centrifugal separator 191 48. Babcock fat-tester 192 49. Apparatus for the transportation of milk 193 50. Ice-box for the transportation of modified milk 194 51. Unmodified cow's milk 204 52. Cow's milk separated and recomposed 204 53. Human milk • 205 54. Modified cow's milk 205 55. Apparatus for home modification 224 56. Sugar-measure 225 57. Jar containing milk, cream, and siphon 226 58. Phonendoscope 251 59. Tongue depressor 251 60. Foetal stomach, natural size, four and one-half months old 260 61. Foetal stomach, natural size, seven and one-half months old 260 62. Foetal stomach, natural size, eight months old 260 63. Foetal stomach, natural size, eight months old 261 64. Infant premature at seventh month 264 65. Infant premature at the twenty-eighth week 267 66. Incubator for premature infants' 26S 67. Section of incubator 270 68. Feeder for premature infants 272 69. Infant premature at thirty weeks. Age, nine months 278 70. Caput succedaneum. Male, two hours old 286 71. Double cephalhematoma. Infant, four days old 287 72. Double external cephalhematoma. Both parietal bones 288 73. External cephalhematoma. Parietal bone dissected 288 74. Meningocele. Female, three years old 289 75. Hydro-encephalocele. Female, two months old 291 76. Double harelip 292 77. Congenital depression of sternum. Male, six years old 297 78. Spina bifida, Male, four and one-half years old 299 79. Spina bifida of dorsal lumbar region 300 80. Spina bifida of lumbar region 301 81. Large umbilical hernia. Infant, five months old 303 82. I. Normal bone. II. Bone of cretin. III. Rhachitic bone 329 83. Spindle-shaped rhachitic bone 331 84. Inner surface of sternum, showing rhachitic rosary 335 85. Rhachitic kyphosis , 335 86. Khachitis, with enlarged spleen. Male, three years old 337 87. I. and II. Khachitis. Age, six vears 342 LIST OF ILLUSTRATIONS. xix fk;. page 88. Congenital rhaehitis 348 89. Vertical section of a leg in a case of infantile scorbutus 845 90. Section of scorbutic bone 345 91. Infantile scorbutus. Female, ten months old 348 92. Infantile atrophy. Female, nine months old 352 93. Infantile atrophy. Female, ten months old 352 94. Infantile atrophy. Female, one and one-half years old 353 95. Infantile atrophy, showing extreme emaciation 354 96. Tinea tonsurans. Male, eight years old 360 97. Eczema capitis 371 98. Method of treating eczema capitis , 371 99. Chronic pulmonary tuberculosis with involvement of the cervical lymph-nodes. 391 100. Chronic tuberculosis of the lungs. Female, eight years old 398 101. Tubercular ulcers of the colon , 400 102. I. Tubercular ulcers of the small intestines 400 102. II. Large tubercular ulcer of the caecum 401 103. Tubercular peritonitis. Male, nine years old 404 104. Tubercular peritonitis. Male, four years old 405 105. Tubercular meningitis. Male, three years old 418 106. Recurrent tubercular meningitis. Female, twenty-one months old 422 107. Tubercular dactylitis 430 108. Chronic intermittent cerebro-spinal meningitis. Female, eight years old 443 109. Secondary choroido-iritis, occurring in cerebro-spinal meningitis 444 110. Chronic cerebro-spinal meningitis, with spastic condition of the hand 445 111. Typhoid fever. Male, five years old 457 112. Typhoidal ileo-colitis, showing ulcers of the colon. Female, two years old 458 113. Enlarged Peyer's patches closely simulating the lesions of ileo-colitis 459 114. Irrigation of the nose in diphtheria 473 115. Malaria. Enlarged spleen. Boy, nine years old . , 491 116. Malaria. Enlarged spleen. Girl, nine years old 493 117. Pertussis during paroxysm. Female, four years old 508 118. Acute articular rheumatism. Adult type of the disease. Male, three and one- half years old 518 119. Rheumatism. Subcutaneous fibrous nodules. Male, thirteen years old 519 120. Syphilitic macula?, ulcers, and bulla? on the soles of the feet. Male, two and one- half months old 535 121. Congenital syphilis. Enlarged spleen. Male, two and one-half months old. .. . 536 122. Syphilitic teeth of the second dentition 537 123. Late manifestations of syphilis. Female, three and one-half years old 540 124. Hereditary syphilis. Male, six years old. Abnormal prominence of frontal bone 541 125. Interstitial nephritis. Section of kidney from child with scarlet fever '. . . . 551 126. Capsular glomerulo-nephritis. Section of kidney from child with scarlet fever. . 552 127. Typical condition of the face in measles, fifteen days from infection. Female, six years old 587 128. Varicella. Stage of efflorescence, third day 610 129. Enlargement of submaxillary glands 614 130. Mycelium of thrush, interspersed with spores and fatty degenerated cells 628 131. Thrush, showing the formation of spores in the mycelium 629 132. Stomatitis gangrenosa, left cheek. Female, four years old 632 183. Stomatitis gangrenosa, secondary to measles and pneumonia. Female, five years old 632 134. Showing the connection between the sensori-motor nerves and the sympathetic. . 635 135. Showing the anatomical nervous connection between the teeth and the membrana tympani 636 136 and 137. Showing the relations of the teeth to the gums in difficult dentition .... 637 138. Gum-lancet 638 139. Hypertrophy of the pharyngeal tonsil (adenoid growths). Female, ten years old 648 140. Retropharyngeal abscess. Male, seven months old 658 XX LIST OF ILLUSTRATIONS. FIG. PAGE 141. Retropharyngeal abscess secondary to cervical spondylitis 659 142. Section of a child's lungs in acute bronchitis 667 143. Lobar pneumonia. Female, eight years old 688 144. Lobar pneumonia. Three invasions. Male, six years old 688 145. Broncho-pneumonia complicating measles. Early stage 692 146. Bronch-pneumonia secondary to diphtheria 693 147. Chronic broncho-pneumonia 695 148. Acute broncho-pneumonia. Female, four and one-half years old 702 149. Congenital cardiac disease. Unclosed ventricular septum. Female, ten months old 727 150. Congenital cardiac disease. Stenosis of pulmonary orifice. Incomplete septum ventriculorum. Male, four and one-half years old 728 151. Congenital cardiac disease. Transverse section of heart near apex, showing thickened septum ventriculorum 728 152. Congenital cardiac disease. Open ductus arteriosus. Male, sixteen days old . . . 729 153. Acute endocarditis: Mitralinsufficiency. Lacking compensation. Orthopnoea. Female, nine years old 750 154. Chronic recurrent endocarditis. Mitral insufficiency. Disturbance of compen- sation. Dilated heart. Enlarged liver. (Edema of lungs. Ascites. Male, ten years old 752 155. Chronic endocarditis. Mitral insufficiency. General oedema and anasarca 752 156. Chronic endocarditis. Mitral insufficiency. Returning compensation. En- larged liver. Enlarged heart 753 157. Chronic endocarditis. Mitral insufficiency with returned and complete compen- sation 753 158. Areas of absolute dulness in enlarged heart and in distended pericardium , 760 159. Congenital dilatation of the oesophagus. Female, ten weeks old 768 160. Colon showing presence of bismuth which had been given by the mouth 774 161. Dilated stomach. Rhachitic infant, seven months old 784 162. Dilatation of the stomach. Age. six years 787 163. Follicular ulceration of the stomach. Female, one year old 788 164. Dilatation of the colon. Male, twelve years old . , 810 165. Hyperplasia of the lymph-follicles 826 166. Xon-ulcerative follicular inflammation. Simple hyperplasia of the lymph-folli- cles. Female, three years old 826 167. Colitis follicularis non-ulcerativa. Male, two years old following 826 168. Colitis follicularis non-ulcerativa " 826 169. Microscopic section of hyperplasia of lymph-follicles (solitary glands). " ' 826 170. Microscopic section of follicular ulceration of the colon " 826 171. Ileo-colitis. Ulcerative follicularis. Infant, sixteen months old " 826 172. Acute ulcerative catarrhal colitis. Female, three months old " 826 173. Inflammation of follicles and surrounding parts of the colon, with necrosis. Female, three months old " 826 174. Pigmented follicular ulcers of the colon. Chronic catarrhal ulcerative follicular colitis " 826 175. Pseudo-membranous colitis. Child, three and a half years old " 826 176. Microscopic section. Pseudo-membranous colitis. Female, four years old 827 177. Microscopic section. Superficial necrosis of the mucosa of the colon, with swelling of the lymph-follicles 827 178. Oxyuris vermicularis. Ascaris lumbricoides 830 179. Tamia?. I. . without head : II. . with head 833 180. Amyloid liver. Pulmonary tuberculosis. Male, seven and three-quarter years old 838 181. Hypertrophic cirrhosis. Female, eighteen months old 839 182. Acute diffuse nephritis, following scarlet fever 855 183. Probable chronic parenchymatous nephritis with an acute exacerbation. Male, eleven years old 860 184. Probable chronic parenchymatous nephritis with an acute exacerbation. Female. nine years old 86 1 LIST OF ILLUSTRATIONS. XXI PIG. PAGE 185. Chronic cervical adenitis , 899 186. Hyperemia of the thyroid gland. Female, thirteen years old 900 187. Myxedema. Female, live and one-half years old 903 188. Myxoedema. Female, nine years old 904 189. Rheumatic arthritis. Endocarditis. Cardiac enlargement. Chorea. Female, eight years old 922 190. Reflex connection between the ear and larnyx 946 191. Cerebral paralysis. Spastic paraplegia. Cross-legged progression. Male, five and one-half years old 957 192. Cerebral paralysis. Diplegia. Female, five years old 957 193. Poliomyelitis anterior. Left leg. Female, nine years old 965 194. Poliomyelitis anterior. Abdominal muscles, left side. Female, two and one- half years old 965 195. Poliomyelitis anterior. Flail-leg, left side. Male, six and one-half years old. . 966 196. Poliomyelitis anterior. Talipes equinus, right side. Male, eleven and one-half years old 966 197. Hydrocephalic brain 972 198. Hydrocephalic skull, child three years 972 199. Normal skull, child three years 972 200. Congenital internal hydrocephalus. Male, seven months old 974 201. Congenital internal hydrocephalus. Female, five years old 974 202. Congenital athetosis. Female, two years old 977 203. Pseudo-hypertrophic muscular paralysis, showing enlarged calves 995 204. Pseudo-hypertrophic muscular paralysis, showing position assumed in rising from the floor 995 205. I. and II. Acute rheumatic torticollis. Fifth day of attack 1002 PEDIATRICS DIVISION I. THE NORMAL INFANT. I. INTRODUCTION. Pediatrics is a branch of medicine of the greatest practical importance. Those who enter into general practice will at once be called upon to treat infants and children. The proper appreciation of the sensitive tempera- ments and needs of this class of patients will be of great aid in success- fully establishing a practice among those whose favorable opinion may make or mar professional success. The difficulties to be surmounted in correctly diagnosticating and treating young children are far greater than those which are encountered in adult life. The reason for this is that for adult cases there is some standard by which we can be guided, being our- selves adults. What standard, however, is there for the feelings and sensitive organization of the child ? We have none within ourselves ; it must all come from long and patient observation, with its resulting expe- rience. The mere knowledge that certain diseases exist, and the usual methods of diagnosticating them, prove to be very inadequate when we are brought face to face with a sick and fretful child, or with an infant who is unable to describe its symptoms. Much additional knowledge is needed to enable us to understand the variety of symptoms which may arise in the same disease according to the age and individuality of the patient. It is now well recognized that there is a necessity for making a special study of children beyond what is learned in the general clinical study of adults. As our knowledge advances, we learn to appreciate that the various methods of treatment must be modified to correspond not so much to the special disease as to the special group of symptoms brought about by the age of the individual and the phase of its development. In studying. then, the different stages of development in children, we are in reality acquiring an alphabet, which when once thoroughly mastered will enable us to read the otherwise obscure language presented to us for translation by the various diseases of early life. The proper method of learning to 2 17 18 PEDIATRICS. understand sick infants and children is first to notice their peculiarities in health and to follow these peculiarities through the different stages of their development up to puberty; Thus, a pulse which would indicate an abnormal condition in the adult, or a convulsion which would be of serious import in the older subject, may often be but physiological or of slight consequence in the child. In fact, there are a large number of physiological and anatomical truths concerning the young the knowledge of which will simplify to a great degree otherwise almost insurmountable difficulties in diagnosis. The lack of this preliminary training, this alphabet, places the student who is endeavoring to understand diseases in children in the position of attempting to read without having first learned Ms letters. It is the province of pediatrics to begin with the human being at birth, to study it as it appears in the early hours of life, and to follow it in its development during the periods of infancy and childhood up to the age of puberty. For purposes of simplicity, we speak of infants and children, the anatomical and physiological conditions being sufficiently apparent to warrant this distinction between them. The period of infancy is usually spoken of as covering about the first two years of life. Its most distinctive features are presented in the first twelve months, the second year, month by month, rapidly approaching the conditions which exist in childhood. The second year, however, is influenced to such a degree by the various growing functions and tissues that its picture both in health and in disease resembles more closely the infant than the child. Childhood is empirically reckoned from the end of infancy to puberty, or the beginning of adolescence. A distinction must be made between the sexes, the girl becoming a fully developed woman some years before the boy becomes a man. The age of puberty is usually reckoned as beginning from the twelfth to the fourteenth year. Much latitude as to age. however, must be given for the special idiosyn- crasy of the individual, and also for the climate, as it has been found that children who live in a warm climate arrive at the age of puberty much earlier than those who are exposed to the lower ranges of temperature. In taking the period of birth as a starting-point for our studies we must not overlook the fact that it is simply a stage of development with which we are dealing, and not a perfected being. The better, therefore, we understand the evolution of the embryo to the infant, the better shall we be prepared to appreciate the evolution of the infant to the child and of the child to the adult. It is especially important to understand the stage of development which exists just before birth, for on this depends the knowledge whether we have a physiologically and anatomically normal being before us. or one that is abnormal. Disease does not merely mean a pathological change in the tissues, but. as is especially well exemplified in the infant, may simply mean a retardation or arrest of development. Thus, what would be perfectly normal anatomically at the seventh month of intra-uterine life may at birth be abnormal, and hence constitute a ffi - o 3 fcn c iO tr — ■s 1 -§ H > so £3 Pi '- tK > S3 ... os fc o - W 'oS - .2 M >> n>- > - > V = - 33 a 6 oS - - '55 > a s-i 1 "3 > Tr 43 i; o 2 5 = o ^ C cS g - — 7s h"i H H-S S -g H oS - S -" O « : k .s - - ■- d =2 i> 53 •- -^ £ g g o & -B s " THE FlETAL CIRCULATION. 19 disease. In like manner what may be normal at birth may if it persists into the second and third weeks become an abnormal condition. Disease, therefore, is a relative term. We may, however, simplify our classifica- tion of diseases by adopting two broad divisions corresponding to the changes which take place during intra- and extra-uterine life and desig- nated as congenital and acquired. By congenital diseases we mean those resulting from changes occurring during intra-uterine life. These may arise from an arrest of development or from a continuation of normal intra-uterine conditions beyond the usual period of their cessation ; also those which are caused by pathological processes such as inflammation. By acquired, we mean a pathological condition of existing tissues occur- ring after birth, and without regard to the stage of development. If we thoroughly understand the anatomical conditions existing just before birth, we can intelligently examine the young human being as it emerges from the uterus, and can judge in the early days of its existence whether we have under our care a normal infant or one that is to need special treatment. II. THE FOETAL CIRCULATION. The chief anatomical change which takes place at birth is the transi- tion from the intra-uterine circulatory mechanism to a form adapted to extra-uterine life ; in other words, from the oxygenation of the blood through the placenta to the same process carried on by the lungs. A general knowledge of the foetal circulation is, then, evidently of consider- able importance, especially when it is considered that a large proportion of the cases of congenital heart disease which we are called upon to diagnosticate is represented by perfectly normal prenatal conditions, such as absence of the ventricular septum, an open ductus arteriosus, or a patent foramen ovale. Fig. 1 represents the course of the (red) oxygenated blood from the placenta to the infant, and that of the darker (blue) deoxidized blood from the infant back to the placenta. We must consider that in the foetus the lungs are in a collapsed, inert condition, performing no part in the foetal economy, but remaining quiescent until called upon to perform their special function at birth. The true lung of the foetus, therefore, is repre- sented by the placenta of the mother. It is here that the blood is oxygen- ated, and is carried by means of the umbilical vein directly through the umbilicus of the foetus to the liver, as seen in the diagram. In the liver, the umbilical vein divides into three branches : (1) the smallest, carries the blood directly to the liver tissue, whence it is returned as in the adult to the inferior cava by the hepatic veins ; (2) the largest portion meets and mixes with the blood from the portal system, and is distributed with it to the liver ; (3) the remaining portion is carried, by a vessel called the ductus venosus, directly to the inferior cava, where it meets the deoxidized blood from the lower extremities, mixes with it, and is carried to the right 20 PEDIATRICS. Fig. 2. auricle : here, instead of passing as in the adult into the right ventricle, it is directed by a membrane, called the Eustachian valve, through an opening between the two auricles, called the foramen ovale, into the left auricle. It then passes into the left ventricle through the mitral valve, and thence through the aortic valve into the aorta. The greater part of the blood- current is then carried by the carotid and subclavian arteries to the head and upper extremities, where, after doing its work in vitalizing the tissues and taking up their waste (a small portion also passing, as usual, into the descending aorta), it is returned as deoxidized blood through the veins to the superior cava into the right auricle, thence through the tricuspid valves into the right ventricle, and up through the pulmonary artery, where a small portion is distributed as usual to the lungs, while the remaining portion is carried directly over to the descending aorta by a vessel called the ductus arteriosus. It here mixes with the small portion of oxygenated aortic blood mentioned above, and passes down the aorta, being distributed on its way, as in the adult, until it reaches the internal iliac arteries. From these arteries it is carried, by branches called the umbilical arteries, through the umbilicus back to the cord and placenta. Thus, by simply referring to this diagram, we can tell at a glance which part of the young infant should be most developed, and the reasons for it. A noticeable point of clinical interest, in tracing the course of the foetal circulation, is that the fresh oxygenated blood is mainly carried to the liver, head, and upper ex- tremities, while the devitalized blood is distributed to the thorax and lower ex- tremities. We should therefore expect, and we shall find it to be true, when we examine a normal new-born infant, that the head is larger than the thorax, that the abdomen is prominent from con- taining the large liver, and that the legs are insignificant and poorly devel- oped. When the placental circulation is cut off, an increased amount of blood is carried by the pulmonary artery to the lungs, and by degrees the foetal circulation is replaced by that of extra-uterine life. The ductus venoms and ductus arteriosus become fibrous cords. The Eustachian valve disappears. The foramen ovale closes. The umbilical vein and umbilical arteries become obliterated, with the exception of the lower parts of the latter. Heart, natural size, at two days. A marks the aorta ; PA marks the pulmo- nary artery ; DA marks the ductus arteri- osus. THE INFANT AT TERM. 21 During the first two weeks of infancy we may have conditions exist- ing physiologically which after that time would become pathological, and hence, to be well grounded in the diagnosis of disease in the infant, we must appreciate the importance of these facts. Fig. 2 represents a heart taken from an infant two days old. It is of natural size, and shows the ductus arteriosus connecting the aortic and pulmonary arteries. III. THE INFANT AT TERM. By the infant at term we mean one that has been born at the termina- tion of what is considered the usual period of pregnancy, two hundred and eighty days. SKIN. — A normally developed foetus when it first emerges from the uterus has a reddened skin and is covered thickly in many parts by a substance made up of the contents of the amniotic sac, in which the foetus has been floating, and of the excretion of the sebaceous glands. This substance is called the remix caseosa. In certain rare cases also this sebaceous matter is so universal and so impenetrable as to constitute a disease of serious import, and at times even to cause death. Infants also may be born with the skin almost entirely free from the vernix caseosa. After the infant has been bathed, and the vernix caseosa has been removed, it should present the color of a healthy skin reacting normally to its external surroundings. The skin should usually be some shade of delicate pink. General Description. — The body and limbs should be well rounded, the cry vigorous, the extremities warm, and the grasp of the hands strong and active. The hair at birth is often thick, dark, and quite long, perhaps 2 to 5 cm. (1 to 2 inches), but we also frequently find the hair to be short, fine, some shade of light brown, small in amount, and the temples bald, the hair coming down to a round point on the forehead. The eyes are almost always half open when awake, expressionless, and of a dull grayish blue. The head is large in comparison with the thorax, the arms more rounded and large in proportion to the legs, and the abdomen is prominent. The cord dries up and falls off at about the sixth or seventh day. It is important to know how it should look normally up to the day when it separates from the umbilicus in order to distinguish it from abnormal conditions. There is a slightly reddened areola where it joins and is to part from the abdominal wall. (Plate III.) Palpation, percussion, and auscultation show that the heart has about the same proportionate position in reference to the lungs as is found in the adult, but that the liver occupies much more space, coming fully 1 to 2 cm. (J to 1 inch) below the edge of the ribs in the right hypochondriac and the epigastric regions, and encroaching on the lung-space in the right back to the extent of fully one rib and interspace. The testicles have de- scended, and the bladder, when full of urine, presents an area of dulness of about 2 cm. (1 inch) just above the pubis in the median line. It i< an 22 PEDIATRICS. important fact that the bladder is an abdominal rather than a pelvic organ in the infant and young child. The dull area of the spleen corresponds in its position to that found in the adult, but is scarcely perceptible. The following anatomical and physiological truths relating to the infant at term are based on what is usually found to exist in the average infant. I am especially indebted to Professor Thomas Dwight for the assistance which he has given to me from his own original investigations, and from his verification of the anatomical part of the work. It has not been at- tempted to give the complete anatomy and physiology of the various periods of early life, but merely to pick out the practical points in these periods which will aid in clinical diagnosis and treatment. The great importance of thoroughly understanding the normal anatomy and physi- ology of human beings before attempting to deal with the morbid condi- tions which arise in them is now so well recognized that no preliminary remarks are needed to show how vital to all advance in clinical medicine is the proper reading of anatomical and physiological truths. There are several points in the anatomy and physiology of the new-born infant which would be better understood if the fact were borne in mind that in many respects the body at this age is more adapted to its intra-uterine life and to its means of exit into the external world than to the conditions which surround it in extra-uterine life. It is not uncommon at birth for the face to be swollen and the features out of shape ; this comes from pressure, and will soon pass away. At birth the trunk is egg-shaped, the larger end being below. The pelvis as a region hardly exists, and the thorax is very small when com- pared with the large abdomen. The latter is very large, owing to the disproportionate development of the liver, presumably a great organ of nutrition during fcetal life. A striking peculiarity is the almost complete absence of shoulders, which with the arms are relatively insignificant out- growths from the sharp end of the egg. It is evident that the small size of the thorax, its Avant of solidity, and the slight development of the pectoral and shoulder muscles indicate that its action in respiration must be very different from that in adult life. The greatest breadth of the trunk is in the region of the lower ribs. During intra-uterine life, and especially at the time of delivery, great flexibility and compressibility are requisite. Respiration has not yet oc- curred, and the assimilation of nutriment for the growth of the body and for preparing the rudiments of future organs has been the function most actively employed. When, therefore, we study the new-born infant, we must remember that we see it at an essentially transitional stage. Adap- tations, the marked utility of which is past, still persist, and new func- tions are carried on with very imperfect apparatus. SPINE. — At birth the spine consists of little bone and much cartilage and fibrous tissue. It can be twisted and bent at will in any direction. It appears relatively broader in proportion to its length than does the THE INFANT AT TERM. 23 adult spine. The height of the vertebrae is relatively less, and appears even less than it is. from the fact that the broad, narrow, bony nucleus of the vertebral body, which catches the eye, does not represent the whole thickness of the body, as it is embedded in cartilage. At this early stage of development the whole column is cartilaginous, with the exception of the nuclei of the bodies of the vertebrae and those of the lamina? on either side, forming a small portion of the body and Infant at birth. Fig. 3. SPINAL CURVES. Infant sitting. Infant standing. Front — ► (3) C represents cervical curve ; D represents dorsal curve ; L represents lumbar curve ; S represents sacral curve. the beginning of the arch. The time of the consolidation of the bodies is not accurately known. In the young embryo, the proportion of the neck in the movable part of the spine is greater than that of the loins, a condition which is reversed in the adult, where the neck is less, being a little over one-fifth, and the loins a little less than one-third. In fact, the proportions of the spine change considerably from an early period of intra-uterine life to that of the perfected adult condition. At birth, however, the change lias pro- 24 PEDIATRICS. gressecl sufficiently to make these two parts very nearly equal. The union of the laminae to form the spine begins in the upper part of the spine sooner than in the lumbar region. Throughout the greater part they are nearly united, and in some places are quite joined, at birth. Fig. 3 represents (1) the natural curve at birth, (2) the curve which comes especially in the cervical region when the infant has learned to sit up and the superincumbent head has to be supported, and (3) the addi- tional dorsal and increased lumbar curves which appear when the child stands and walks, and which correspond to those of the adult condition. At birth, when the child is lying in what may be called its normal position, — that is to say, on its side, with the head flexed and the thighs drawn up, — the whole spinal column presents one long concavity from the atlas to the coccyx, the front of which is subdivided into two curves by the slight projection of the promontory of the sacrum. Above this there is a tolerably regular concavity. The head can be thrown back so as to make a slight convexity in the neck, and by bringing the knees against the table (the infant being on its back) the lumbar region will spring forward ; but the former of these positions is rather unnatural, and the latter impossible without assistance. We can then consider the part of the spine above the sacrum as essentially a fibrous and cartilaginous rod, with a number of separate disks of bone embedded in it at different places. The extent of the movements possible at birth, both in the dis- sected spine and in the whole body, is remarkable. At all ages, from birth upward, the spine of the fourth lumbar verte- bra is (as in the adult) on a level with the highest point of the crest of the ilium (Dwight). Under certain circumstances this might advanta- geously be used as a starting-point from which to count. At birth the spinal cord descends only the space of about one vertebra lower than in the adult. The third lumbar spine, which should mark its termination, cannot be easily recognized under three years, but the correspondence of the top of the ilium with the fourth vertebral spine allows its position to be estimated. It is desirable to know how far the cavity of the spinal dura mater descends inside the sacrum. Recent investigations by Wagner show that in children under a year old it ends usually near the top of the third sacral vertebra, which makes it a little lower than its usual termina- tion in the adult. The point on the surface corresponding to this could be approximately estimated without any definite landmarks. NECK. — It is customary to say that young babies have no necks ; and yet when speaking of the spine it was stated that the cervical region of the vertebral column of the infant and young child is relatively longer than in the adult. From this point of view the shortness of the infant's neck must be seeming rather than real, but from a clinical stand-point it is real enough. The causes of the short neck are, first, the large head, which naturally falls forward, covering the upper portion, and next, the high position of the sternum encroaching on it from below. The lame THE INFANT AT TERM. 25 proportion of subcutaneous fat tends to make the neck appear still shorter. The larynx is at first placed much higher than later (Symington). In the adult the lower border of the cricoid is about on a level with the top of the seventh vertebra. In the infant it usually seems to be near the lower border of the fourth vertebra. HEAD. — Young infants frequently have at birth a startling shape to their heads produced by pressure. One side of the skull may be flattened, while the other bulges, or the natural diameters of the head may be Fig. 4. V-VV-"--*-. Skull of infant at term, natural size. Posterior view, showing parietal and occipital bones and posterior fontanelle. Warren Museum, Harvard University. altered, presenting a long, narrow head instead of a round, well-formed cranium. These shapes at times give an idiotic expression to the infant which causes much distress to the parents. In almost every case these abnormal appearances pass away in a few months, as the skull and brain grow, and do not, as a rule, indicate disease unless very extreme, so that it is well to state this fact to parents at once and thus to relieve their minds. As a rule, if the measurements of the head are taken over the middle of the forehead and around to the occipital protuberance, it will be found that at birth the circumference is about 33 cm. (13 inches). Fontanelles. — The opening between the frontal bones and the anterior borders of the parietal bones is called the anterior fontanelle, and. though 26 PEDIATRICS. somewhat depressed below the level of the bones at first, should soon be about on a level with them. Its size is variable, but is usually about 1 to 2 cm. (| to | inch) long, and about 1 cm. (J inch) wide. In the early days and even weeks of infancy the frontal suture is usually open in its upper part, as shown in Fig. 28, facing page 86. The opening between the occipital bone and the posterior edges of the parietal bones is much smaller, is of less significance than the anterior opening, is often temporarily obliterated by the overlapping of the bones, and is called the posterior fontanelle. Face and Cranium. — In infants the proportion of the face to the cra- nium is strikingly different from what is found in adults, where it is as one to two, while according to Froriep the face in the infant is to the skull as one to eight. If the front view of the face and cranium of the infant and of the adult is contrasted by counting as face all below a line at the tops of the orbital arches, and as skull all that is seen above that line, considering it projected on a vertical plane as in a photograph, it will be found that in the infant the skull forms about one-half, and in the adult much less. The height of the orbit bears pretty nearly the same proportion to the skull at all ages, except that it equals barely a third of the adult face, while it makes nearly a half of it at birth. While the top of the nasal opening retains pretty nearly the same relation to the orbit at all ages, its lower border is but very little below the lowest point of the orbit at birth, while it is much below it in the adult. In the latter, a line connecting the lowest points of the malar bones crosses the nasal cavity, or at least touches its lower border, while in the infant it runs almost half-way be- tween the lower border and the edge of the alveolar process. The breadth of the skull in its greatest diameter in the infant equals, or even exceeds, the total height of the skull and the face, while in the adult it is but about three-quarters of it. Still more striking is the difference be- tween the length and the breadth of the face at different stages. The breadth, measured between the most distant points of the zygomata, is to the height of the face in the adult about as nine to eight, while at birth it is perhaps as much as ten to four. The side view is equally or even more characteristic. The auditory meatus is situated about midway between the front and the back in the infant, but in the adult it is decidedly behind the middle. The face appears to be but an insignificant part of the whole structure. Jaws. — The lower jaw is almost on the same plane as the mastoid process of the temporal bone, and the upper border of the zygoma is about on a level with the floor of the nasal cavity, while in the adult it is at or near the level of the floor of the orbit. It is evident that a very important factor in the adult face is the development of the jaws and of the teeth, and that it is due to their rudimentary condition that the face is so small in infancy. The difference in the comparative development of the THE INFANT AT TERM. 27 lower jaw at birth and at three years is well exemplified by the skulls shown in Fig. 12. page 49. Gums. — The gums do not meet in the new-born (McClellan). They are composed of a dense fibrous tissue covered by vascular mucous mem- brane of very slight sensibility, and are protective to the growing teeth. Xaso-pharyxx. — A median section of an infant's head shows very strikingly the want of height of the naso-pharynx and the great obliquity (approaching the horizontal) of the posterior edge of the vomer. The naso-pharynx is relatively very long from before backward. Strange as it may seem, the distance from the back of the hard palate to the soft parts of the back of the pharynx (excluding the tonsil) is about as great at birth as in the adult. A knowledge of the change in size and shape of the nasal cavities and naso-jjharyn.v in the course of growth is very impor- tant. The nasal cavity consists of an upper olfactory region, occupying the ethmoidal portion of the cavity, and a lower respiratory region occu- pying the maxillary part. In the infant the nasal cavity is relatively long and shallow, and the respiratory portion is very narrow. The height of the posterior nares at birth is 6 to 7 mm., and the breadth between the pterygoid processes at the hard palate is 9 mm. (Dwight.) In the infant the naso-pharynx is simply a narrow passage running obliquely backward and downward from the constricted opening of the posterior nares. The soft palate of the child is placed more horizontally than in the adult. The posterior nares (not the inferior meatus alone, but the whole opening on either side) is just large enough to admit the end of a medium-sized male catheter ; this leads into the passage just mentioned, and therefore a congestion of the nasal mucous membrane in infancy, with the addition of the mucous secretion, may effectually close the opening from the nose to the pharynx. It is, perhaps, not sufficiently recognized clinically how important a function is performed by the nasal passages in early infancy, — far more important, indeed, than at any other age. In fact, the age of the infant is in inverse ratio to the dangers which may arise from obstruction of the nares. These dangers, consequent on obstruction, congestion, and the result- ing mechanical disturbance of neighboring parts, thus leading to actual disease of those parts, become in the new-born infant of most serious and even vital import. I have seen an infant die of simple acute nasal catarrh in the first two or three days of life. In this case the infant, was, indeed, puny and ill cared for. There is no doubt that, with due appreciation of the value of the nasal function and the danger of allowing it to be interfered with, we can. as a rule, even in extremely weak infants, prevent a fatal result. Lymph- Vessels of the Pharynx. — An anatomical condition of groat importance is that in comparison with the faucial tonsils, which are rela- 28 PEDIATRICS. tively poor in absorbents, an exceedingly rich plexus of absorbents exists in the posterior wall of the naso-pharynx. Eustachian Tubes. — In the foetus the nasal opening is below the level of the hard palate, which it reaches at birth. While in the adult the car- tilaginous portion slants downward, nevertheless the opening of the tube is opposite a higher part of the nose than in the child. At birth the tube is horizontal or nearly so. It must be borne in mind that even if the opening of the tube be below the level of the hard palate, the soft palate none the less runs beneath it, shutting it off from the cavity of the mouth and the passage from it to the fauces. In the infant and in the young child there is but a slight development of the end of the cartilage which makes in the adult so prominent a fold at the back of the pharyngeal opening of the tube, and by its prominence does much to determine the depth of the fossa of Rosenmuller, the recess behind it at the lateral posterior angles of the pharynx. At birth this prominence hardly exists. The opening of the tube is at first very small. That the catheterization of the tube at this age presents great difficulties of its own, apart from the intractability of the patient, is sufficiently obvious. The tube in infancy, while of course shorter than in the adult, is stated to be not only relatively, but absolutely, wider at its narrowest point, which may explain the case with which catarrhal processes travel at that age to the middle ear. Paucial Tonsils — Pharyngeal Tonsil — Lymphoid Tissue.— The faucial tonsils, the pharyngeal tonsil, the lymphoid masses under the mucous membrane of the posterior third of the tongue, the lymphoid tissue about the orifices of the Eustachian tubes, to say nothing of irregu- lar aggregations of the same tissue in the neighborhood, form a lymphoid ring around the pharynx which is most important. It is to be noticed that the passage from the nose, as well as that from the mouth, is guarded by this apparatus. That its function is in part protective seems very probable, in spite of the fact that when hypertrophied it gives rise to serious trouble. Before birth this system is but slightly developed. In- deed, the follicles at the back of the tongue are not always to be found at that time. A pocket in the pharyngeal tonsil is the famous bursa pharyngea. It is clinically important merely as a recess in which inflammation may linger and secretions be retained. The supposition that this system is protective receives support from Killian's observation that the pharyngeal tonsil is much developed in mammals that live in the dust of houses. It is not impossible that this lymphatic ring forms a bulwark against septic invasion. Goodale's investigations show that bacteria are found in the tonsillar crypts and that such organisms may be absorbed in the gland, but as soon as absorbed they meet with such conditions as would be likely to termi- nate their life. The small size of the naso-pharynx in the infant and the THE INFANT AT TERM. 29 young child explains its obliteration by the enlargement of the pharyngeal tonsil. Mouth. — The mouth, as a whole, is pre-eminently an organ intended for the reception of a liquid food, its mechanism being that of suction. It is a natural and necessary passage-way to the organs of digestion, but is not at first intended to aid the digestion by a salivary secretion. Tongue. — The tongue at birth is slightly coated and comparatively dry. It is greatly wanting in vertical thickness, and on section is shown to be long and narrow. The soft palate, therefore, rests on the tongue, and, the mouth being closed, runs in the main backward, descending very much less than in the adult. The uvula is rudimentary (Merkel). Owing to the depth of the pharynx (from before backward), the soft palate is unable to shut off the passage to the naso-pharynx as completely in early infancy as subsequently. Teeth. — At birth there are twenty embryo teeth, ten in each jaw, en- veloped in their respective tooth-sacs, protected above by the submucous tissue and mucous membrane, on either side by alveolar bone-substance, and below by the groove in the maxillary bone from which the alveoli have developed. Hard Palate. — At birth and in the early months of life the line of the hard palate, continued backward, strikes near the top of the basi- occipital, that is, near its junction with the sphenoid, or perhaps even strikes the latter. Accordingly, at this age, if the finger be introduced directly backward through the mouth, pushing the soft palate upward, it will strike the occipital bone, and being carried a little downward, will pass over the arch of the atlas, the base of the odontoid, and the body proper of the axis. Going still lower, the top of the third cervical verte- bra might be felt, but the larynx would hardly permit the finger to go lower, and the parts are so small that it is questionable if much could be recognized below the axis. Brain. — The brain of the new-born infant is proportionately very much larger than in the adult, bearing a relation of about 15 to 1. (Vierordt.) Eye. — The eye is anatomically perfectly developed in the new-born. (McClellan.) Ear. — The development of the ear is in its several parts very unequal (McClellan). The structures of the internal ear, the tympanic cavity, and the auditory ossicles are fully formed at birth, while the external auditory meatus, the Eustachian tube, and the mastoid portion of the temporal bone undergo many modifications before their full development at puberty. At birth the meatus passes inward and inclines downward, and the mem- brana tympani is almost horizontal, conditions to be remembered as necessitating a little different management of the ear speculum from what is taught in the examination of the adult ear. The mastoid antrum exists at birth, but the cells do not develop until later. 30 PEDIATRICS. Petro-Squamosal Suture. — An important anatomical condition exist- ing at birth is, that the petro-squamosal suture is open, allowing a close con- nection between the blood-vessels of the brain and the middle ear, with its resulting clinical significance. THORAX. — The thorax of the infant forms the upper and smaller end of the egg-shaped body which has been already described, while the small shoulders make the chest very different from that of the adult. Besides this, the whole shape of the thorax is very peculiar.- The pro- portion of the dorsal region of the spinal column is pretty nearly the same throughout life, but the thorax itself varies greatly. At birth the thorax is very insignificant. In front the breast-bone is relatively much smaller than that of the adult male, but not very different from some very small breast-bones which are occasionally met with in women. The lower part is, however, but slightly developed. The borders of the ribs diverge relatively rapidly. This is perhaps due to the great breadth of the abdomen. Top of the Sternum. — The sides of the thorax are not relatively so long as in the adult, which is probably partly due to the lesser develop- ment of the lower ribs and partly to the very important characteristic of the infant's thorax, — namely, that the top of the sternum is placed higher than in the adult. The top of the sternum in the latter is about on a level with the disk between the second and third dorsal vertebrae. The top of the sternum, according to Symington, is opposite about the middle of the first dorsal vertebra in the new-born infant, and a frozen section by Ruclinger shows it to be rather below the middle of the first. Diameters. — Another most important peculiarity of the infantile and child's thorax is its want of breadth. In the adult throughout the thorax, from about the level of the second costal cartilage, or even a little higher, to the top of the diaphragm, the antero-posterior diameter of the interior of the thorax is to the transverse as one to two and a half or one to three, there being, of course, a certain amount of variation. At birth, on the other hand, it is as two to three. It is well known that in the infant the ribs are more nearly horizontal than in adult life. A striking feature of the young infant's chest is that the ribs form the sides of the chest, and the sternum and cartilages the front. Ossification. — At birth the sternum is practically a strip of cartilage in which a varying number of bone-centres have been deposited. There is one for the manubrium and usually one or two for the second and third pieces, those for the latter being very frequently double. These, however, are mere thickenings of the cartilaginous strip, which is flexible and pliable in all directions. (Figs. 28 and 29, facing page 86, show these divisions of the sternum.) Respiration. — An important feature in the mechanism of thoracic res- piration is the rigidity of the thorax. In the infant at birth this rigidity is almost wholly absent, as it is found only in the ribs. THE INFANT AT TERM. 31 The sternum is at this age practically a perfectly flexible strip of carti- lage, for the small points of ossification in it only modify the softness of certain separate parts. The dorsal region of the spine is not fixed as a concavity, but can be bent freely backward. The motions of the ribs are practically the same as in the adult, but the effect of these motions is different. In the first place, as has been shown, the ribs are more nearly horizontal, and the thorax, even after death, is in what is called the in- spiratory condition. The nearly horizontal first rib can hardly rise any higher unless the whole spine is bent backward. The ribs, being straighter than in the adult, do not when raised increase the breadth of the chest to the same degree. The nature of the infantile respiratory movements is far from easy to analyze. Sometimes it seems abdominal and sometimes thoracic. The fact is, that at first it is of a very indefinite type. The thorax seems to expand as it can. It is common to see its lower part drawn inward by the contraction of the diaphragm. At birth no especial part of the respiratory apparatus has attained a sufficient develop- ment to insure its continuous equable action, and, as would be expected, irregular respiratory movements and no decided type of respiration are found. A sufficient number of observations, however, have not yet been made to warrant our stating any especial age at which the type of respiration in the two sexes separates and the female infant assumes the thoracic type of respiration. But if the breathing of the infant is essentially irregular in type, it is admirably adapted to the wants of its age. The elastic thorax can give way under pressure and expand in almost any direction. The flexible sternum submits to liberties which no adult breast-bone would endure. One-half of the chest may be compressed and yet the other go on acting independently. The facts that the top of the sternum is higher, reckoning from the spine, that the ribs are more nearly horizontal, and that probably the lower part of the sternum is relatively less developed than in the adult, — necessarily imply certain peculiarities in the relations of the internal parts. Diaphragm. — The diaphragm rises highest on the right over the summit of the liver, is a little lower on the left, and lower still at its tendinous centre in the median line. It is generally stated that the diaphragm is higher in the child than in the adult. Dwight's observations, partly origi- nal, partly on the frozen sections of other writers, give the following re- sults. In the infant the diaphragm appears to be opposite the disk between the eighth and ninth dorsal vertebras. In the infant it appears as if there were a lower insertion of the diaphragm to the sternum and the seventh costal cartilages than in the adult. Usually the line runs from one costal arch to the other, somewhat above the apex of the ensiform cartilage, leaving, therefore, a space on either side of the latter, where the interior of the thorax is against the abdominal walls. Owing, perhaps, to the greater flexibility of the body and to the less firm attachment of the in- 32 PEDIATRICS. ternal parts one to another, it certainly seems that at least after death the thoracic cavity is more accessible at the sides of the ensiform than it is in the adult. We may conclude that, while there is some variation, on the whole, the central point of the diaphragm is in the infant higher in relation to the spine than later in life, and that it gradually becomes lower. How high the diaphragm rises laterally is hard to say, for it is a point very difficult to observe. According to Kolliker, in the foetus at term, on the right it reaches the level of the anterior end of the fourth cartilage, and on the left that of the fourth intercostal space. Henke adds to this that certainly after respiration has begun it will never be so high again. Thymus Gland. — The thymus gland exists at birth, and lies above and to some extent before the heart. Heart. — The most striking peculiarity of the infant's heart is that it is less covered by the lungs than in adult life. Together with the thymus gland it forms a solid mass from the posterior mediastinum to the sternum, pushing the lungs far apart. It is to be noticed, however, that the pleural cavities extend as far forward as in the adult. The relations of the heart to the chest walls are curious in the infant, for these anterior walls are, as already stated, high in relation to the spine, yet the heart itself is high in relation to the walls. At least the upper half of it is so. With regard to the apex and the lower borders the relations are less certain. We usually find the impulse of the heart rather higher and nearer to the mammary line in the infant than in the adult. The weight of the heart at birth is 20.6 grammes (about § ounce), according to Boyd, and its proportion to the rest of the body is largest at about the time of birth. Common Carotid Artery. — The common carotid artery has in the new- born half the length of the descending aorta, but this proportion is much lessened at a more advanced age, when the vertebral column increases in length. Veins. — According to Jacobi, there are one hundred valves in the veins of the lower extremities of the new-born. Pulmonary Artery. — The pulmonary artery also, as stated by Jacobi, is from two to four centimetres (three-fourths to one and five-eighths inches) larger than the descending aorta. Lung. — Anatomically on the right side the eleventh rib behind marks the lower border of the lung, while it descends as low as the twelfth rib on the left side. In front the lung extends to about the fourth or fifth rib on the right side and the sixth rib on the left side. The lung at birth is charac- terized by its embryonic type. The infant's lung represents an interme- diate condition of growth, which illustrates the gradual change from the foetal to the adult condition. (Figs. 5 and 6, Northrup.) According to Northrup, if we examine the lung of a five months' foetus it is found that the bronchi constitute the entire respiratory tract thus far developed. At the terminal end of the bronchi there are bud- Fig. 5. Section of foetal lung- at 5 months, showing development of bronchi ; no alveoli. ^^aSSyy? Section of infant's lung at 10 months, showing increased proportionate amount of parenchyma in comparison with the foetal condition ; distended alveoli. THE INFANT AT TERM. 33 like dilatations, which are the rudimentary air-spaces. Between these dilatations, and separating them from each other, is loose, delicate con- nective tissue, which makes up the remaining bulk of the lung, so that what subsequently becomes the alveoli is about equal in extent to the previous bronchial development. This rudimentary air-space is destined to enlarge, subdivide, and finally, in early adult life, to occupy all the available room among the bronchial branches. The loose connective tissue becomes finally thin, dense bands constituting the stroma. This serves to distribute the vascular net-work, and upon this are laid the close-fitting epithelial linings of the air-spaces. In foetal life the mucous membrane lining the bronchial tubes is loosely attached to the muscular walls, and is commonly seen lying in wavy folds within the contractile ring, where the same delicate connective tissue loosely holds the growing tissues together. As has been said, the aerating portions of the lungs develop as bud-like dilatations at the tips of the smallest bronchi. These dilatations in the course of their development extend into the stroma. The epithelium, changing from the columnar type characteristic of the smaller bronchi, covers the newly made walls with flat respiratory epi- thelium. At birth the loose connective-tissue stroma of the fcetal lung of five months has been condensed into rather thick alveolar walls. Another feature of the child 1 s lungs as contrasted with those of adults is the be- havior of the blood-vessels. Being loosely restrained in the walls, they easily become distended and tortuous and encroach upon the cavity of the alveoli. With small alveoli, thick walls, and abundant distribution of vessels, it is easy to understand how, in hypostasis, distention of the ves- sels may be an important factor in displacing the air in feeble subjects with weakened respiratory vigor and partially obstructed bronchi. Finally, the lung of the infant differs from that of the adult mainly in the following respects. Proportionately the extent of the bronchial tubes is greater than that of the air-spaces. The connective-tissue stroma is likewise in greater abundance and tends to cellular proliferation. The submucous connective-tissue of the bronchi is loose and more abundantly supplied with nuclei, and its vessels are held more loosely. The cells lining the air-spaces form a continuous layer. The alveoli are small. their epithelium proliferates abundantly, and the absorbents accomplish their work slowly, the blood-vessels playing a more important role. These facts are to be borne in mind in connection with the bronchial lesion which forms so important a part of bronchopneumonia. ABDOMEN.- — The essential differences between the abdomen of the infant and that of the adult are the great size of the liver in the former. and also the relatively large size of the kidneys and the suprarenal capsules. The liver, especially on the right side of the abdomen, encroaches on the space which is later occupied by other organs. Its relative weight to that of the whole body at birth is about 1 to 18. (McClellan.) On the left side of the abdomen these conditions are not of much 34 PEDIATRICS. Lobulated kidney, natural size. Infant importance, but on the right, occurring as they do in connection with the great size of the liver, the large kidney occupies a lower position, and thus still further curtails the free space in the right flank. Viewed from the stand-point of the adult condition the relations are, as has been pointed out by Henke, much more peculiar on the right than on the left. The kidney as a whole is lobulated, as seen in Fig. 7. Uric Acid Infarction. — At birth a prenatal condition, represented by an orange or a light red colored deposit near three days old. 8 R marks the suprarenal ^he pyramids in the straight tubules of the capsule. Warren Museum. Harvard Uni- _ vereity. kidney, exists normally, lhis condition is called the uric acid infarction, and the deposit consists of urate of ammonium, amorphous urates mixed with uric acid crystals, and some epithelial cells. (Plate III., 3 and 5, facing page 84.) The suprarenal capsules at birth quite cover and surmount the kid- neys, as seen in Fig. 7. Stomach. — The stomach at birth is remarkably small, and more tubu- lar than in the adult, the fundus being but slightly developed. It is con- sequently even more vertical than in the adult, for it is the enlargement of the greater cul-de-sac that makes the obliquity of the axis pronounced. Fig. 8, representing a stomach taken from an infant three hours old, shows very well the organ at birth. Its capacity was 25 c.c. (f ounce). The weight of the infant was 2500 grammes (5} pounds). Although the weight was below that of the average infant at birth, the stomach was of about the aver- age size, as was shown by its gastric capacity. Duodenum. — The duodenum, in the adult, has of late usu- ally been described as ring-shaped, but it generally presents pretty well marked angles, which divide it into a horizontal part running back- ward, a descending one along the right side of the spine, a transverse one crossing usually the third lumbar vertebra, and, finally, an ascending part along the left of the spinal col- Fig. 8. "" "-' Stomach, natural size. Infant three hours old. Warren Museum, Harvard University. THE INFANT AT TERM. 35 mini, which brings the end to about the same level as the beginning. Sometimes the last two parts are represented by a single one running obliquely upward to the left, in which case the duodenum is called V- shaped. The first horizontal portion is often somewhat dilated, and its walls are smooth, the folds beginning usually with the descending por- tion. The walls of the duodenum just beyond the pylorus are lined by a continuous layer of Brunner's glands, which extends through the first part, becoming more or less broken up towards the end. In the infant the shape of the duodenum, as shown by plaster casts (specimens in Warren Museum), is more nearly that of a ring, the two lower angles being rounded off. A constriction is often (perhaps usually) seen at the junction of the first and second parts, but D wight's casts of the infant's duodenum do not show the folds, which are very striking in the casts taken from adults. That is to say, those of the infant show a few deep cuts into the cast instead of a great many near together. I have seen the folds, however, very richly developed in an infant of three weeks. In one case, that of a female six weeks old, Dwight found the duodenum of the V-shaped pattern, and, what is more remarkable, after it had passed the gall-bladder it was surrounded by peritoneum so as to swing freely as a loop suspended from the posterior abdominal wall. As to Brunner's glands, a few observations on young children have suggested that they were rather less developed relatively than in the adult, but this may not always be the case. The duodenum has been compared to a trap, its ends being always higher than its middle, which is thus fitted to retain the fluid poured into it from the liver, the pancreas, and its own glands, besides that which it receives from the stomach. The number and size of the folds and the shape of the duodenum in the adult would tend to delay the passage of its contents through it, and thus it also prevents the passage of gases from the small intestine upward into the stomach. If it be true that in the infant the system of folds is less developed, its j>assage would be relatively easy, Avhich with a fluid diet seems desirable. Intestines. — From what we know of the development of the intestinal tract, Avhich was at first merely a loop loosely attached to the posterior abdominal wall, it is natural to expect that in the infant and young child it should be less fixed than in adult life ; and this is. in fact, the case. The difference is most striking in the large intestine, and is shown particularly in the caecum, ascending colon, and sigmoid flexure. That this condition gives rise to dangers is evident, and I should say that there is a strong probability that the cases of infantile intussusception which occur with unusual frequency during the middle of the first year may arise from this anatomical peculiarity, and this makes a thorough knowledge of the anatomy of the intestine important. In the foetus at full term the length of the intestine, and especially of the colon, is singu- larly constant. 36 PEDIATRICS. Small Intestine. — The average measurement of the small intestine in infancy is 287 cm. (9 feet 5 inches). The variation may amount to 61 cm. (about 2 feet). Large Intestine. — The large intestine at birth, according to Treves, measures 56 cm. (about 1 foot 10 inches). So regular are these measure- ments that the greatest variation that I have met with in the colon was as little as 12.7 cm. (about 5 inches). Sigmoid Flexure. — But little of the sigmoid flexure is found in the pelvis at birth. PELVIS. — The small size of the infant's pelvis is to be noted also as the cause which, to a greater or less extent, forces the pelvic organs of later life into the abdomen during infancy. BLADDER. — In the infant the bladder is practically wholly an ab- dominal organ. UTERUS. — At birth, part of the uterus is above the brim of the pelvis. TEMPERATURE. — The temperature at birth is slightly higher than a few days later. It is about 37.2° C. (99° F.). PULSE. — The pulse varies from 120 to 140 to the minute at birth, and it is at times irregular, especially during the first few hours. RESPIRATION. — The respiration is about 45 to the minute, but it is of a very irregular type, and the rhythm changes continually. The breathing is superficial, sometimes quick, and again dying away so as to be almost imperceptible. This condition, if occurring in an older child, would be a symptom of grave disease, but may be said to be normal at birth. The rate may be much quicker than 45, and I have frequently observed it as high as 60 or 70. Fig. 9. Quick Pause Slow Quick Respiration at birth for one-fourth minute. Awake, but quiet. HEIGHT. — The new-born infant's average height is in the male about 49.5 cm. (19} inches): in the female 48.5 cm. (19^ inches). WEIGHT. — The weight of the male infant is usually rather greater than that of the female. The average weight in a large number of cases showed that of the male to be 3250 grammes (7| pounds), while that of the female is 3150 grammes (7 pounds). Parker, in a careful examination of 170 infants at birth, of whom 89 were males and 81 females, found that the average weight of the males was 3520 grammes (7f pounds). while that of the females was 3290 grammes (7J pounds). There is. then, a certain amount of latitude to be accepted in this question of weights. THE INFANT AT TERM. 37 The weight, however, has so close a connection with the vitality of the infant, that although we often see infants- -of light weight vigorous and thriving, and those of considerable weight failing to gain, yet as a general index of vitality the weight is a valuable starting-point and guide for our treatment. Rules and averages of this kind are not to be depended upon absolutely, but simply represent conditions which with other important factors aid in solving the problem of vitality. VITALITY. — In the early hours and days of existence it is the dis- turbance of the equilibrium of the infant's vitality which is especially to be feared and combated rather than the specific morbid processes of later childhood. We should therefore in each infant carefully determine the degree of inanition which we are called upon to deal with at this period of life, and I have personally found it useful, as shown in the following table, to divide the weak and strong infants into groups according to their weights, allowing a somewhat lighter weight for girls than for boys. TABLE 1. Relation of Weight to Vitality. Groups. Weight. Vitality. 1 2000 grammes (about 4J pounds) Very low. 2 2500 " < : b\ " Low. 3 3000 •• " 6£ : ' Fair. 4 3500 ;; " 7J " Normal. 5 4000 i: " 8 " High. 6 4500 " " 9 " Very high. HANDS. — At birth it is quite remarkable to find with what manifest strength the infant can grasp your finger. The nails are well formed. FEET. — A very important part of the infant's anatomy is the foot. The later researches of Dane have shown that the foot of the new-born infant is not normally flat. On the contrary, the bones are so arranged as to form an arch that is even higher in proportion to its length than that found in adult feet. The flat appearance is caused by the presence in the sole of a very large amount of fat tissue and the greater proportionate size of the adductor pollicis muscle. BONE MARROW. — At birth, and in the early months of life, the marrow of the bones is red, as shown in Plate II., facing page 80. The red color caused by the numerous injected blood-vessels is more intense at the central portion of the section of this bone than at the periphery or towards the ends. FUNCTIONS. — A t oice. — The normal infant at birth should present a developed voice, and should cry vigorously, thus assisting the lungs to expand and the new circulatory mechanism to be well started. Sight. — Although the eye is anatomically developed and is sensitive to light, and although the visual perception is also possibly developed, yet there is still a lack of power to interpret the images perceived. 38 PEDIATRICS. Hearing. — The auditory sensations appear to be rather dull during the first few days of life. This is possibly due to the absence of air from the tympanum and a tumid condition of the tympanic mucous membrane. Touch. — The sense of touch is well developed. Taste. — The sense of taste is well developed. Smell. — The sense of smell is probably well developed; but this is still a matter of dispute. Sebaceous Glands. — The function of the sebaceous glands is fully de- veloped at birth. Lachrymal Glands. — The secretion of the lachrymal glands is not de- veloped at birth. The new-born infant does not shed tears, a fact of some clinical consequence in connection with the prognosis as to the convales- cence of disease in the early days of life. Sweat Glands.— The function of the sweat-glands is not developed at birth as a rule, but according to my observations perspiration in certain individuals certainly occurs at a much earlier period than is usually sup- posed. I have seen an infant, premature at the seventh month, perspire freely one week after it was born, and in a number of individuals this function must exist in the early days of life. Salivary Glands. — The salivary secretion is not fully established at birth, and consequently the mucous membrane of the mouth is compara- tively dry. The peculiar whitish color of the young infant's tongue is caused by the epithelium not being washed away by the saliva to the extent that it is after the later development of the function of the salivary glands. The amylolytic function of the saliva is very slightly present at birth. The amylolytic action is indeed so insignificant that it merely shows us that the function of the salivary glands in the early months of existence is only partially developed and certainly should not be called into use. Pancreas. — The amylolytic action of the pancreatic secretion at birth is probably not all developed. The fat digestion is fairly developed at birth. The proteid digestion is fairly developed, but not fully. Bile. — According to Foster, "the excretory functions of the liver are developed early, and at about the third month of intra-uterine life bile- pigment and bile-salts find their way into the intestine. A quantity of bile secreted during intra-uterine life accumulates in the intestine, espe- cially in the rectum, and forms, together with the slighter secretion of the rest of the canal and some desquamated epithelium, the meconium. The distinct formation of bile is an indication that the products of foetal metabolism are no longer wholly carried off by the maternal circulation, and that to the excretory function of the liver are now added those of the skin and kidney." BLOOD. — It is impossible by the methods at present known to deter- mine exactly the total amount of blood in either infant or adult, but, while the adult's blood is approximately about one-thirteenth of the entire weight of the body, the infant's is represented by only one-fifteenth. A NORMAL DEVELOPMENT. 39 full description of the normal blood in infancy and childhood will be found on page 874. LYMPHATIC SYSTEM.— The lymphatic system is very active at birth. URINE. — The amount of urine secreted during the first two days of lite is very small, and its specific gravity is about 1010. The kidney shows the condition of the uric acid infarction, and it is not infrequent to find the napkins stained with a uric acid deposit, such as is represented in Plate III., 3 and 5. faring page 84. INTESTINAL DISCHARGES.— Unless a discharge of the contents of the intestine has taken place during the delivery, as is so often seen in breech presentations, it occurs immediately or very soon after birth. Meconium. — The discharge which first comes from the intestine is called the meconium. It is inodorous, viscid, slightly acid, and of a brownish-black color, such as is represented in Plate III., facing page 84. The meconium contains mucus, epithelium from the intestinal mucous membrane, epidermal cells, hairs, and fat-drops from the vernix caseosa which have been swallowed with the amniotic fluid from time to time, It also, according to Vierordt, contains the constituents of the bile, and its total amount is from sixty to ninety grammes (two to three ounces), of which the solid part forms about twenty per cent. The intestinal con- tents at birth are sterile. IV. NORMAL DEVELOPMENT. In order to differentiate normal from abnormal conditions in the growing infant and child, the different stages of development correspond- ing to the various ages should be studied. CORD. — By a process of disintegration the cord at about the seventh or eighth day separates from the living tissues around the umbilicus. A certain amount of bleeding may take place at the point of separation, but this is usually very slight ; it may, however, be the beginning of one of the most serious forms of disease in the new-born, umbilical hemorrhage. The umbilical depression is well marked, even when the infant cries, and this normal anatomical condition following the separation of the cord can thus be distinguished from the umbilical prominence representing cases of umbilical hernia. SPINE. — The time of consolidation of the bodies of the vertebrae is not accurately known, but it may be roughly stated to begin in the third year, and, probably, to end in the seventh. A large number of observa- tions must still be made before the various stages of ossification can be determined. The statements regarding this point are copied from one book to another, and are often quite imaginary. The union of these chief centres to form the bodies of the vertebrae begins in the lumbar region, and is first completed there. This union, 40 PEDIATRICS. however, had not taken place in the dorsal and cervical region of the child said to be three years old, used for ik The Frozen Sections of a Child" (D wight). On the other hand, in a girl of five or six years, figured by Symington, the process was found to be hardly finished in the lumbar region, and higher up it seemed about the same as in the younger child. The process of union of the laminae is probably completed in the first few months of life. Length. — The following table shows the results of the measurements of the spines of children by various authorities. There is a remarkable uniformity of observations by different men in spite of the errors incident to the personal equation of the investigators and the individual variation which doubtless exists. The relative length of the dorsal (more properly the thoracic) region is shown to be somewhat greater than that of the adult ; still it appears that after the age of five or six the proportions are not far from those of after-life. TABLE 2. Length of Spine to Sacrum. Absolute Length, in Millimetres Relative Length. Total = 100. Age. Observer. Cervical. Dorsal, j Lumbar. | Total. ! 1 i Cervical. Dorsal. Lumbar. 3 months .... 6 months .... 6 months .... 10 months .... 2 years, boy . . 2 years, boy . . 3 years, girl.. 4 years, girl. . 5 years, boy . . 5 years, boy . . 6 years, boy . . 9 years, girl . . 11 years, boy. . 13 years, girl. . 16 years, girl. . 16 yeai*s, girl. . 17 years, girl. . Rasenel .... Aeby Aeby Dwight .... Easenel .... Aeby Dwight .... Aeby Symington . Rasenel .... Symington . Rasenel .... Aeby Symington . Aeby Aeby Dwight .... 50 52.5 53.5 61 70 79.5 78 79.9 80 80 80 85 91 95 100 107.5 113 100 103 107 125 140 153.5 162 162 170 180 175 195 218.7 220 221.9 229.5 250 58 1 208 60 215.5 61 221.5 77 j 263 90 300 98 ! 331 101 341 103.3 345.2 104 354 135 395 106 361 150 i 430 153.5 | 463.2 136 451 151 i 472.8 152.5 ! 489.5 161 524 24 24.3 24.1 23.2 23.3 24 22.9 23.1 22.5 20.3 22.2 19.8 19.7 21.5 21.1 21.9 21.5 48.1 27.9 47.5 : 27.8 48.6 27.5 47.5 29.2 46.7 30 46.4 I 29.6 47.5 29.6 46.9 29.9 48 | 29.4 45.6 34.2 48.5 29.3 45.4 34.9 47.2 33.1 48.7 29.1 46.9 31.9 46.9 31.1 47.7 30.7 The figures to the left of the double line in the table express the abso- lute length of the different portions of the spine, in millimetres. Those to the right are the same figures reduced to terms of 100, within a fraction. Flexibility. — The spine is very flexible at birth. This flexibility be- comes less as the infant grows older. In the cadaver of a female child of ten months it was found that ex- tension was no longer so free as in the earlier months, and it required a strong pull to make the head touch the nates. The dorsal region, how- ever, could still be made concave behind. Flexion was free, especially in NORMAL DEVELOPMENT. 41 the lower part of the lumbar region, where the pelvis and legs could be swung forward. On rotation the head could be turned through an arc of 90° without using the joint between the atlas and the axis. In a male child of the same age, extension of the spine was found to be still more restricted. Curves. — At birth there are no natural curves except the sacral in the infant's spine. An important factor in the production of the curves in the cervical and dorsal regions is probably the pull of the muscles. The dorsal curve seems to be a permanent condition of a part of the general curve of the body. As soon as the muscles of the back of the neck contract so as to raise the head from the chest, the front of the neck will be convex, and finally this becomes the habitual position. As Symington has pointed out, however, this cervical curve is never, prop- erly speaking, consolidated, for it can always be obliterated by a change of the position of the head. The production of the lumbar curve is more complicated. If an infant be laid on its back on a table, the knees are raised and fall apart ; if they are brought together and for- cibly pressed down, the lumbar region will spring up from the table and the beginning of a lumbar curve will appear. It is supposed that this is caused by the shortness of the ilio-femoral ligaments, which, when the thighs are brought down, flex the pelvis, throwing the promontory of the sacrum forward. As the child begins to stand, the body is inclined forward, and when this is straightened by the muscles of the back the same thing occurs, for of course it is unimportant whether the legs are extended on the trunk or the trunk on the legs. This curve, therefore, is first observed when the child is one or two years old, but it is not until some time later that it is habitually present. It can be obliterated up to adult life. The tonicity of the muscles has a great deal to do with retaining the curves of the spine and with limiting its movements. The importance of the muscles in distortions is very great. The spine of the child is flexible in many ways, and the unruly pull of a muscle may easily produce a lasting effect. Not only should the muscles have strength enough to maintain the figure without conscious effort, but their action should be symmetrical on both sides, and should also have a proper relative force before and behind. The importance of light gymnastic exercises is now generally understood. Fig. 3, page 23, represents the curves of the infant's spine at birth and also at different ages up to the period of standing. Surface Anatomy. — The surface anatomy of the spine is of much im- portance in the child. In the infant, except perhaps in the neck, the back is rounded ; later it is more flattened, and the line of the spinous pro- cesses is rather prominent. When we examine the dissected spine from behind we find it very different from that of the adult. In the infant the laminae look more directly backward, and their presence in the median line is marked by knobs and ridges very different from the spine o( the 42 PEDIATRICS. adult. Up to a year, or perhaps eighteen months, the proportions are not very different, but the spine at three years shows that a great change has occurred, for the spinal processes now stand out in a prominent row, and present very nearly adult proportions. The greatest difference is in the dorsal spines, which are relatively broader at their points and less gracefully drawn out than in the adult. The bodies of the vertebrae still remain less deep, and therefore the relative positions of the spines and bodies show less difference than might be expected. At six or seven years the spine has made still further progress towards the adult propor- tions. By the end of the second year the back of the living child is not only flatter and broader (the results of continuous changes), but there is the appearance of the median furrow, and at five or six the differences in this respect from the adult are not marked. It is barely possible to count the spines in the infant and young child, and at three and four years it is not very easy, though less difficult than in the adult. The first dorsal spine, and not the seventh cervical, is the most promi- nent in that region. The atlas has no spine at all ; the spinous process of the axis is thick and prominent, perhaps relatively less marked in the child than in the adult ; the third and fourth spines are very small ; the fifth is not much larger ; but the sixth projects more, and the seventh is said to be usually the first prominent one. The relative size of the lower cervical spines varies considerably. The sixth may be the first to assume prominence, and the seventh cervical and first dorsal may exceed it but little. It is easier to examine a child of three years and upward than an adult, on account of the greater softness of the tissues, which allows us to feel more deeply in through the furrow of the neck, and, having recog- nized the axis by alternately flexing and extending the head, to count the cervical vertebrae in order. If it should be in any case absolutely im- possible to feel the third and the fourth, it is better to allow a certain space for them and to call the next one the fifth than to assume arbitra- rily that a certain one is the seventh. Confirmatory evidence may be gained from the height of the sternum. NECK.— (See also p. 24). Cricoid Cartilage. — Symington states that in two children respec- tively five and six years old the lower border of the cricoid cartilage was found to be at the lowxr border of the fifth or at the top of the sixth ver- tebra. The position of the head, in his observations at intermediate ages, in these measurements varied a good deal. In a girl of thirteen he found that it had reached the adult position ; that is, about on a level with the top of the seventh vertebra. Epiglottis. — Symington found also that the top of the epiglottis de- scends during growth from about the level of the lower border of the atlas to the middle of the third cervical vertebra, or even lower. Larynx. — This high position of the larynx would imply a greater part of the trachea relatively above the sternum, but this is neutralized by the NORMAL DEVELOPMENT. 43 high position of the latter. The amount of fat in the neck makes the trachea less accessible. The greater distance of the trachea from the surface, as it descends, and the greater danger of meeting the large arteries and veins above the sternum in the child, are points of anatomy so Well known in connection with tracheotomy that it seems hardly worth while to dwell upon them. Distance from Cricoid to Sternum. — A condensation of Tillaux's statements of the distance from the cricoid to the sternum is given in Table 3. TABLE 3. Relation of Cricoid to Sternum. Years. Distance from Cricoid to Sternum. 2 h 3.5 centimetres. 3 4 3^ 4 4 3.8 " 4J .. . 4 5 4.5 " 6 4.9 " 6£ 5.5 " 7 5.1 7| 4.5 8 5 8£ 5.25 9 5.25 " 9£ 6.5 •< 10 6.5 10* 6.5 It seems rather remarkable that at ten years the distance should be as great as in the adult, but this may be accounted for by the subsequent descent of the larynx, and also, probably, by its proportionate enlarge- ment (at least in the male) about puberty. The peculiarities of the relations of the top of the larynx and pharynx to the spine in the young child are points of much practical importance. The changes which occur during growth depend largely on changes in the base of the skull, and on the downward growth of the jaws, which will be considered presently. HEAD. — Circumference and Circumference relative to Thorax. — The measurement of the circumference of the head increases very rapidly, and in early childhood almost attains that of the average adult's head. At birth the average circumference of the head is about 33 cm. (13 inches), and the thorax 1 or 2 cm. (J or f inch) less. The following table shows the relative and proportional growth of the head and thorax up to the period of puberty. These figures represent measurements from somewhat over one hundred cases. It will be seen that the circumference of the thorax has become equal to that of the head by the end o( the first year; though in exceptional cases the thorax surpasses the head at a 44 PEDIATRICS. much earlier period, and I have even seen it exceed the circumference of the head at birth. Again, in some cases, the head, even in the second year, remains larger than the thorax. After the second year, the meas- urements of the head vary very little, and depend more upon the individual Earlv Weeks. Fig. 10 Six Months. Head. Twelve Months. Relative circumferences of head, thorax, and abdomen. than upon the age ; the thorax, on the contrary, increases year by year. The measurements which are given were taken almost entirely from boys. Girls, for the same age, show a proportionately smaller circum- ference for the thorax and also for the head. NORMAL DEVELOPMENT. 45 TABLE 4. Circumferences of Head and Thorax from Birth to Thirteen Years. Age. Head. Thorax. Birth. 33 cm. (13 inches) 31 cm. {Y2\ inches). 5 weeks, 38 cm. (15 inches) 36 cm. (14J inches). 5 months 42 cm. (16^ inches) 41 cm. (16^ inches). 9 months 45.5 cm. (18 inches) 43 cm. (17 inches). 1 year. 45.5 cm. (18 inches) 47.5 cm. (18| inches). 2 years 48 cm. (19 inches) 51 cm. (20^ inches). 3 " 51 em. (20£ inches) 55 cm. (21f inches). 4 " 53 cm. (21 inches) 54 cm. (21^ inches). 5 " 53 cm. (21 inches) .54 cm. (21| inches). 6 " 52 cm. (20i inches) 55 cm. (21f inches). 7 " 54 cm. (211 inches). 54 cm. (211 inches). 8 " 53 cm. (21 inches) 59 cm. (23£ inches). 9 " 54 cm. (21^ inches) 61 cm. (24 inches). 10 " 53 cm. (21 inches) 62 cm. (24J inches). 11 " 56 cm. (22£ inches) 63 cm. (24| inches). 12 " 53.5 cm. (211 inches) 63 cm. (24| inches). 13 " 54 cm. (211 indies) 66 cm. (26 inches). The series of circles on page 44, representing the circumferences of the head, thorax, and abdomen, shows what may be expected as to the relations of these parts of the child in the first year. They represent the average of a number of actual cases observed by me. No especial significance need be given to the circumference of the abdomen in this connection beyond what has been previously said con- cerning the liver, as its measurements, of course, vary very much normally according to the degree of distention present. Fig. 10 shows that, although there is great activity shown in the growth of the head, this activity is still greater in regard to the thorax. Fontanelles. — The posterior fontanelle, although ordinarily quite per- ceptible at birth, soon disappears, either from overlapping of the bone or from a permanent closure, and is usually imperceptible by the sixth Aveek. The anterior fontanelle seems to grow larger as the infant grows older, up to about the ninth month ; this point is, however, disputed, and the increase may be apparent rather than real. It also seems to remain stationary, or almost so, from the ninth to the twelfth month, and then decreases slowly. It should be closed by the nineteenth to the twentieth month. Face and Cranium. — The proportion of the face to the cranium in infancy is as 1 to 8. Froriep has also made observations on this point in older children, and finds the following proportions : TABLE 5. Proportions of Face to Cranium. Age. Face. Cranium. Early infancy 1 to 8 2 years 1 t< i 6 5 years 1 to 4 10 years 1 to 3 Adult female I to 2.1 Ad ult male , , 1 to 2 46 PEDIATRICS. The small size of the facial portion of the skull in infancy and early childhood is shown in Fig. 12, page 49, of the infant at birth and at three years, and also in Figs. 28 and 29, facing page 86, of the infant at birth and at nineteen months. Fig. 11. Infant skull, natural size. Anterior fontanelle 4X3 cm. Warren Museum, Harvard University. As the child develops, very important changes occur in the base of the skull, one of the greatest of which is the downward growth of the face. Originally the base of the skull is practically flat. The sudden rise of the basilar process in front of the foramen magnum, the angle formed with it by the body of the sphenoid, and then the sharp descent of the vomer, are adult characteristics of which at birth there is little trace. The nasal cavity is shallow and relatively long, the posterior nares are small, and the vomer approaches the horizontal. The nasopharynx has, therefore, very little height. The alveolar processes are still undeveloped, NORMAL DEVELOPMENT. 47 and the ramus of the lower jaw is very oblique, so that the cavity of the mouth is small. As a consequence, the larynx is placed very high up. One of the chief causes of its descent is the downward growth of the face. Brain. — Up to the seventh year the brain shows an active growth, and after that year increases slowly in weight. The convolutions are not fully developed at birth, and are gradually perfected as the child grows older. The various centres of the brain which gradually become so highly developed in later childhood have but little action, so far as we can judge, at birth and in the early weeks. Dura Mater. — An important anatomical condition in connection with the brains of young subjects is that the dura mater is much more adhe- rent to the skull, and thus presents an obstacle to the collection of extrava- sations between it and the bone. Subarachnoid Space. — The subarachnoid space usually contains a larger amount of fluid in childhood than in later life. Ear. — The osseous meatus is not developed until about the fourth year. In introducing the aural speculum under four years of age, the ear should be drawn forward and downward instead of upward and back- ward as in older children and adults, or the canal will be bent on itself. Petrosquamosal Suture. — The time at which the petrosquamosal suture closes is not at present known. Nasopharynx. — According to Disse, the nasal cavity begins to increase in height directly after birth, and goes on pretty rapidly until the begin- ning of dentition, when it is sIoav until the second year is completed. After the first set of teeth are cut, the growth is rapid until the end of the seventh year. The increase in breadth occurs in the last-mentioned period, which also is the time in which the growth of the olfactory por- tion is most marked. Disse states that the posterior opening doubles its size in six months, remains stationary until the end of the second year, and then increases again. The following measurements were made by Dwkht : TABLE 6. Breadth between Ptery- Age. Height of Posterior Nares. goid Processes at Hard Palate. About birth 6 to 7 millimetres 9 millimetres. From 12 to 16 months 13 " 16 " 12 to 18 " .....15 '■ 16 •• 14 to 20 " ...14 " 17 " 18 months to 3 years 15 " 21 " " 2 to 4 years.. 15 " 20 About 6 years ._./ 16 " 20 7 or 8 years 20 "• 22 About 11 years 18 tl 22 17 years, female 22 20 These figures show that the height does not gain the predominance until adult age. At the end of the seventh month the nasal cavity approaches the adult shape, though it seems broad in proportion, and has 48 PEDIATRICS. not, of course, attained its full size. Merkol has shown that in later adolescence the growth of the respiratory portion takes place chiefly in the middle meatus. In infancy the posterior border of the vomer is very oblique. With the growth downward of the jaw this obliquity is much diminished at the age of seven or eight years. The change in the shape of the pharynx in the first two or three years is very great, and the pharynx of older children resembles more that of the adult than that of the infant. Indeed, at four weeks we find the tip of the epiglottis on a level with the lower part of the odontoid process. Eustachian Tubes. — The course of the Eustachian tube and the posi- tion of its opening undergo changes corresponding to the development of the nasal cavity. At birth the tube is horizontal, or nearly so. In the adult the cartilaginous portion slants downward. Nevertheless, the open- ing of the tube is opposite a higher part of the nose in the adult than in the child. In the foetus the opening is below the level of the hard palate, which it reaches at birth. Up to the ninth month after birth, according to Disse, there is but little change. After that time, however, the opening is distinctly higher than the floor of the nasal cavities. At four years, Kunkel found it to be three or four millimetres higher. In the adult it is opposite the end of the inferior turbinate bone. Pharyngeal Tonsil. — The pharyngeal tonsil increases after birth, an" by the end of the first year has a length of eighteen millimetres. Hard Palate. — In a child of three years or less the line of the hard palate strikes about the middle of the basi-occipital bone. It would hardly be possible, without passing the finger round the soft palate, to feel much higher than the arch of the atlas. The base of the odontoid process would be under the mucous membrane seen at the back of the throat through the open mouth. The tip of the epiglottis is at the junc- tion of the odontoid with the body of the axis. Only the very top of the third vertebra could be satisfactorily explored. At six and at thirteen (Symington's plates) the line of the hard palate has about the adult direc- tion, — that is, it strikes about the top of the atlas or the basilar process near its beginning. In both the finger could probably examine the verte- brae from the first to the fourth inclusive. The atlas, however, would be reached with much more difficulty in the older than in the younger sub- ject, as the relations oft he soft palate are more nearly those of the adult. Mouth. — As the infant grows older the mouth becomes an organ more adapted for certain uses beyond that of a mere means of entry for the food to the stomach. Maxillary Bones. — The ossification of the maxillary bones begins early, progresses slowly, and. together with the final formation of the jaw, is completed at puberty. Fig. 12 represents the characteristic in- complete development of the ramus of the inferior maxillary bone in the early weeks and months of life, and its almost complete development at three years. NORMAL DEVELOPMENT. 49 The chief characteristic, as seen in Fig. 12, is the oblique angle which the ramus makes with the body of the bone at birth, and this becomes more evident when compared with the jaw at three years. The much greater proportion of the ramus to the body of the bone at three years, and the nearer approach to a right angle where Fig. 12. they join are noticeable. Teeth. — The devel- opment of the first set of teeth begins at about the seventh week of in- tra-uterine life. and. pro- ? j|fc? gressing slowlv. is com- .JP**' * I pleted about the end of infancy. At birth the twenty embryo teeth, ten in each jaw. are so enclosed in the alveolar processes that nothing but the smooth mucous membrane is apparent on the gums above. Be- low, they are connected with the branches of the inferior dental nerve (an important clinical fact to be remembered) through openings at the bottom of the alveolar processes. When calcification of the neck of the tooth begins, elongation also takes place, and, as the tooth is enclosed in bony walls below and on the sides, it gradually grows through the point of least resistance, namely, the gum, wdiich covers the top of the alveolar processes. The continued pressure gradually, causes atrophy of the mucous membrane, and the crown of the tooth appears on the edge of the gums. The various teeth come through the gum at times which are regulated according to their development, that is, at times cor- responding to the calcification of their roots and consequent, elongation. This process usually takes place in groups and with considerable regu- larity in the average normal infant. Variations, both as to the order in which the teeth appear and in the time of their appearance, are so com- mon that it seems hardly practicable to have set rules designating these times. The experience of different physicians seems to differ, but all practically are guided by very general rules. An infant may be born with one or more teeth. < w Skulls showing development of ramus at birth and at three years. Warren Museum, Harvard University. 50 PEDIATRICS. The first tooth may appear at any time during the first year of life, or may be delayed until the second year without any other apparent vice of development. In like manner, every kind of variation may be met with in the order in which the teeth appear, without the slightest evidence of any pathological condition, mental or otherwise . being found either at the time or later. It is therefore unnecessary to alarm the parents by stating that their child is abnormal because it has not cut a tooth in the first year. We should, however, carefully watch these children and be sure that their food contains the proper nutritive elements not only for their age. but also for then individual digestion. Fig. 18. Five periods of development in the first dentition. The appearance of the teeth in groups suggests certain practical divi- sions to determine various questions, such as the best time for weaning, or for vaccination. These divisions constitute the dental and interdental periods. In my individual experience, the first tooth appears at about the sixth or seventh month, though at times I find it much earlier, as at the fourth month, and later, as at the ninth, tenth, eleventh, or twelfth month. The first tooth which develops sufficiently to come through the gum is in most cases one of the middle lower incisors. The groups and the dental periods, allowing always for many variations, are as follows : TABLE 7. Temporary Teeth. First Dentition. Twenty in Number. Dental Periods. Groups of Teeth. I. 6 to 8 months 2 middle lower incisors. II. 8 to 10 months 4 upper incisors. III. 12 to 14 months. 2 lateral lower incisors and 4 first molars. IV. 18 to 20 months 4 canines. V. 28 to 32 months 4 second* molars. 20 NORMAL DEVELOPMENT. 51 The second set of teeth begins to replace the first at about the sixth year. TABLE 8. Permanent Teeth. Second Dentition. Thirty-two in Number. Years. Groups. 6 4 first molars. 7 4 middle incisors. 8 ......... 4 lateral incisors. 9 . 4 first bicuspids. 10 4 second bicuspids. 11 4 canines. 12 .......... 4 second molars. 17 to 25 , 4 third molars ( wisdom-teeth) . 32 The first four teeth of the second dentition are usually called the sixth-year molars. They do not replace any of the permanent teeth, but, the jaw having grown so as to provide space back of the temporary teeth, they appear back of and next to the second molars. This usually occurs at about the sixth year. In the seventh and eighth years the permanent incisors replace those of the temporary set. In the ninth and tenth years the bicuspids replace the temporary molars. In the eleventh year the permanent canines re- place the temporary, and in the twelfth year the four second molars appear. This really completes the second dentition of childhood, twenty- eight teeth. The remaining four molars belong to a period of adult growth. Fig. 14 (page 52) shows the manner in which the permanent teeth replace the temporary set between the ages of six and twenty-five years. THORAX. — Top of Sternum. — From the few observations which have been made, the top of the sternum in infancy and early childhood seems to be opposite some part of the first or second dorsal vertebra. (Dwight.) Diameters. — The anteroposterior diameter of the interior of the thorax is to the transverse diameter at three years, according to D wight's "Frozen Sections." as one to two, and in a child of from five to six (Symington) the depth is even relatively greater. The ribs bend much less backward than in the adult, and the back first becomes rounder and then flatter. At four or five years great progress in growth has been made, and the infantile form of the thorax has wholly disappeared. Slight changes, "however, probably go on for some years. Ossification. — Towards the end of the first year the bone-centres of the sternum have grown, and the sternum has gained a good deal in sta- bility. New points of ossification have probably appeared, but still the sternum is essentially cartilaginous, the bone merely consisting of islands in a sea of cartilage. At two years of age the manubrium and the second 52 PEDIATRICS. and third pieces are nearly ossified, but their shape is made by their carti- laginous borders. At three years I have twice seen the manubrium and the second piece of the sternum presenting in bone their real shape, while the third piece was still framed in cartilage. Sometimes, however, the process of ossification is more backward. The ossification of the lower Eight periods of development in the second dentition. part of the sternum is less advanced than the upper part. As to its rela- tive size opinions differ. Probably the individual variation is very great. The ribs being comparatively horizontal, the cartilages rise very little, and at the lower part of the chest in front they are nearly together, making narrow intercostal spaces, the seventh cartilages often meeting below the body of the sternum. In the dead body of a young child, especially if it NORMAL DEVELOPMENT. 53 be emaciated, it is striking to see how, after the cadaveric rigidity has passed away, the sternum and cartilages, forming the front of the chest, fall in at the point where they join the ribs. Respiration. — At birth there is no decided type of respiration for the two sexes. As the infants, both male and female, however, grow older and a more equable respiratory mechanism becomes established, I have found that, as a rule, in the early months of life, the type of respiration is abdominal. Fig. 15 shows the irregular respiration of infancy. Fig. 15. AWW AAmaa AaAam Quick. Pause. Irregular. Pause. Irregular. Respiration for one-half minute in a healthy infant nine months old ; awake, but quiet. Diaphragm. — A limited number of observations by D wight showed the diaphragm to be opposite some part of a space between the lower part of the eighth and the upper part of the tenth vertebra. Thymus Gland. — The thymus is most developed in the first two years of life, but it persists longer than was formerly taught. During its greatest development it is found in the neck as well as in the thorax, ex- tending perhaps 2 cm. (f inch) above the sternum, which, you must re- member, is no small part of the surface of a child's neck. The thymus extends down the anterior mediastinum, lying on the pericardium in two long lobes on either side of the median line. The extent of these lobes is very variable, and the two are not usually symmetrical. 1 have seen them, even in an infant, so developed that the longer nearly reached the lower end of the sternum ; but it is very uncommon for it to reach the diaphragm. These prolongations become thinner as they descend. The thymus is a thick mass behind the first piece of the sternum, where it rests on the top of the heart against the great vessels concealing the in- nominate veins, more or less of the superior vena cava and the arch of the aorta, and extending back to the trachea. Lower down it extends on either side into the angle between the pericardium and the lungs, or rather pleurae. A section of the thymus made by D wight Avas found to run nearly horizontally from the top of the fourth dorsal vertebra to just above the junction of the second costal cartilage with the sternum. The cavity of the thorax seems to be divided into three parts, one on either side of the lungs and a median one occupied by the thymus, the transverse part of the arch of the aorta, with the superior vena cava on its right, and the trachea and oesophagus behind. The area occupied by the thymus is very nearly equal to that of the left lung. The thymus reaches backward on the left of the aorta behind the level o( the front o( the spinal column. There is also what seems to be a piece of it between 54 PEDIATRICS. the vena cava and the trachea. On the upper surface of the same sec- tion, at about the level of the sternoclavicular articulations, it is in front of both innominate veins and behind the right one. The lungs are pre- vented from approaching each other so nearly behind the manubrium as they do in the adult. Fig. 16. Frozen section, child of three years : E.L marks right lung ; LL marks left lung : T marks thymus gland ; G marks gullet ; CS marks superior vena cava ; AA marks aortic arch ; VA marks vena azygos ; F marks some fluid which happened to be in the right chest ; BT marks bifurcation of trachea. A frozen section (D wight) of a child three years old (Fig. 16) shows that behind the manubrium there is much more of the thymus to the left than to the right of the median line, and its dulness on percussion must have been evident at the left of the sternum. Below it merges into the cardiac dulness, and no distinction between the thymus and heart is possi- ble by percussion. The theoretical results of enlargement of the thymus are very serious. Resting on the anterior and weaker ventricle, which is prolonged upward into the pulmonary artery, it may interfere with the pulmonary supply of blood, and by compressing the innominate veins and the superior cava it may interrupt the return of venous blood to the lungs. Whether or not it may compress the thoracic duct is doubtful, but it certainly may press on the trachea. The thymus is said often to persist for several years after puberty, but observations are not numerous on this point. It seems to disappear from the neck and from the front of the heart and to remain longest behind the first piece of the sternum. Heart. — The changes which take place in the infant's heart after birth are not simultaneous, which is a point to be remembered in making a differential diagnosis of cardiac disease during the first ten days of infancy. The following table states the time at which these changes should occur: ,\Q * 5 s N -«N^ NORMAL DEVELOPMENT. 55 TABLE 9. POST-NATAL CHANGES OF FCETAL CONDITIONS. Ductus Venosus. — The ductus venosus becomes a fibrous cord in the fissure of the ductus venosus in from two to five days. Eustachian Valve. — The intra-uterine function of the Eustachian valve practically disappears at once at birth, but its remains can be found for an indefinite period. (See heart dissected by Dr. F. Dexter, Fig-. 17 7 facing page 54.) Foramen Ovale. — The foramen ovale usually closes about the tenth day, but the upper part sometimes never closes. The closed foramen ovale is seen in this same heart. (Fig. 17. facing page 54. ) Ductus Arteriosus. — The ductus arteriosus is about 1.5 cm. (finch) long, has a diameter of about .25 cm. (J inch), and is usually, so far as being pervious to the blood is con- cerned, obliterated in from four to ten days. Its remains forms a fibrous cord connect- ing the pulmonary artery and the aorta. (See Fig. 18, facing page 54.) Umbilical Vein. — The umbilical vein becomes the round ligament of the liver, and is obliterated in from two to five days. As pointed out by Jacobi, it differs from the arteries very much less than is usual with the veins and arteries in other parts of the body. Its muscular layer is- very large and strong. Umbilical Arteries. — The umbilical arteries in their upper parts become obliterated in from two to five days, forming the anterior true ligaments of the bladder, while the lower parts remain pervious and form the superior vesical arteries. The umbilical arteries are usually thick and strong, owing to the great development of their muscular layer. It is generally held that in the first year of life the long axis of the heart is more nearly horizontal than later. The apex is thought by many to be higher. This is true in the first few years, but somewhat later it may be found in the adult position, or, in cases where the lower part of the sternum is backward in development and the cartilages crowded together, it may be in a lower space than normal. It is not unlikely that a subsequent change in these portions of the walls would correct this. Thus, if in the early condition the apex were at the sixth intercostal space, a lengthening out of the lower end of the sternum might cause such a descent of the ribs as would bring it into the fifth space. Weight. — As shown by Boyd, the weight of the heart in proportion to that of the whole body does not vary much at different ages, so that the relative labor of the heart does not materially differ between the young subject and the adult. In the first few years, however, the increase of the weight of the heart is greater than at about the fourth or fifth year, and this increase is again greater at about puberty. These are facts of practical importance to be remembered when we are studying the dis- eased conditions of the heart. TABLE 10. Weights of the Heart during its Development. (Boyd. ) Age. Grammes. At birth 20.6 1| years 44. 5 3 years 60.2 5J years 72.8 10£ years 122.6 17 years 233. 7 Figs. 17 and 18 show the heart in the early days o( lite. (Dexter.) 56 PEDIATRICS. Blood-Vessels. — " According to a number of actual observations made by R. Thoma, the post-foetal growth is relatively smallest in the common carotid, and largest in the renal and femoral arteries. Between these two extremes there are found the subclavian, aorta, and pulmonary arteries. These are differences which correspond with the differences in the growth of the several parts of the body supplied by those blood-vessels. In regard to the renal artery and the kidney, it has been found that the transverse section of the former grows more rapidly than the volume and weight of the latter. Thus, it ought to be expected that congestive and inflammatory processes in the renal tissue were almost predestined by this disproportion between the size of the artery and the condition of the tissue. Moreover, the resistance to the arterial current offered by the kidney-substance depends also upon the readiness with which the current is permitted to pass the capillaries. It has been found experimentally that within a given time more water proportionately can be squeezed through them in the adult than in the child. These anatomical differences may therefore be the reason why renal diseases are so much more fre- quent in infancy and childhood from all causes, with the exception of that one which is reserved for the last decades of natural life, atheromatous degeneration." (Jacobi.) Pulmonary Artery. — It is doubtful whether there is any essential difference at different ages in the origin of the pulmonary artery. If Ave say that in the infant it is rather higher than later, we have stated about all that is justifiable. Lungs. — At what age the lungs reach their full expansion forward has not been determined. It would appear that it is not before five or six years, and it is probably still later. As the chest expands laterally the lungs of course increase, and the relatively greater size of the heart to the lung in the infant depends essentially on the size of the lungs. During the first year of life (according to Xorthrup) the alveolar walls are thick and their blood-vessels are held loosely. It is not until the fourth or fifth year that the proportionate adult development between the alveoli and the bronchi is attained, and the stroma has become dense and bind- ing, restraining the capillaries as in adult life. In infant life the underlying loose tissue lining the bronchial tubes gradually binds the mucous mem- brane to the fibromuscular wall. From this time it keeps pace in its growth with the other compact tissues, until in adult life it appears as dense fibrous bands. During the first two years the air-cells have not attained the proportionate capacity which exists in adult life, and the bronchial tree is still large in proportion to the dilating and multiplying alveoli. Again the air-spaces developed from the terminal bronchi have covered themselves with a continuous layer of flat nucleated epithelium. In its subsequent growth in adult life it is believed that the expanding alveolus does not increase its number of epithelial cells to cover the more extended wall, but somewhat enlarges their size, and, still further, that Stomach, spleen, and pancreas at 10 months. Natural size, posterior view. S marks the spleen ; P marks the pancreas ; D, the duodenum. Warren Museum. Harvard University. NORMAL DEVELOPMENT. 57 some of the flattened epithelium loses its nuclei and expands to form large, very thin plates, called respiratory epithelium. ABDOMEN. — Liver. — The liver is proportionately large at birth and in early childhood, and can be felt below the edge of the ribs in the right hypochondrium, its border being about 1 or 2 cm. (f to f inch) below the lower rib. G-all-Bladder. — The fundus of the gall-bladder is in relation to the surface of the body about that of the ninth costal cartilage near the border of the right rectus muscle. (McClellan.) Spleen. — There is nothing especially to be noted in the spleen in child- hood, as it corresponds in its position to that of the adult. According to Foster, the spleen grows rapidly in early infancy, but in proportion to that of the adult is both absolutely and relatively smaller. It is said that the spleen when enlarged, encroaches more upon the thoracic cavity than in the adult, owing to the greater resistance offered by the costocolic fold of the peritoneum upon which it rests. In many cases of enlarged spleen from varied causes which I have met in infants it has seemed to me that the abdomen was encroached upon to a greater extent than in adults, and that both the physical and the rational signs of the enlarged splee in the thorax were relatively insignificant and often difficult to detect. Pancreas. — The function and the anatomy of the pancreas correspond very closely to that of the salivary glands. It is situated in front of the first lumbar vertebra, behind the stomach, and, according to the variations produced by age and the growth of other parts, lies somewhere between the umbilicus and the ensiform cartilage. The relative position of the spleen and pancreas to the stomach and duodenum is shown in Fig. 19. The organs were obtained at the autopsy of an infant ten months old. The spleen is behind the cardiac end of the stomach, and very near its extremity. The pancreas extends from the spleen (its tail being in close apposition to the latter organ) along the posterior surface of the stomach and somewhat upward to the smaller curvature, passing behind the duodenum and its head resting in the con- cavity of the duodenum. The curve of the duodenum is also clearly shown in the specimen. Kidneys. — The kidneys are lobulated at birth. This condition con- tinues for a long time and then disappears, the lobulation being repre- sented by the pyramids of Malpighi. A few years after birth the position and relations of the kidney approximate those of the adult (McClellan). Suprarenal Capsules. — The suprarenal capsules are relatively large in size, and gradually approach the adult proportions as the child grows older. Bladder. — Although small at birth, the bladder soon becomes capable of great distention. Symington, from a frozen section which he made in the median plane through the body of a child seven months old, shows the position of the 58 PEDIATRICS. bladder, which happened to be distended. It takes up, practically, the whole of the lower portion of the abdomen, an observation which at once suggests the difficulty of making a correct physical examination of the infantile abdomen during life, unless certain that the bladder is empty. The above fact was strikingly exemplified in a little girl, three years old, who was in my wards at the Children's Hospital. She was sent to the hospital for an ex- amination in reference to the advisability of an operation to remove an abdominal tumor. On inspection, a rounded prominence extending from the pubes to 3 cm. (1J inches) above the umbilicus could be plainly seen. By palpation the tumor could be felt extending from the right inguinal region over to the crest of the left ilium. The tumor was soft, elastic, and fluctuating. It was evidently not in the abdominal walls, but intra-abdominal. The child was said to have been ailing for over a week, and to have grown thin. She passed her urine frequently, but in small quantities. Nothing abnormal was found on an analysis of the urine. Suspecting a distended bladder, a catheter was introduced, and 270 c.c. (9 ounces) of urine were withdrawn. The tumor immediately disappeared, and the abdomen became soft and resonant. A practical lesson to be drawn from this case is, that the bladder should invariably be carefully examined and emptied before diagnostica- ting or operating in abdominal disease. I have seen a distinguished laparotomist neglect this precaution in a young child while operating for appendicitis, and on opening the abdominal cavity cut directly through the walls of the bladder. The urine flowing out through the wound was the first indication to him that he had failed to appreciate that in early life the bladder is essentially an abdominal organ. Stomach. — Many peculiarities of the digestive tract may arise from such causes as the different proportionate stages of development of the parts of the gastro-enteric tract at different ages, and to differences in their peritoneal attachments. The stomach grows very rapidly, and pecu- liarities of shape appear at an early age. I have seen a stomach of four and one-half months which, although small, was relatively broader than in the adult. The adult shape, however, is soon acquired. How perma- nent this may be is as yet unsettled. There is no doubt that great dila- tation may be induced, and it is highly probable that Avhere too small quantities of food are given the normal stomach will contract. It is also very likely that certain shapes are acquired at a very early period. Dwight has shown me in a young child a well-marked antrum pylori, — that is, a pouch above the pylorus, which, in extreme cases, forms almost a separate chamber. It is evident that the clinical significance of our anatomical knowledge of the growth of the stomach in the first year is very great. This question of growth is, in fact, one of the most important factors in the problem of the substitute feeding of infants, and a lack of its thorough comprehension often leads to most unfortunate results. Capacity. — There has been much dispute as to the proper method of determining the gastric capacity during infancy. All methods are open to NORMAL DEVELOPMENT. 59 criticism, but by combining all the methods and making general deduc- tions we can arrive at practical conclusions concerning the size of the stomach at different ages. One of the methods which may be employed is a clinical one. and is as follows : A mother is selected who is young, healthy, has plenty of good milk, and who has a healthy infant of normal size and weight, and appetite according to its age, and one that is thriving. — that is. digesting well and gaining regularly about 30 grammes (1 ounce) a day. The infant is first carefully weighed ; next it is allowed to nurse until it is evidently satisfied. — that is, practically, until it feels that its stomach is full. The infant is then weighed again, and the increase in weight denotes the gastric capacity in ounces of milk. Careful investigation has shown that one fluid ounce of milk weighs very nearly 30 grammes. Certain control experiments have shown that this method of determining the gastric capacity is a practical one. It is well known among those who deal in cattle that when fat cattle are transported long dis- tances, as from Chicago to New York, they are found to have lost materially in weight, perhaps thirty or forty pounds. If these cattle are allowed to fill their stomachs with water, an increase in their weight will be found corresponding exactly to the weight of the water which they have drunk. If a number of healthy infants of different ages and of average weights are fed and weighed in this way, we can approximately, by comparing the gains in weight which correspond to the same ages, determine the gastric capacity for each age. I should not, however, consider this by itself a reliable method for determining the gastric capacity, as it is open to many objections, which need not be discussed at present. One source of error, for instance, is the variation of the infant's appetite, which may cause either too great distention or underfilling of its stomach. Another method is the actual measurement of the gastric capacity at the autopsy, with suitable precautions to avoid over-distention. In this way it has been determined that the stomach grows very rapidly in the first three months after birth, grows slowly in the fourth month, and is then almost quiescent for about two months. It then begins to grow again until it has reached its adult size. Frolowsky's rules for determining the gastric capacity of young infants approximate in their results so closely my own investigations that I have prepared from them figures of infants' stomachs at different ages and at different periods of growth. The tracings of the stomachs are life-size. Frolowsky shows that the activity of the stomach's growth is very great in the first quarter of the first year, that it is very slight in the second quarter, and that it again shows a moderate activity in the last part of the year. He represents this activity of the stomach's growth by the ratio of 1 for the first week to 2J for the fourth week and 31 for the eighth week, while it is only 3J for the twelfth week, 3^ for the sixteenth week, and 3f for the twentieth week. As a starting-point from which to calculate the above proportions I have taken the infant's stomach shown on page 34, Fig. 8, which is also intended to represent an infant of the average birth weight. 60 PEDIATRICS. Fig. 20. Gastric Capacity in the First Five Months of Life. Infant 3 hours old. Capacity of stomach, 25 to 30 c.c. (f to 1 ounce). II. Infant 4 weeks old. Stomach 2% times larger than I. Capacity, 75 c.c. (2% ounces). NORMAL DEVELOPMENT, 61 in. Infant 8 weeks old. Stomach 3^ times larger than I. Capacity, 96 c.c. (3J ounces). Infant 12 weeks old. Stomach 3K times larger than I. Capacity. 100 e.e (3% ounces* 62 PEDIATRICS. Infant 16 weeks old. Stomach 3f times larger than I. Capacity, 107 c.c. (3.56 ounces). VI. _L Infant 20 weeks old. Stomach 3f times larger than I. Capacity, 108 c.c. (3.6 ounces). NORMAL DEVELOPMENT. 53 In comparing these measurements with actual stomachs, the gastric capacity as given for sixteen and twenty weeks is somewhat small. They are. however, extremely valuable to begin with, as it is always better to err on the side of giving too little food than too much. The gastric capacity, according to Fleischmann, is greater at the same age in the artificially fed than in the breast-fed infant. This observation, however, in all probability only emphasizes the importance of bearing in mind the normal gastric capacity of the different ages, and of using this knowledge to prevent the overfeeding which has produced so noticeable a difference between the sizes of the stomach in breast-fed and artificially fed infants. Since the development of the methods of substitute-feeding in connec- tion with milk modification, there is no reason to suppose that when the infant's stomach has been properly managed it is any larger than in breast-fed infants. The cause, however, which produces the most uniform individual dif- ference in the gastric capacity at the same age is the weight of the infant. In general it can be said, the greater the weight the greater the gastric capacity. A good illustration of the correctness of this rule has lately come under my notice, where a breast-fed infant of twelve months with a stomach normal in shape presented a gastric capacity of only 90 to 105 c.c. (3 to 3J ounces). This capacity corresponded to its weight, 4289 grammes (9J pounds), about the average normal weight of an infant at eight or ten weeks, rather than to its age, which in the average infant would present a gastric capacity of 240 c.c. (8 ounces). I have also had under my care an infant of six weeks whose general development and weight corresponded so closely to those of the normal average infant of twelve weeks that it was self-evident that the two ounces of food which would ordinarily have been the proper allowance, so far as the age was concerned, was not sufficient, and that its weight indicated a gastric capacity for an allowance of four ounces, which, in fact, it took and digested with the greatest ease, while with any amount less than the four ounces it was never satisfied. In this connection it is important to note that at autopsies in measur- ing thfe gastric capacity it should be done before the stomach is separated from its mesenteric attachment, as otherwise it is easily stretched by the fluid introduced, and will then show a greater capacity than would be within the normal limits during life. In looking at the following illustra- tions, which represent the actual sizes of a number of stomachs which have come under rny observation, it is interesting also to note the different shapes which these stomachs represent, as some of them are very differ- ent from the usual classical figures represented in books. So far as could be ascertained, these shapes did not occur from any especial disease, such as would influence the outline of the stomach. On examining Fig. 8 (page 34) and Figs. 21 and 22. it is clear that one 64 PEDIATRICS. cannot always depend on an infant's weight for determining its gastric capacity in the early days of life. Thus, the weights of 2500 grammes, 3000 grammes, and 4000 grammes all had the same gastric capacity of Fig. 21. Stomach of infant Z% days old, natural size, Weight, 4000 grammes.. 25 c.c. Again, the weight of 2700 grammes had a greater capacity, 40 c.c., than the weights of 3000 and 4000 grammes. One must, however, also allow that there might be an error in measuring the gastric capacity. Stomach of infant 5 days old, natural size. Gastric capacity, 25 c.c. Weight. 3000 grammes. No rules for growth can be deduced from this very limited number of cases. The significance of these figures will be understood a little later when the feeding of the early days of life is discussed. Fig. 24 represents the stomach of an infant twelve days old. It represents the usual shape and position of the stomach in early life, and has been distended beyond NORMAL DEVELOPMENT. 65 Fig. 23 Stomach of infant 7 days old, natural size (posterior vi 2700 grammes. sapacity, 10 c. c. Weight, Fig. 24. Stomach of infant 12 days old, distended to hold 80 c.c. Natural gastric capacity . 40 c.e. 5 $6 PEDIATRICS. the limit of its normal capacity to show the great elasticity of the ventric- ular walls already referred to. The gastric capacity was about 40 c.c. (1J ounces) : when distended it held 80 c.c. (2| ounces). Fig. 25 shows the stomach, duodenum, spleen, and pancreas of a well-developed infant five months old. Stomach of infant 5 months old (posterior view). Weight, 6000 grammes. Distended to hold 225 c.c Natural gastric capacity, 120 c.c. S marks the spleen ; P the pancreas ; D the duodenum. Fig. 26 shows the stomach of an infant seven months old and weighing 5500 grammes (12 pounds). Its capacity is 220 c.c. (7 J ounces), which corresponds to its age rather than to the weight, which is that of an infant four months old. Another stomach taken from an infant also seven months old, but whose weight was that of an infant four months old, had a capacity of 150 c.c. (5 ounces), which corresponded to its weight rather than to its age. NORMAL DEVELOPMENT. 67 Fig. 2~ shows the stomach of an infant nineteen months old and weighing 6270 grammes (13j pounds). Its capacity is about 300 c.c. (10 ounces). According to these figures the gastric capacity in the third, fourth, and fifth months may appear rather small, and considerable differences will arise in the measurements by different observers. This, however, only emphasizes the fact that the problem of gastric capacity has not been solved by any system of measurement. When all observers have agreed to make use of a mathematically precise and constant pressure in measur- ing the stomach, we may possibly arrive at more uniform results. Even then the degree of elasticity will be found to differ so greatly in the indi- vidual stomach that most diverse measurements will result. There is no doubt that the value of these calculations lies in making us recognize evident changes in the activity of growth at certain periods, in making us allow that great differences arise irrespective of age and weight, in impressing us with the fact that the gastric capacity has been over- rather than under-estimated, and in insisting that more exact clinical observations should be employed to reinforce our anatomical and physiological data. Through the aid of a milk laboratory one may adapt exactly to the apparent needs of the infants, as well as to their age and weight, the amounts of food on wilich they have seemed to thrive. The following figures represent the average amounts of food taken at different periods during their first year by three hundred and forty-one infants. They were all well and strong, of average weight, and all were thriving and steadily gaining during the year. They received only stated amounts of food carefully ordered by prescription at the milk laboratory, and were watched with the greatest care to see when they evidently were hungry enough to have the total amount of their food increased. Of course the opportunity for exact work is almost unlimited where one has a milk laboratory at his command, and it has therefore seemed to me that this method of determining the gastric capacity is an unusually good one, and one which' has never thoroughly been carried out before. The follow- ing case explains the significance of the general figures : An infant was fed with the greatest care both as to the quality and as to the quantity of its food. The following table represents the amount of food given at each meal from birth to ten months : TABLE 11. Amounts of Food in an Especial Case. CUb iet?e e s nti - Oimce. . Birth 30 1 4 weeks 45 1£ 8 weeks 60 2 12 weeks 75 2J 16 weeks 90 3 20 weeks 132 Al . Cubic Centi- n ,„, , lo Age. metres. Ounce*. 6 months 150 5 7 months 150 5 8 months 150 5 9 months 195 6 A 10 months 240 8 68 PEDIATRICS. This case shows the necessity for frequent and great increase of the total amount in the first four or five months, the comparative quiescence of growth in the sixth, seventh, and eighth months, and the increase again in the ninth and tenth months. It does not, however, correspond so closely to my previous results as does this table, in which averages taken from the three hundred and forty-one cases already referred to are given. TABLE 12. Three Hundred and Forty-one Infants fed at the Milk Laboratory. Number of Cases for Average Amount of Food at A £ e - each Age. each Feeding. C.c. Ounces. Birth 45 29.4 0.98 4 weeks .....76 70.5 2.35 8weeks.... 84 96.6 3.22 12weeks 97 118.8 3.96 16weeks 87 137.0 4.57 20 weeks # 86 158.4 5.28 6 months ' 73 171.3 5.71 7 months 56 185.4 6.18 8 months 54 208.5 6.95 9 months 45 226.2 7.54 10 months 33 238.8 7.89 11 months 28 242.0 8.07 In this table the same infant has of course been recorded a number of times at different ages. The whole question of gastric capacity is so closely connected with the subject of infant feeding that it can be spoken of in detail later, when it will be seen to be of infinite importance in our attempts to regulate the substitute-feeding of infants. Intestine. — Small Intestine. — During the first month after birth, it may be reckoned that the small intestine will grow about two feet (about sixty-one centimetres), and a like rate of growth may usually be recorded at the end of the second month of extra-uterine life ; but after that period its development proceeds in a most irregular manner. Thus, in a child of one year the small intestine measured eighteen feet (about five hundred and forty-nine centimetres), while in another, aged two years, the length was only thirteen feet eight inches (four hundred and seventeen centi- metres). Again, in a child aged six years the small intestine was no less than twenty-one feet (about six hundred and forty and five-tenths centimetres) in length, while in another child, eleven years of age, its length was fourteen feet (about four hundred and twenty-seven centi- metres). According to Treves, the great variations which appear so early in the length of the small intestine bear no relation to the growth of the child. They probably depend on the diet. Not only the quantity but the quality of the food is an important factor in the growth of the intestine. The NORMAL DEVELOPMENT. 69 amount of residue, also, and the more or less irritating qualities of the food, must all have their effect. Peyer's patches are found very early. I have seen them at three days and again at thirteen days. In another case, sixteen months old, Peyer's patches were found, and one of them was five inches long. Larg-e Intestine. — Treves has also observed that up to three or even four months the length remains the same, but that nevertheless a remark- able change occurs. This is that the large intestine grows at the expense of the sigmoid flexure, which at birth is nearly one-half of the large intes- tine, while at four months it has assumed about its permanent proportion. Treves found the large intestine to measure at one year two feet and six inches (about seventy-six centimetres) ; at six years about three feet (about ninety-one and five-tenths centimetres) ; and at thirteen years about three feet and six inches (about one hundred and seven centimetres). CcEcum and Ascending Colon. — In about thirty-five observations on children under four years of age, most of them new-born infants, the caecum was found in about thirty cases to range from the right lumbar region to the lower part of the iliac fossa. It was very frequently found at the junction of the rather vague lumbar and iliac regions. More or less would usually be found between two parallel horizontal lines, one at the level of the highest point of the crest of the ilium and the other at its anterior superior spinous process. In five cases the caecum was either in the right iliac fossa or over the true pelvis, the fact being that it was so free as to have no fixed position. It is comparatively recently that the truth has been recognized in America, England, and France that normally the caecum is at every age completely invested by the peritoneum, and that the idea that a large part of the posterior surface rests on areolar tissue without any intervening serous membrane is baseless, except in rare instances. In young children the ascending colon differs in some respects from that of the adult. Owing to the high position of the caecum, to say noth- ing of the relatively greater size of the liver, it is very short. There is no question that the ascending colon much more frequently has a mesen- tery than in the adult, and also that a relatively larger portion of the part above the caecum is also invested with peritoneum so as to be absolutely free. Dwight believes that the caecum of the infant and that" of the young child are much more movable than that of the adult, and are also usually situated higher. Vermiform Appendix. — The length and direction of the vermiform ap- pendix are very variable. I have found it six and a half centimetres (two and five-eighths inches) long in a girl of thirteen days, live and three-tenths centimetres (two and one-eighth inches) in one of three years, eight centi- metres (three and one-quarter inches) in one of ten months, and seven and a half centimetres (three inches) in a girl eleven weeks old. It 70 PEDIATRICS. would appear from Treves' s researches that the fcetal shape of the caecum is that of a pouch hanging down from the point of junction of the small and the large intestine and continued into the appendix, which grows symmetrically from the middle. Later, however, an irregular growth of one side of the caecum generally leaves the origin of the appendix near the end of the ileum. Dwight has found that this condition usually occurs in the child. The position and direction of the appendix are most uncer- tain. It is. however, as a rule, on the posterior side of the caecum. Its little mesentery passes to its beginning from the caecum and is only ex- ceptionally attached to the walls of the abdomen or pelvis. The importance of the lymphatic glands about the caecum as possible starting-points of inflammation is very great. Tuffier states that the lym- phatics of the front of the caecum follow the anterior ileocaecal artery to empty into two glands which he has found constantly in the superior ileo- caecal fold, and which are very distinct in the child. The posterior glands are also found constantly on the posterior and inner wall of the caecum itself beneath the peritoneum. They usually form a group of from three to six. Sigmoid Flexure. — In some cases, according to Dwight. the sigmoid flexure is obviously very long, in others apparently of about the adult relative proportions. Even in infants, in whom the sigmoid flexure does not. as a rule, seem large, it often has a relatively broad mesentery, allow- ing free displacement. Descending Colon. — As is well known, the descending colon usually has no mesentery, but still one is often found. Lesshaft. in his observa- tions made on subjects of many different ages, found it once in six times. Dwight. in rather more than twenty infants, found a mesentery to the descending colon in about half the cases. Lesshaft found a mesentery less often in young subjects than in others. A great part of the large intestines in infants is less fixed than in adults. TEMPERATURE. — The temperature of the infant at term, although varying within a slight limit, is usually slightly raised. Very soon, how- ever, as would be expected from the tax which is immediately made on its vitality by so many new surroundings, the temperature falls rather below the normal adult standard. In about a week the normal infant has recovered its equilibrium, and. if its nutriment has also been properly adapted to its digestive power, it usually presents the average normal adult temperature. 36.8° C. (98.2° F.). TABLE 13. Temperaiun of Infant at Term. At birth 37.2° C. (99° F.). Within an hour 36.1°-35.5° C. (97°-96° ¥.). In about a week , 36.8° C. (98.2° F.). NORMAL DEVELOPMENT. 71 These figures are the average of a large number, and are subject to great variations, as is seen on comparing them with a number of observa- tions undertaken at my request by Dr. C. W. Townsencl at the Boston Lying-in Hospital : TABLE 14. Tovmsend-s Temperature Observations, Age. Temperature. 1 day 37.2° C. (99° F.). 2 days 37.3° C. (99.2° F.). •5 days 36.(3° C (98° F.). 5 days, 37.5° C. (99.5° F.). 6 days 37.3° C. (99.1° F.). 7 days 37.5° C. (99.5° F.). 7 days 37.2° C. (99° F.). 7 days 37° C. (98.5° F.). Age. 9 days 37.4° C. 9 days 37.1° C. 9 days 36.9° C. 10 days 37.1° C. 13 days 37.2° C. 13 days 37.3° C. 16 days 37.3° C. 20 days 37.3° C. Temperature. (99.4° F.). (98.8° F.). (98.4° F.). (98.8° F.). (99° F.). (99.2° F.). (99.2° F.). (99.2° F.). PULSE. — The pulse in uterine life is, as a rule, somewhat higher in girls than in boys, the former being about 130 to 140, and the latter 120 to 130. Anything over 130 points towards the female sex, but these fig- ures as a means of distinguishing the sexes before birth are not to be relied upon. At birth the pulse soon falls somewhat, and may be quite irregular. This, as a rule, is merely what we should expect would be the result of the sudden and great change which has taken place in the circu- latory mechanism, and of the additional force which the heart is called upon to supply when it becomes the central station from which the blood is propelled. The lungs also are scarcely ready to perform at once their function, and are often somewhat more of an obstruction than an aid to the blood-current. The pulse in early life, especially during the first year, varies very much, but, as a rule, allowing that the girl's pulse is usually more rapid than the boy's, the following table represents pretty well what may be expected in males. TABLE 15. Pulse-Rate for Males. Age. Pulse-Beats per Minute. Early weeks 120 to 140 Until 2d year 110 2 to 3 years 100 5 to 8 vears 90 From the eighth year up to puberty the pulse gradually acquires the adult rate. The pulse in children varies greatly under the many nervous influences which are continually affecting it in early life. Townsend has also made a record of the pulses taken in the same infants whose temperatures were recorded in Table 14. They do not especially correspond with the general averages, but are what may be expected in cases seen at random, 72 PEDIATRICS. TABLE 16. Townsend's Pulse Observations. Age. Quiet. Crying. 1 day . 130 158 2 days 120 156 5 days 152 164 5 days 160 6 days 152 7 days 120 154 7 days 160 7 days 152 9 days 148 9 days 160 180 9 days 156 10 days 152 13 days 136 13 days 168 16 days 168 172 20 days 168 RESPIRATION. — The respiration, although quicker in early life than in adults and corresponding somewhat to the pulse, assumes the equilib- rium of a later period of development much earlier than is found to be the case with the pulse. It varies with changes of temperature and with excitement, and has its rhythm much more easily affected by diseased conditions than in later life. The following table represents fairly well what is usually found on counting the respirations when a child is quiet : TABLE 17. Respirations. Age. Respirations per Minute. At birth 45 Until the 3d year 15 to 40 3 to 5 years 25 The following is the record made from observations on a healthy male eight months old, when he was lying quietly on his nurse's lap : The type of respiration was decidedly abdominal. Counting the respirations by the rise and fall of the ensiform cartilage, which stood out quite distinctly, the respi- rations varied from 50 to 70 in the minute. They were, also, quite irregular, and by making with a pencil an upward stroke for every inspiration, a downward stroke for every expiration, and a horizontal line for every pause, the same lack of rhythm was found that appeared in the infant at term, described on page 36, and also the rhythm corresponding to that of the infant nine months old which is described on page 53. Townsend has also observed for me the respiration of four healthy infants at the Lying-in Hospital, with the following results : TABLE 18. 1. Age, 1 hour Respirations, 48 to 56. (Awake. ) 2. Age, 2 days " 30 to 52. (Asleep. ) 3. Age, 3 days " 24, 32, 44. (Asleep. ) 4. Age, 6 days " 28 to 40. (Crying. ) NORMAL DEVELOPMENT. 73 The respiration in all these cases was very irregular, and both ab- dominal and thoracic in type. In the baby two days old the respiration was chiefly abdominal. HEIGHT. — The average height of the male infant at term, is, accord- ing to a large number of measurements made by Quetelet, Vierordt, and others, about 49.5 cm. (19 j inches). These figures correspond very closely to those which I have myself measured. Insufficient nourishment and improper food, especially as represented in rhachitic children, seem to retard the growth, while on the contrary, the various fevers seem to increase the activity of growth in length, while decreasing the total weight. In the first three or four months the growth is proportionally rapid to that in the latter part of the first year. In like manner the activity is greater in the first month than in the second, and in the second than in the third, becoming still less in the fourth, fifth, and six months. The average increase for the first month is about 4.5 cm. (If in.). " " " " second month is about 3.0 cm. (1J in. ). " ' ; third to the fifteenth month is about 1 to 1. 5 cm. ( £ to f in. ) . " " " " " first year is about 20 cm. (8 in. ). " " " " second year is about 9 cm. (3 J in. ). " " " " " third year is about 7.4 cm. (3 in.). " " " " fourth and fifth years is about 6.4 cm. (2-| in.). " " " " fifth to the sixth year is about 6 cm. (2f in.) The height is about doubled in the first six years, and at fourteen years the final height has usually been attained to within about one-twelfth. The height at different ages will be shown in comparison with the weight on page 81. The growth in height seems to be most active in the spring. • WEIGHT. — In quite a number of cases it has been found that the careful and systematic weighing of infants gives warning of the approach of disease some days before any other symptoms are evident. This point was very clearly illustrated in a case which was under my care at the Infants 1 Hospital. The infant entered the hospital to have its food regu- lated. It was apparently perfectly well, but after a few days the daily weighing showed that it was losing. The loss of weight continued to be the only perceptible symptom for a number of days, when it manifested certain nervous phenomena and died a few days later of cerebral thrombosis. We sometimes notice a loss in weight preceding a chronic nutritive disturb- ance by several weeks, and if the coming disease is an acute one. or is of unusual severity, the loss is often sudden and great. The careful and systematic weighing of children may be of considerable A'alue, there fore. in preventive medicine. Thus, if we have noticed that a child has without perceptible cause lost weight, we can, by guarding it from an exposure which in health would not be too great, prevent it from having complica- tions such as of digestion or from cold, and render the coming disease milder in its type and more readily dealt with. In a paper on the Rela- tion between Growth and Disease, by H. P. Bowditch, these changes in 74 PEDIATRICS. weight are especially dwelt upon, and it is apparently shown that this method of determining the onset of the disease is more useful in chronic than in acute diseases, though even in the latter class it is not impossible that the warning may be given in time to be of use, and to merit the term of " danger signal" which has been given to it by Bolton. Bowditch shows in the following table the rate of growth of a girl between two and three years old, and the relation between growth and disease. The figures represent the absolute weight of the child obtained by weighing in the ordinary manner, and then deducting the weight of the clothes : TABLE 19. Age. in Weeks. "Weight. Date. Kilo. Lbs. 1880. September 19 October 3 107 109 114 118 119 121 122 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 11.40 11.40 11.78 12.25 12.28 11.90 12.15 11.80 11.65 11.55 11.55 11.95 11.75 11.94 12.15 12.20 12.41 11.91 11.71 11.98 12.00 12.03 12.01 12.34 12.15 12.09 25.08 25.08 25.91 26.95 27.01 26.18. 26.73 25.96 25.63 25.41 25.41 26.29 25.85 26.26 26.73 26.84 27.30 26.20 25.76 26.35 26.40 26.47 26.42 27.14 26.73 26.60 Enlarged cervical glands noticed February Clay-colored dejections February 12-15. Attack of measles beginning April 5. Cold in the head beginning about May 22. November 7 December 5 December 12 December 26 1881. January 2 January 23 January 30 February 6 February 13 February 20 February 27 March 6 5. March 13... March 20 March 27 April 3 April 10 April 17 April 24 May 1 May 8 May 15 May 22 May 29 An examination of this table shows that the child, having grown rapidly during the autumn, suddenly, and without any manifest cause, began to lose weight about the middle of December. This loss of weight was irregularly progressive until February 6, when an enlargement of the cervical lymphatic glands was noted, followed a week later by clay-colored dejections. These symptoms yielded to appropriate treatment, and the child again gained weight rapidly until March 27, when a sudden loss of weight occurred, followed by an attack of measles. A subsequent loss of weight in May seems to have been associated with a rather severe cold in the head. We have here, then, a case in which a disorder of nutrition NORMAL DEVELOPMENT. 75 manifested itself by enlarged glands and by clay-colored discharges, but in which these symptoms were preceded for several weeks by a progres- sive loss of weight. It seems not unreasonable to suppose that this loss of weight was the first symptom of a disturbance which afterwards mani- fested itself by more unequivocal signs. Even in the case of the acute attack of measles it will be noticed that the loss of weight preceded by at least a week the actual eruption of the disease. It must not be sup- posed, however, that loss of weight in a growing child is in every instance a precursor of actual disease. The weight of a healthy child is liable to oscillation within limits which have not been accurately determined, but it may sometimes amount to ten or fifteen per cent, in a week. Children lose in weight and regain their loss in a wonderful manner, so easily are they affected by even slight physical disturbances, and so great are their recuperative powers. The. weight of boys, as a rule, is somewhat greater than that of girls at birth, and remains greater up to the age of puberty, when the girl rapidly overtakes the boy, surpasses him, and becomes a developed woman very soon, while the boy does not become a man until some years after puberty. This fact is exemplified in the table on page 81, which shows that the girls have surpassed the boys in their height at the eleventh year, and in their weight at the twelfth year, when they are found to be taller and heavier than the boys, as is the case also in the thirteenth and the fourteenth year. The systematic and frequent weighing of infants during the first year of their lives I consider to be of great importance, and far more useful as a means for determining their nutritive condition than any other one method of which we know. For many years I have had the infants at the Infants' Hospital weighed every day as regularly as they are fed, and a glance at the column containing their weights in the various weeks and months gives information as to their general health, and serves as a guide to the changes which it may be necessary to make in their food. The informa- tion gained in this way is far beyond what the most careful physical ex- amination could disclose. The weight is, in fact, an index of the nutri- tive processes to such an extent that it is representative of the child's well-being, while the height gives us information rather as to its cellular activity. The normal average weight of quite a number of infants at term is for males 3250 grammes (7y pounds), and for females 3150 grammes (7 pounds) ; many individual cases occur, however, where the weight is either greater or less than these figures, and yet the infant is healthy. The increase in weight is in direct proportion to the original weight, and if the original weight is small the gain is usually correspondingly small. This, however, is only a general rule, for at times infants of light weight are met with whose gains are remarkably large, and often surpass those of infants with a heavier initial birth weight. During the first three or four days of life there is usually a loss in weight, and the original weight is in a large number of cases regained 76 PEDIATRICS. only in the second week. If it is not regained by the third week, we should consider that it is a warning that the nutrition of the infant is at fault, and that especial measures should be taken to increase its vitality. This initial loss of weight is usually designated as physiological . We must, not, however, be misled by this term, or place too much confidence in it, for, as a rule, this initial loss, which often amounts to from 270 to 300 grammes (9 to 10 ounces) can be accounted for only partially by natural physiological causes. The additional loss is evidently pathological, and is to be so regarded, in order that Ave should endeavor to obviate it, and thus prevent imposing an additional tax on the infant's vitality at a time when any tax whatever should be regarded as serious. Townsend has made some interesting investigations on this loss of weight at the Boston Lying-in Hospital, which show that the infants of primiparae lose about 45 grammes (1J ounces) more than those of multiparae; also, deducting 45 grammes (1J ounces) as the average loss from removal of the vernix caseosa, the meconium still remaining, that the loss in weight is reduced to 247 grammes (8 -J- ounces) in the infants of primiparae, and to 222 grammes (7| ounces) in those of multiparae. The whole loss should in- clude the meconium, which is computed to weigh about 60 to 70 grammes (2 to 2 J ounces), so that a loss of from 90 to 150 grammes (3 to 5 ounces), which includes also the urine, on the first clay, can, in a very general way, be admitted to be purely physiological. Townsend' s figures also show that although the infants of primiparae lose more and are slower to recover the loss than are those of multiparae, yet after the second week they overtake and keep pace with the latter. The whole question is simply one of nutrition, it being well known that the milk of primiparae is somewhat longer in acquiring its equilibrium than that of multiparae, but that finally it is equally nutritious. It was also found that the presence of the colostrum corpuscles in the milk had something to do with the loss or with the failure to gain. Where the colostrum persisted the infants lost more than when it speedily disappeared. The colostrum should normally disappear in the first week. Where its presence is prolonged into the third week, the infants do not thrive. Three cases at the hospital illus- trated this point : all the mothers seemed healthy and had plenty of milk, (1) Multipara — no colostrum on third day, — infant's loss 8 ounces. (2) Multipara — colostrum until ninth day, — infant's loss 16 ounces. (3) Primipara — colostrum until thirteenth day, — infant's loss 14 ounces. The average loss in five infants of multiparae in whose milk the colos- trum was absent by the fifth or sixth day was 10 ounces. The whole nervous system of the young child is much more active and excitable than that of the adult. The brain, for instance, besides being fifteen times as large proportionately in the infant as in the adult, increases with much greater rapidity up to the age of seven years than at any other period. In connection, probably, with the constructive labors of the NORMAL DEVELOPMENT. 77 growing tissues is the activity of the lymphatic system. The absorption of oxygen is said to be relatively more rapid than the production of car- bonic acid. — that is, there is a continued accumulation of capital in the form of oxygen-holding compounds. The food represents so much poten- tial energy, but it must be converted into tissue before the energy can be- come vital, and in such conversion a large amount of molecular energy must be expended. The metabolic activity is more pronounced in the infant than in the adult, and is expended not so much on the energy required in the external world as for the rapidly increasing mass of tissue. Another reason for the presence of more active metabolism in the infant than in the adult is the necessity of rapid molecular interchange to keep up the temperature. The infant having the smaller body, and yet the relatively larger surface (the extent of skin thus being proportionately greater), it loses more heat proportionately than does the adult, and thus suffers more easily from changes of temperature (Foster). Disturbances of the nutritive process from these conditions very easily arise, and the process of assimilation is much more important than in adult life, for the child's activity implies a greater consumption of nutri- ment in the form of food or tissue. The child's equilibrium is thus much more easily disturbed than the adult's, and this creates a greater suscepti- bility to disease and less power to resist external influences. This is well exemplified by the rule that the younger the individual the greater the mortality. There are three times as many deaths in the first half of the first year as in the second half, and a large proportion of those dying in the first half-year die in the first month. Of those dying in the first month, death occurs in a large proportion in the first week. A consider- able number of the deaths which occur in the early weeks of life, espe- cially in the first week, are from asthenia. These facts are very significant in connection with the child's loss of weight in the early days of life over that which we have just described as being physiological. Lack of suf- ficient nourishment and an unstable equilibrium are the factors in the problem which represent this early loss of weight. These conditions are enhanced by the state of the mother, who, exhausted by the process of labor, is not able to supply a food for her infant which is adapted to its sensitive and incompletely developed digestive function. (Evetsky). In addition to these manifest causes for loss of weight, we must con- sider that the new-born infant is much more susceptible to external im- pressions than when after the first weeks its various functions have become adapted to their new surroundings. The whole system is stimulated to greater activity of tissue interchange not only by the sudden change of temperature to which the skin is ex- posed, but also by the change from darkness to light, and from silence to a greater or less degree of sound. This transient early period of life, therefore, is marked by a superactive metabolism, insufficient nourishment. and resulting asthenic conditions which are analogous to starvation. This 78 PEDIATRICS. is represented as a whole by a loss of weight evidently of a pathological character, in addition to that which has been described as physiologi- cal. One will, therefore, understand with what care the newly born in- fant should be protected from too great changes of temperature, too much light, and too much noise. The analogy of this statement is found in the sensitive organization and habits of the lower animals. In this way only can the digestive function be made to correspond to such an extent, in the early days of life, to the work which is required of it, as to keep the loss of weight within the physiological limit. Starvation, as is well known, proves fatal primarily not from the amount of food furnished being too little for the processes of disintegration, but from exhaustion of the ner- vous system. The endurance of the starvation is in proportion to the capability of resistance of the nervous tissue. This nervous tissue is so highly sensitive and has such great functional activity in the infant, pro- portionately to the adult, that it needs much more nourishment, and suc- cumbs much more quickly to deprivation from nourishment. Young ani- mals die in a very much shorter time when deprived of food than do older ones from this cause. It is not surprising, therefore, that when the early period of life is represented only by hours and days, the various disturb- ances which would be of minor consequence at a later period of exist- ence should have a decidedly pathological effect and produce a marked loss in weight beyond the natural physiological loss. The following case exemplifies the practical bearing of what has just been said. A male infant was born December 16 at term. It was healthy and vigorous, and gave no evidence of organic disease. The mother, a multipara, strong and healthy, was twenty-eight years of age. Her other children were living and healthy. On the third day, December 19, the infant had a slight attack of icterus neonatorum, which disappeared in twenty-four hours. On the fifth day, December 21, the weather was very cold and bleak, but the infant was taken to church and christened. The church was warm and the infant reasonably well protected from cold, but there was a large number of people present, and an unusual amount of noise. The infant, on being taken home, immediately began to show symptoms of asthenia, and on the following day was found to be cyanotic and breathing rapidly, with a subnormal temperature and no apparent organic disease. It died in the afternoon. The asthenia seemed to be produced by too early exposure to change of temperature, light, and sound. As a rule, the average daily gain in the first two months should not be below twenty grammes (two-thirds of an ounce). It has been found at the Infants' Hospital that if the gain is less than this the infant, as a rule, is being' badly nourished, is sick, or is going to be sick. There are, of course, exceptions to this rule, and it should be clearly borne in mind that observations of weight including only that of two or three days are very misleading, and that it is the week's weight which gives us the fairest idea of loss or gain. Thus, one frequently finds infants showing a daily gain of only five or ten grammes (one-sixth or one-third ounce), or even losing fifteen or thirty grammes (one-half or one ounce) on one day, NORMAL DEVELOPMENT. 79 and then gaining one hundred to one hundred and fifty grammes (three and one-third to five ounces) on the next day. From this it will be readily understood that we should obtain from one day's observation too low and on the next day too high an estimate of the nutrition. By the end of the week, however, the weights usually equalize each other, and we have fairly correct figures to guide" us. The following table shows about what would be expected of the average infant as to weight during the first year. Girls, as a rule, gain less than boys, but this is only if they are of lighter initial weight. The heavy girls make the same large gains as the heavy boys, but, as a rule, their initial weight is smaller than that of the boys, and they therefore make smaller gains. TABLE 20. General Figures of Weight. Ao . p Weight. Average gain per day. s Grammes. Pounds. Grammes. Ounces. At birth 3000 to 4000 6.6 to 8.8 From birth to 5 months. ... 20 to 30 | to 1 From 5 months to 12 months 10 to 20 J to \ Ase Weight. Grammes. Pounds. At 1 year 9,500 20.90 At 7 years 19,000 41.80 At 14" years 38,000 83.60 [The above figures are on a basis of 3500 grammes (7.7 pounds) at birth, and of a gain of 30 grammes per day for the first four months and 10 grammes per day for the last eight months of the first year.] Useful figures to remember are that the initial weight is doubled at five months and trebled at fifteen months ; also that the weight at one year is doubled at seven years, and that this weight is again doubled at fourteen years. There are, of course, both gains and losses in weight during the year, the weight acting as an index of the disturbances which arise. As a rule, what may be called the line of nutrition rises from the initial weight in the first week up to the fifty-second week. A uniform increase is, however, exceptional, on account of the many disturbances, such as from food, the dental periods, weaning, improper hygienic care, and dis- eases. Instances of continual weekly gains during the first year have occa- sionally come under my notice in both hospital and private practice, and the chart on page 80 gives the exact weights of a healthy male infant fed by a wet-nurse for over a year, and will serve as an example of the ideal line of nutrition. The infant was gaining so regularly that the weighing- was omitted for several weeks, which was unfortunate, as the weights would probably have shown the same uniform gain. A weekly gain is also shown in this same chart of a male and a female infant, brother and sister, nursed by their mother. The double line represents the boy's 80 PEDIATRICS. weights in the first twenty-nine weeks of his life ; and the dotted line the girl's weight for twenty-one weeks. CHART 1. to ht*. en cr; *. \ ^ \ s \ ^ v ~Tv ^ ■£ ^_ - >^ = V- -£*, T ^ _S S \ ^ \ £ \ 5^_ 4 -&.- *r 5^ 5 ^£ \ * \ \ s ^L S X \ i S r v, V V v V \ ^ \ i \ \ \ \ -> \ .. \ „ Name, Date of Birth, June 21. Initial Weight, 4650. dual Wt. Date ol fg, 4,500 June 27. 4,612 July 4. 4,916 " U. 5,332 " 18. 5,684 " 25. 6,004 Aug. 1. 6,292 " 8. 6,644 " 15. 6,852 " 22. 7,172 " 29. 7.476 Sept. 5. 7,802 " 12. 7,994 " 19. 8,170 " 26. 8,362 Oct. 3. 8,586 " 10. 8,912 " 17. 9,136 " 24. 9,376 " 31. 9,968 Nov. 14. 10,912 " 21. 10.912 Dec. 20. 11,680 Feb. 20. 11,904 " 27. 12,032 March 5 40 41 42| 12,544 43 44 45 46 47 48 12,640 Cn OJ -3 00 to 13,104 13,376 Pounds. April 9. April 30. June 1. " 20. The figures for birth, for five months, and for one year represent my investigations, combined with the figures which have already been shown. The figures for the second and third years are taken from a series of in- vestigations made by Peckham, of Milwaukee, in the Report of the Wis- consin State Board of Health for 1882. The figures for the fourth year are approximate averages taken from children of three and five years. The figures from the fifth year to the fourteenth year were taken from Bowditch's article on the Growth of Children, in the Twenty-second An- nual Report of the State Board of Health of Massachusetts. They rep- resent the average figures of a large number of school-children. In the following table the weights at birth, and in the first, second, PLATE II ^} Icterus Neonalorum Red Bone Marrow Natural Size. Yellow Bone Marrow. 3 /+ Natural Size. Erythema Neonatorum. NORMAL DEVELOPMENT. 81 and third years, were taken without clothing. The ordinary school-clothes were worn in the weighing from five to fourteen years. TABLE 21. Average Heights and Weights from Birth to Five Years, and of Boston School Boys and Girls, irrespective of Nationality, from Five to Fourteen Years. Boys. Age. Girls. Height. Weight. Height. Weight. Centimetres. Inches Kilogrammes. Pounds. Centimetres. Inches. Kilogrammes. Pounds. 49.37 19.75 3.25 7.15 Birth. 48.12 19.25 3 15 6.93 61.87 24. 75 6.50 14.30 5 months. 59.12 23.25 6.30 13.86 73.82 29.53 9.54 20.98 1 year. 74.17 29.67 9.00 19.80 84.55 33.82 13.80 30.36 2 years. 82.35 32.94 13.31 29.28 92.65 37.06 15.90 34.98 3 years. 90.77 36.31 15.07 33.15 98.27 39.31 17.27 37.99 4 years. 97.00 38.80 16.53 36.36 103.92 41.57 18.64 41.00 5 years. 103.22 41.29 17.99 39.57 109.37 43. 75 20.49 45.07 6 years. 108.37 43.35 19.63 43.18 114.35 45. 74 22.26 48.97 7 years. 113.80 45.52 21.50 ' 47.30 119.40 47.76 24.46 53.81 8 years. 118.95 47.58 23.44 51.56 124.22 49.69 26.87 59.00 9 years. 123.42 49.37 25.91 57.00 129.20 51.68 29.62 65.16 10 years. 128.35 51.34 28.29 62.23 133.32 53.33 31.84 70.04 11 years. 133.55 53.42 31.23 68.70 137.77 55.11 34.89 76.75 12 years. 139.70 55.88 35.53 78.16 143.02 57.21 38.49 84.67 13 years. 145.40 58.16 40.21 88.46 149.70 59.88 42.95 94.49 14 years. 149.85 59.94 44. 65 98.23 FEET. — According to Dane, the pad of fat that fills the hollow under the bones in the infant's foot is designed to support the arch until the muscles are strong enough to hold it by themselves. The fat in this way acts as a kind of physiological flat-foot plate. As soon as the muscles become strong enough to protect the arch the pad of fat is no longer necessary, and is slowly absorbed, until by the fourth or fifth year the foot presents the same appearances found in the adult. In a few children the pad of fat is found to be wanting, and in many of these cases the arch is so far obliterated that the tubercle of the scaphoid may even rest on the ground. These latter are the true cases of " flat- foot." BONE MARROW. — The change from the red bone marrow of early life to the yellow marrow of a later period begins, according to Minot, before birth, and progresses in each bone from the centre towards the periphery, or in the long bones towards the ends. It begins earlier in the distal bones and then goes on from bone to bone ceniripetally. Concerning the exact time when these changes take place very little is known, and nothing definite. Plate II., facing page 80. shows the red and yellow bone marrow. SKIN. — As the infant grows older the skin changes gradually to a deli- cate pinkish white in place of the decided pink of the early days of life. 6 82 PEDIATRICS. CORD. — The cord should be carefully wrapped in antiseptic absorbent cotton, and no water should be allowed to come in contact with it. It will thus become dry sooner, and will gradually loosen and fall off. FUNCTIONS.— The different functions of the infant, like its physical characteristics, vary considerably as to the time of their development. It is difficult, therefore, to give exact average figures, and, in fact, my obser- vation of individual cases has differed so often from these average figures that we must allow much latitude in stating the proper time for an especial function to develop. Voice. — During the first year of its life the average infant uses its voice merely in crying to express its discomforts and desires. At about the twelfth month it usually begins to enunciate single words, and in the middle or towards the end of the second year it learns to form short sen- tences. Children vary very markedly as to the time when they really learn to talk connectedly, but this is usually accomplished by the third or fourth year, though it is somewhat later before they master the details of language, such as the proper use of prepositions. Mental Impressions. — The infant seldom smiles before the fifth or sixth week, the change of expression of the mouth before that time being usually an indication of some discomfort. In individual cases, however, there is no doubt that the true smile of enjoyment comes earlier, even by the fourth week. The infant usually does not recognize objects before the sixth or eighth week. Its hearing is soon established. The functions of touch, taste, and smell are apparently more or less developed at birth. Lachrymal Glands. — The development of the function of the lachry- mal glands varies considerably, but the infant will usually be found to shed tears when it is three or four months old. I have known tears to appear as early as the first month. They do not at first come every time the infant cries, so that a number of observations must be made on the same individual before deciding whether this function is present. I have also noticed that even older infants do not shed tears with each crying-spell. These facts are at times quite important to remember, as a suppression of the lachrymal secretion occurs where the infant's vitality has been profoundly affected by disease, and a return of the tears is an indication for giving a favorable prognosis, and often that convalescence is about to be established. Sweat Glands. — The sweat glands are developed at about the third to the fifth week. I have seen an infant in the second week of its life suffer- ing so much as to have its circulation seriously interfered with from the high temperature of a bath-room where it was being bathed, while the nurse who was bathing it was perspiring profusely, and was apparently perfectly comfortable. There is, however, a great variation in the time when these glands develop, and at times even in the second week of life I have noticed cases where the head was seen to perspire quite freely. In NORMAL DEVELOPMENT. . 83 certain individuals, therefore, the function of the sweat glands is fairly developed at birth. Salivary Glands. — The saliva is a secretion which is somewhat slow in being established, both in quantity and in its amylolytic property, There is not much flow of saliva in the infant's mouth for the first three or four months of its life, and even when the function of the glands has become so developed that the saliva appears in the mouth in abundance, a comparatively small amount reaches the stomach by being swallowed. It flows out of the mouth over the chin, and until the latter part of the first year, when its amylolytic action has become established, it probably plays but an insignificant role in digestion. The salivary secretion contains a certain amount of ptyalin, but its diastatic powers seem to be in process of development, and this should indicate to us that this function ought not to be forced into use in digestion until it has become much better estab- lished, as towards the end of the first year. Pancreas. — The amylolytic action of the pancreatic secretion is but little, if at all, developed at birth. Towards the end of the first year the function seems to have become fairly well established, and to a degree which will not be harmed by a moderate call upon it for the digestion of small quantities of starch. The pancreatic power of digesting fat also seems to be slight in the early months of life, but to increase gradually and to be well established by the end of the first year. Bile. — The large size of the liver at birth and during infancy is well adapted to the great metabolic activity which is needed for the develop- ment of this period of life. The investigations of Jacubowitsch and Baginski show that the bile in children is poor in inorganic salts, with the exception of the iron salts. It is also distinguished by its small amount of cholesterin, lecithin, and fat, and the smaller percentage of its glyco- cholic and taurocholic acids, as compared with the bile of later life. The bile acids have the property of arresting pepsin digestion, and thus the small amount of bile acids present in infancy favor the action of the gastric juice, whose feeble ferment would otherwise be neutralized. The incomplete assimilation in infancy of very fatty food, such as creamy milk, is clue to this lack of bile acids, for the latter aids in the emulsification of fat and its decomposition into fatty acids and glycerine. The feeble an.iseptic properties of the bile in infancy and the resulting danger of intense fermentation of the intestinal contents is due to the lack of bile acids. LYMPHATIC SYSTEM. — The high development of the lymphatic system in early life is very marked. According to Foster, not only are the lymphatic glands largely developed and more active than in the adult (as is probably shown by their tendency to disease in youth), but the quantity of lymph circulation is greater than in later years. The observations of Kramstyk show that particles of fat are very easily absorbed in early life. Brunner's and Lieberkiihn's glands are only partially developed PLATE IIL A. Intertrigo. B. Seborrhoea capitis of infants. C. Cord, 24 hours old and 6 days old. Napkins. 1. Detritus of uric acid infarction (stain on napkin during early days of life). 2. Meconium. 3. Color of faeces resulting from good human breast-milk. 4 (( it C< Ct li It cc 5. Crystals of uric acid and urate of ammonium (hedgehog crystals) taken from 10. 6. Substitute feeding. Pat, 2 per cent. ; milk-sugar, 5 per cent. ; proteids, 1 per cent 7. " " " 3 " "6 " " 1 <: 8. " " » 4 " "7 " " 1 9. " " " 4 " "7 " " 1 " 10. Detritus of uric acid infarction in excess. 11. Bile-stain on napkin. 12. Color of faeces after bismuth 3 grains was given every two hours for six doses. 13. " " " " 4 " " " " 14. " " " " was omitted for twenty-four hours. 15. Color on napkin commonly seen, but in this case excessive in amount and patho- logical from uric acid. 16. Color of " clay-colored" faeces. 17. Color of the change in milk-fed (breast or otherwise) infant's faeces which may occur just before or just after they are passed (not necessarily pathological). 18. Pathological color as seen in case described on page 809. 19. '• « " '■ •• •• . « 84 PLATE III P \ <* & r NORMAL DEVELOPMENT. 85 in early life : the solitary and agminate follicles are rich in lymphoid tissue. THYROID.— The thyroid body is relatively greater in the infant than in the adult. URINE. — The function of the kidney begins quite early in foetal life, and the bladder has been found to be full of urine at birth. The urine is small in amount at birth, and during the first twenty-four hours it is not uncommon to find little or none passed. The urine which is first passed is usually dark, cloudy, and acid ; later it becomes clear, pale straw-yellow, and usually of neutral reaction. Its specific gravity (1.010 at birth) falls in two or three days to 1.003, by about the fifteenth day is found to be 1.006, and rises from this time steadily till puberty. By the end of the first week and throughout childhood the amount of urine passed in twenty-four hours is relatively greater than in adult life. This in early infancy may be due to the preponderance of liquid food, but is in part the result of the infant's more active metabolism, for the urea is also found to be proportionately increased. According to Foster, the presence of uric and oxalic acid in unusual quantities is a frequent characteristic of the urine of children. It is also stated that the phosphates are deficient, being retained in the body for the purpose of building up the osseous system. The chlorides, sulphates, and urinary pigments are less abundant than in the adult. The proportion of salts increases as soon as a mixed diet is given and closely approaches to the normal proportion for adults. Indican is normally absent in breast-fed infants ; in others it is usually absent unless there is a disturbance of digestion. The uric acid infarction, which has been referred to, and evidences of which may last for two or three weeks, consists of urate of ammonium (hedgehog crystals), amorphous urates mixed with uric acid crystals, and some epi- thelial cells (Plate III., facing page 84). The variations in the amount of urine which has been computed to be passed during the early clays of infancy and childhood are very great, as the amount in all probability depends very largely on the quantity of liquid ingested, and also upon the activity of the skin and bowels. It is well, however, to have some general idea of the normal total amount of the urine at different ages in order to understand better the diseased conditions of the kidney. The difficulties in accurately measuring the amount of urine excreted by very young infants are such that few positive statements can be made as to the quantity. It is sufficient to say that it is about ninety cubic centimetres (three ounces) a day for the first few days, and then rises in amount very rapidly. Rietz and Cruse state that during the first few days of life the urine contains more or less albumin, and that this disappears at about the seventh or eighth day. It also frequently happens that the first urine that is passed is cloudy. Sugar is occasionly found in the urine of healthy infants during the first two months. 86 PEDIATRICS. The following figures, compiled in part by Holt, are the averages obtained by combining the results of the investigations of Schabanawa, Cruse, Camera, Pollak, Martin-Ruge, Berti, Schiff, Herter, Yierordt, Renault, and others : Days Months Years } Daily Quantity of Urine in Health. Specific Gravity. TABLE 22. Ratio of Uric Acid to Urea. o-60 c.c.... ) 1.010-i.or: 10-90 " .... >- 1 to 14 90-250 150-400 1.004-1.008 1 to 60-80 . 210-500 250-600 500-800 " 600-1200 9 10 11 !► 1000-1-500 ' 12 13 14 1.008-1.016 . 1.012-1.020 . L 1 to 50-70 1 to 45-60 . Daily Quantity of of Urea in Gin. 0.076-0.114 . . 6.146-6.660 '. . , Quantity of Urea per Kil. of Body Weight. 0.0205 0.0919 . 0.23 . . . 0.90-1.40 i 3.0 (?) i 6.5 (?) : 13.09 to 14.01. 16.05 to 21.03. Bov, 1.017 Girl, 0.961 Boy, 1.06 0.811 0.61 0.88 0.606 No. of C.C. of Urine for each Kil.ofBody Weight. Adult 0.55 Boys, 53.03 Girls, 48.00 Boy, 78.00 " 47.06 75.64 23.12 .28.66 The urinary sediment of the young infant shows on microscopical examination mucus, many epithelial cells, crystals of uric acid, urates, and calcium oxalate ; also amorphous urates, occasionally a few hyaline casts, and rarely a granular cast. The urine of later infancy and child- hood has no microscopical peculiarities. INTESTINAL DISCHARGES.— The contents of the intestine con- tinue to be mixed with meconium for three or four days or a week, the longer time being when the infant is weak and does not nurse well. After this time the infantile discharges, which have a characteristic appearance as distinguished from those of the older child, appear. It is necessary to be familiar with their characteristics, as they are an important guide to the proper feeding of the infant and are an index showing whether the food is properly digested and assimilated. When the nutriment is milk, with the percentages of its different elements corresponding to what is normally found in good average human milk, the discharges are of a golden yellow color, smooth, unformed, of medium consistency, showing a large pro- portion of water, and sometimes changing on exposure to the air to a Fig. 29. Infant at term, showing large head, large ante- lniarit at 19 months, showing large head, small rior fontanelle, small thorax, cartilaginous ster- anterior fontanelle, ossification ot sternum, tilted num, tilted pelvis, and bow-legs. pelvis, and straight legs. Warren Museum, Harvard University. NORMAL DEVELOPMENT. 87 greenish yellow. They as a rule contain undecomposed bile-pigment and bile-salts, while the older child's and the adult's discharges do not contain the bile undecomposed. The amount of faecal discharge in the first day of life is about forty-five grammes (one and one-half ounces), and in- creases in the following days to fifty grammes (one and two-thirds ounces). It consists of mucous, fat, epithelial remains, and a slight amount of albu- minoid material. In early infancy there are from two to four discharges daily. As the child grows older there are two and finally one in the twenty-four hours. They do not lose their yellow color until amylaceous or albuminous food is given, when the different shades of brown begin to appear. They are not formed until something besides milk is swallowed. Starting at birth with the sterile meconium, infection by the mouth and rectum quickly occurs, and in a short time almost any form of bacteria may be found in the discharges, but chiefly such putrefying forms as pro- teus vulgaris (Jeffries). With the suckling of the infant and the substitu- tion of the refuse of the milk and the secretion of the digestive tract for the meconium, a sharp transition occurs. Instead of the generally dis- tributed forms, causing decomposition, only two kinds of bacilli are now regularly found, the bacillus lactis aerogenes and Brieger's bacillus, the first chiefly in the upper parts of the intestines, the second in the lower part. When the infant begins to take a mixed diet, quite a number of forms of bacilli appear, among them the streptococcus coli gracilis, the putrefying green fluorescing, a tetrad coccus, and several kinds of yeast. The color of the infantile intestinal discharges when the nutriment is milk alone, whether human or animal, seems to depend somewhat on the per- centage of fat, as is seen in Plate III., facing page 84, where the color resulting from the food containing different percentages of fat is repre- sented in Nos. 3, 4, 6, 7, 8, and 9. INFANTILE SKELETONS.— Fig. 28 represents the skeleton of an infant at term, and Fig. 29 that of an infant at nineteen months. These skeletons illustrate some of the differences which occur in the bones during their process of development. In the younger subject the head is large in proportion to the small thorax, and there is a lack of development of the face in comparison with the head, which is very evidently due to the rudimentary development of the jaws. The anterior fontanelle is widely open. On examining closely the sternum it will be noticed that it is not in one piece, as in the adult, but that the centres of ossification with the intervening cartilaginous connec- tions are well marked. The pelvis is tilted forward, as compared with the adult's, and is small and contracted. The legs are not straight, as in the older child, but show decided bowing of the tibia and fibula. This characteristic condition of the legs in intra-uterine life is present a( birth and continues for some months, the bones usually becoming straight by the time that the period of walking has been reached. In the skeleton of the infant nineteen months old, the legs have developed naturally in their 88 PEDIATRICS. growth and are straight. The pelvis still tilts somewhat, but is evidently less contracted, or rather has begun to enlarge. The thorax has broad- ened in comparison with the head, and the cartilaginous sternum has become to a large degree bone. The head is still large proportionately to the face, although the jaws have developed considerably beyond what is seen at birth. The anterior fontanelle is quite small in comparison with the fontanelle of the new-born infant. These are the chief characteristics of the infant's and child's skeleton. NORMALLY DEVELOPED INFANTS.— One of the greatest draw- backs to the proper appreciation of the kind of knowledge which is needed to examine and treat children successfully and intelligently when they are sick, is the lack of precise facts concerning healthy children. It is therefore important to know at a glance whether it is normal for a child not to sit alone or not to stand alone, and to understand its childish actions, whether in creeping or in walking. The ages at which infants develop so as to gradually become chil- dren are important to determine, for it is just as wrong to task by prema- ture use the function of locomotion as that of digestion. A normal infant should hold up its head without support at the second or third month ; it should sit alone at from seven to nine months, creep at about ten months, stand at about twelve months, and walk at about fifteen months. TOPOGRAPHICAL ANATOMY OP THE EARLY PERIODS OP LIFE. — It is important, for purposes of diagnosis, to recognize the fact that the organs differ in the space which they occupy in the body accord- ing to the stage of development of the child. Well-marked periods are thus shown to exist by physical examination as well as by anatomical re- search, and the results of these different methods of investigation are found to correspond. I have always found that a careful consideration of the period of development is of the first importance when beginning to make a diagnosis of disease, especially of the heart and lungs. The large size of the liver in infants and the comparatively greater proportionate size of the heart to the lung in the middle years of childhood are striking in- stances of the truth of this statement, and should warn us that more than ordinary care should be employed in diagnosticating a pneumonia of the right lower lobe behind in infancy, or a dilated heart in childhood. Three periods of growth are of especial significance in this connection : 1. A period corresponding to the development of the organs in the first year, especially in the first half of the year. 2. A period occurring during the fourth, fifth, sixth, seventh, and perhaps eighth and ninth years. 3. A period embracing the later years of childhood. Figs. 30 and 31 represent the first period. This infant, seven months old and normally developed, has, outlined in black, the principal points both in front and be- hind which will be useful to remember when making a physical examination at this age. NORMAL DEVELOPMENT. 89 lu Fig. 30 the plain dark lines have followed the lower margin of the ribs and the outline of the ensiform cartilage and manubrium. To the left of the lower pari of the left sternal line is a small curved line. This represents the absolute dulness of the heart. The relative dulness is very slight, and indeed almost imperceptible, Fig. 30. Pig. 31. Normal infant seven months old. even on light percussion over the sternum. This area of dulness can almost be covered by the end of the fmger used for percussion. It is bounded by the fourth rib or third interspace above, and is just within the mammillary line. There is A'ery fair resonance under the whole length of the sternum. The interrupted lines represent the upper and lower borders of the liver. There is not much to say about the upper line, but the lower one is interesting and instructive as illustrating the large size of the liver in early infancy, and how little of the stomach, which is here represented by a dotted line between the edge of the liver and the left border of the ribs, is to be reached by percussion. The stomach is, of course, in this infant, empty. When full, it comes out much farther under the edge of the liver. This general idea of its position, however, is very important when we come to consider cases of improper feeding where we have to determine whether we have a dilated stomach to deal with. The broad black line just above the level of the umbilicus marks the transverse colon, which in infancy has a relatively low position. The caecum, which is marked by a black circle, stands high in the abdomen, near the anterior superior spine of the ilium. The upper piece of the sternum is also outlined, as is the clavicle and first 90 PEDIATRICS. rib. Fig. 31 shows the same infant's back; the lower borders of the thorax, the kidneys, and the lower borders of the lungs are outlined. The left kidney is de- cidedly higher than the right at this age. While the lower border of the lung on the left comes down as far as the tenth rib, the corresponding border of the right lung, owing to the large size of the liver, descends only as far as the ninth rib. Figs. 32 and 33 represent a child in the second period of its growth. In this middle period of childhood the heart has developed more rapidly proportionately than the lungs, and takes up more space in the anterior portion of the thorax. Fig. 32. Tig. 33. s Normal development at six years. He was six years old, properly developed for his age, and presented certain points of interest which differ from the infant and the adult, and which should be carefully taken into account when we are making a physical examination at this age. The manubrium, the clavicles, the first and second ribs, the ensiform cartilage, and the lower borders of the thorax are marked in black. The area of cardiac dulness is far greater than in the infant, Figs. 30 and 31. The dulness should, so far as the sternum is concerned, be determined by light percussion directly over the sternum from above downward. In this way we can detect the change in the percussion note over the lower part of the sternum better than by percussing from the lung to the sternum, NORMAL DEVELOPMENT. 91 since the former is so much more resonant that the sounds are more difficult to dis- tinguish and are often misleading. The upper resonant part of the sternum, on the other hand, presents an excellent opportunity for comparison, and hrings out the delicate shades of sound which are needed in getting the relative dulness. This relative dulness. however, is usually pronounced under the lower part of the ster- num in this period of development, and it shades off into the absolute dulness of the precordia. Absolute dulness under the sternum, unless depending on pathological conditions, is rare even at this age, when it is also rare not to have this physiological relative dulness. In this period the dulness of the heart extends higher in the left parasternal line than at any other time of life. The lower border of the third rib usually marks the upper border of the absolute dulness, which extends also to the left sternal line and keeps well within the mammillary line. The relative dulness, on the other hand, reaches as high as the lower border of the second rib. It then passes to the right under the upper third of the sternum, descends obliquely to the fourth right costal cartilage, and then keeps closely to the right sternal line. To the left it extends well out to and perhaps a little over the mammillary line. This is a far different result of percussion from that which is found in the adult, and also in the infant represented in Fig. 30, in whom there is no dulness under the ster- num and the absolute dulness rises only as high as the fourth costal cartilage in the left sternal line, and the relative dulness only to the third interspace. The relative dulness also extends only as far as the mammillary line. The impulse of the heart is usually found a little higher in infants and in young children, irrespective of these periods, than in older children and in adults. A much smaller space is occupied at this age by the liver than in infancy. The liver is indicated by the double line, which rises as high as the fifth rib in the mam- millary line, and to the attachment of the sixth or seventh right costal cartilage to the sternum. The dotted line of the stomach, on the other hand, occupies a much larger space than in the infant. The line of the transverse colon stands proportionately higher, the caecum rather lower. Fig. 33 shows the lower border of the right lung still to be a trifle higher than that of the left, and to come to about the upper border of the tenth rib, while on the left side it extends to the lower border of the same rib. At this age the liver has diminished in size relatively to such an extent that the differ- ence of the position of the lower borders of the lung is but slight. The kidneys are about on a level on both sides. The first and twelfth dorsal vertebrae are also indicated as landmarks. This child is passing through transitional stages of physical development, and is gradually approaching the adult type of per- fected growth. Perfected growth, so far as the topography of the organs is concerned, is reached in the third period represented in the last years of childhood and at about the age of puberty. The organs of the child seem at this age, although they have not yet acquired their complete growth, to present for purposes of percussion the outlines which we are accustomed to see in the adult, with the exception possibly of the position of the caecum. Fig. 34 shows a normally developed boy, twelve years of age, and illustrates re- markably well the relative topographical correspondence of later childhood and adult life. As in the boy of six years, the manubrium, clavicle, first and second ribs, ensi- form cartilage, and the lower borders of the thorax are outlined in black. The curved line passing up the left sternal line to the fourth rib and keeping within the mammillary line marks the absolute dulness of the heart, and corresponds to the topog- 92 PEDIATRICS. raphy of the adult's heart. The upper line of the liver is about at the level of the fifth rib in the mammillary line, and does not extend beneath the lower border of the ribs, but is just below the tip of the ensiform cartilage. The dotted line represents the stomach. The spleen has its upper border at the ninth rib. and its lower portion comes down as far as the lower border of the eleventh rib. The caecum is marked Fig. 34. Fig. 35. Normal development at twelve years. in the upper part of the right groin. The transverse colon is about midway between the stomach and the umbilicus. Looking at this same boy from behind (Fig. 35), it will be seen thai the kidneys and the lower borders of the lungs are in about the same relative position as occurs in the adult. I have also indicated the first and twelfth dorsal vetebrae. These representatives of the normal development of important periods of life not only were carefully mapped out by myself by percussion and in accordance with the anatomical knowledge which we possess on this subject, but also were verified by Professor D wight, who examined each child carefully and satisfied himself that my marking was correct. NURSERY. — Before undertaking to treat the various diseases of early life, it is of great importance to acquire a practical knowledge of the care NORMAL DEVELOPMENT. 93 of the infant and child in health. It is essentially in the nursery that we should study the healthy child, as the nursery is its home, where it feels most at ease and behaves in the most natural manner. The general hygiene of the child is represented in its nursery, and we should therefore by our knowledge and advice so direct these questions of nursery hygiene as to give this sensitive, easily impressionable young human being the best opportunity to develop into a healthy and vigorous adult. We cannot, of course, in every case procure for the child the surroundings which are best for it, but we can at least impress on the parent what these surround- ings should be. and how important they are for the general health of the child. The nursery should be high from the ground and out of reach of the dampness which arises towards the latter part of the day. Sun and Windows. — It should have a sunny exposure and large win- dows high enough from the floor to avoid having the younger children continually pressing their faces against the glass to look out, and thus frequently catching cold from the little currents of air which penetrate most window-casings. The mothers often overlook this simple manner of catching cold, and wonder how their children, who are so closely watched, could have contracted the catarrhal conditions which arise in this way. Papers and Carpets. — It is much better not to have a paper on the walls or a carpet on the floor. Young children are very susceptible to inhalation poisons, and to organisms of all kinds. Many a case of anaemia, nasopharyngeal catarrh, and stomatitis ulcerosa has apparently arisen from arsenic in the paper. Dust also, with its multitude of organisms, which with the most careful sweeping it is impossible to get rid of, is an- other source of irritation to the respiratory tract. Even small amounts of arsenic in the contents of the house appear to affect certain children, and the paper itself is a receptacle for micro-organisms which are difficult to eradicate. Picture-Mouldings. — It is advisable not to have any picture-mouldings on the walls, as they are a place for dirt to gather which it is impossible to remove properly. Floor. — There should be as few cracks as possible in the floor, and it should be smooth, so as to be easily cleansed. The floor, however, should not be highly polished, for children frequently fall while playing, and sometimes quite severe accidents occur in this way. Walls and Ceiling. — The floor, the walls, and the ceiling should be painted. Not only can they then be frequently washed and scrubbed, but when the child happens to have any of the contagious diseases, the whole room can so easily be disinfected that it saves much trouble and expense. r ugs . — A rug is desirable in the middle of the room. It should never be an antique ; in fact, it is better to have new, simple carpet rugs. The rugs should not be too large nor too heavy to be frequently taken out into the open air and thoroughly beaten. 94 PEDIATRICS. Bed. — The child's bed should be iron, painted so that it can be care- fully cleansed by wiping, and its sides, as the child grows older, should al- ways be kept high enough, by some simple contrivance, to prevent the child from climbing over them. As Fig. 36. f ew hangings and useless curtains, with which the mother is usually so desirous of draping the bed, should be used as possible. Fig. 36 represents the bed used in the wards of the Infants' Hos- pital, and it is to be noticed that the bed is of such a height that the infant can be easily handled and examined when sick by the physician without his stooping much. Having the bed high from the floor serves another purpose, — namely, that the draughts from the windows and doors pass under the bed rather than on to it. Pillow and Mattress. — The pillow and mattress should be of felt, folded so as to be soft and comfortable, and pillow and mat- tress cases should be used. When this is done the felt can be unfolded and aired every day, and both the felt and the cases washed and boiled when necessary. The mattress should be protected by a rubber sheet. Especial precautions should be taken that the child does not kick off the clothes at night. It is well for the nurse's bed not to be close to that of the child. This entails a little extra trouble on the nurse's part, but her breath is not a healthy pabulum for the child's lungs, which require fresh, pure air of their own. Closets and Drawers. — The child should have its own closet and its own bureau-drawers. The nurse's belongings ought to be kept in a separate room. The closets and drawers should be cleansed at least once a week. Furniture. — There should be sufficient furniture in the room for com- fort, but stuffed furniture should be avoided. As little as possible that is complicated or cumbersome should be kept in the child's nursery. Curtains. — Only simple muslin curtains, which can be washed, should be used at the windows. Toys. — As a child puts everything that it gets hold of into its mouth, care should be taken not to allow it to have toys with colors that can be Infant's bed, Infants' Hospital. NORMAL DEVELOPMENT. 95 soaked off by its saliva, which would perhaps poison it. Toys also which are made of woollen materials or of feathers should be avoided, as parti- cles easily come off them. Heating and Ventilation. — The heating and ventilation of the nursery are of great importance. The child requires pure, warm air. The tem- perature of the room can vary somewhat according to the climate, but, as a rule, the average should be from 18.8° to 21.1° C. (66° to 70° F.). The open wood-fire is best both for the character of the heat which it gives, and for its value as a means for promoting ventilation. A plain piece of wood the width of the window, about 10 cm. (4 inches) high, and made to fit closely to the window-sill, is the best ven- tilator, but is rarely needed where a wood-tire is burning in the room. The upper sash can also be lowered for a few inches if more air is needed. Draughts. — We must take into consideration the currents of air in the nursery, so that the mother, understanding the atmospheric conditions which surround her child, can give the simple directions, which she has learned from us, to the nurse. This is by no means an unnecessary pre- caution, for one of the worst cases of rheumatism in the hip-joints which has come under my notice was that of a child two years old who was allowed to sit on the floor with its back to the open door, and directly in a line with the open fireplace. The direction of the currents of air between the doors, windows, and open fireplace is admirably and scien- tifically described by Mr. John Pickering Putnam in his valuable work entitled " The Open Fireplace," in which the direction of the cold-air cur- rents is shown to enter the windows, descend to within a few inches of the floor, and then to radiate towards the open fireplace and doors. If the child is much on the floor, a sheet can be placed over the cracks of the door ; and plain w T hite sheets are always the best articles for screens or portieres. Where the current of air is too strong it can be tempered by pinning a towel across the opening between the upper and the lower sash. This should at once suggest to the mother that parts of the room, on account of these currents of air which from doors and windows pass over the floor to the fireplace, should be avoided not only for bathing but also for playing on the floor. A high fender covering the entire opening of the fireplace, and fastened so that the older child in playing cannot pull it down, is an important part of the nursery equipment. It answers two purposes. — one to pre- vent the sparks from flying out on the child, the other to prevent the child from falling into the fire. Serious accidents have happened from a lack of proper precaution regarding this apparently self-evident necessity. The hot air from the fire radiates in all directions into the room. Scales. — Properly adjusted scales are an important part of the nursery equipment. The scales which are usually provided arc. as a rule, very 96 PEDIATRICS. inadequate for the minute and daily weighing, the results of which are at times of such great assistance to the physician in the management of the infant's food. Never hang an infant in anything on a hook to weigh it. Such weights are usually, from the continual kicking of the infant, quite incorrect. Do not think that the kitchen grocery scale is good enough for the infant. We can afford to have incorrect and approximate grocery weights, but cannot afford to apply these methods to the growing infant, with its unstable equilibrium. The scales should be of a small but solid platform variety, which can be placed on a firm table by the tub where the infant is to be bathed, for use before the bath. The scales should weigh as low as four or five grammes (one drachm). A basket, with a small soft blanket lining it, is placed on the platform of the scale, and the naked infant is weighed in the basket. The scale is balanced, and the infant immediately taken out of the basket without stopping to read the weight, so as not to expose it too long while uncov- ered. When the infant has been dressed the scale can be read, and the balance-weight minus the weight of the basket and blanket (which can, of course, always be a constant quantity) gives us the exact weight. Weighing with the clothes on is a very unsatisfactory procedure. BATHING. — The question of the bath is of a good deal of importance in the early months of life. Unless there is some definite contra-indica- tion, an infant should be bathed every morning. The contra-indications are if the skin or nails turn blue, or if the infant seems in any way to show symptoms of weakness or lowered vitality after bathing, such as are represented by cold extremities and nose, or an unusually quickened res- piration. In these cases sponging, merely sufficient for cleanliness, is to be substituted for the bath. The bathing should be done with celerity, the tub being placed on the side of the fireplace opposite from the win- dow, and fronting the latter, so as to avoid draughts and insure a good light. The nurse should sit with her face to the light and have the in- fant on her lap, wrapped up in a warm blanket, with its feet towards the fireplace, and its head in such a position as regards the window as to avoid having too much light in its eyes. There should be a rack for the towels, which should be kept warm in front of the fire while the infant is being bathed. The clothes should in like manner be neatly spread out on another rack, ready to be put on as soon as the infant has been dried. Temperature of Bath. — The water should vary in its temperature somewhat with the age of the infant, but should never be so cold as to cause blueness or cold extremities. We must also be careful not to have the water too hot, as this has sometimes proved to be injurious. Each infant, however, must have the temperature of its bath adapted to its own vitality. A convenient bath thermometer is one which is guarded from breaking by a wooden frame, which also allows it to float in the water, and the nurse is thus enabled to see at a glance that the bath-water is NORMAL DEVELOPMENT. 97 remaining at the proper temperature. The following table may be taken as a guide : TABLE 23. Temperature of the Bath for Different Ages. Age. Centigrade. Fahrenheit. At birth 3D. 0° 98° During first three or four weeks 35° 95° One to six months 34° 93.2° From six to twelve months 32.2° 90° Twelve to twenty-four months 30° 86° Then gradually reduce in summer to 26.6° 80° In the third or fourth year, if possible, reduce to . 23.8° 75° The nurse should first wash the face in clear water, keeping the body and limbs wrapped up in a warm blanket. The face is then wiped with a soft towel. She should gently cleanse the nose, the corners of the eyes, and the external ears. The nose is especially important, for the infant's vitality is easily affected by occluded nares. The nurse should then soap, wash off, and dry the scalp. The sponge and water in the other division of the bathing basin are then used for soaping the body and extremities. Especial care should be paid to the folds of the neck, the axillae, groins, genitals, and anus. The temperature of the water in the basin and bath should be taken from time to time with the wooden bath thermometer until the washing is over. The proper warmth of the water is to be kept by adding when - necessary a little hot or cold water from cans within easy reach. Tub. — The tub, which is preferably made of rubber hung on a simple wooden frame and sufficiently high to prevent needless stooping on the part of the nurse, is placed on the nurse's left, at a convenient distance from her chair. Basin. — In front of the nurse is the double washing basin, which is merely a china basin divided into two compartments, and fitted to a wicker stand, also sufficiently high to prevent the nurse from stooping as she uses it. To the right of the nurse is the table, with the scales on one end and the toilet basket on the end towards her. Soap. — The soap should be white castile, or any kind which is free from irritating elements. Sponges. — There should be two sponges : one goes in one side of the washing basin, and is for the head and face ; the other is to be used in the opposite side of the basin, and is for the body and extremities. The body and limbs having been thoroughly and quickly soaped, the nurse should gently lower the infant with its face up into the clear water in the bath, being careful not to frighten it or to drop it. This is not an unnecessary warning. I have known infants, even in the hands of ordinarily careful mothers, to be dropped from the bath or scales, with a resulting perma- nent injury of the spine or hip. After allowing the infant to kick and 7 98 PEDIATRICS. splash for a few seconds, it is taken back into the nurse's lap and care- fully dried with a warm, soft towel. Never soap and wash the infant in the bath, but always on the. lap. Powder. — When the skin is perfectly soft, clear, and in a normal con- dition, no powder is needed. Where there is any slight irritation, which, at times, is liable to occur when the skin has not been kept sufficiently dry, especially if there is a decided redness in the folds of the skin, as of the neck, axillae, or groins, the following powder can be applied : Prescription 1. Metric. Apothecary. Gramma. R Pulv. zinci oxidi 7 15 R Pulv. zinci oxidi ^ii ; Pulv. amyli trit. 60 j Pulv. amvli trit ^ ii. M. M. No perfume of any kind should be added to the powder. The infant should be sweet and pure in itself, without accessory odors. CLOTHING. — It is very important that those who care for the infant should not only clothe it properly but should understand why one method of clothing is better than another. The surface of the infant's body is greater in proportion to its entire weight than is the case in the older and hence larger human being. Greater surface means that there is a greater opportunity for radiation, and hence that the smaller subject will cool off more quickly, other conditions being equal, than the larger one. We therefore see at once that much care should be given to the question of warmth in the infant. Any exposure of the body or limbs in either in- fants or children is unwise. A very important factor in the problem of growth in the infant is perfect freedom of motion for its legs and arms and for the respiratory and abdominal muscles. It should also be thoroughly understood that pressure on any portion of the body or limbs must pro- duce evil results, by displacing organs which should be allowed to have entire freedom of position in their respective cavities. Too litttle warmth will do harm, by preventing the proper metabolism of the tissues and thus reducing the animal heat. Too great warmth, on the other hand, by causing inequalities in the circulation, will in like man- ner be detrimental to the child's growth and vigor. Clothes which bind any part of the infant tightly cannot but press out of their natural position whatever happens to be beneath the point of pressure, whether it be the liver, the intestines, or the toes. The clothes, then, must evidently be warm and loose, and we must bear in mind that loose clothes are warmer than tight ones, from the very fact that they do not interfere with the natural activity of the circulation, and that they give freer play to all the muscles which produce the normal warmth arising from exercise. We must remember that the only way in which the infant can obtain the exercise so much needed for proper growth, and which is so easily ob- tained by the older child in running about, is by continually moving its NORMAL DEVELOPMENT. 99 legs and arms and thus accelerating- the muscular action of its thorax and abdomen. An important item in the proper management of the infant in its nur- sery is that it should be irritated as little as possible by unnecessary delay in dressing it after its bath. Useless stitches, buttons, and articles of clothing should be dispensed with, and a method adopted which, while combining the necessities of dress, will allow the dressing to be finished before it has time to annoy the infant. Abdominal Band. — There is no necessity for using beyond the first two or three weeks the usual flannel band supposed to be so indispensable by the average nurse. Hernia?, whether umbilical or inguinal, cannot be obviated, and in fact may be produced, by undue abdominal pressure. The abdominal band shown in Fig. 37 A, made of light, soft flannel, can be smoothly applied over the dressing of the cord and kept in place with moderate pressure by means of safety-pins. The band can soon be replaced by a somewhat elastic knitted garment (Fig. 37 E, a), half band and half shirt, with shoulder-straps of the same material to hold it in place, and a tab in front to fasten it with a safety-pin to the napkin (Fig. 37 E, b). This shirt can be made of soft wool or silk, or, as I have recently found, can be knitted in any form or size from half cotton and half silk. This knit material can also be used for the undershirts (Fig. 37 B and Fig. 38 F, pages 100 and 103). Garments made in this way are the best that I have ever seen. They are warm, soft, and delicate, have no seams, can be washed without shrinking, and retain their elasticity much better than those made from other materials. Napkins. — The napkin (Fig. 37 E, b, page 100) is folded and fastened with safety-pins as is customary for keeping it in place. The usual nap- kin is very cumbersome and heavy, besides being expensive. It can be replaced by rolls of soft absorbent gauze, which absorb the urine from the skin, an important quality in cases where the skin is easily irritated. These napkins can simply be cut from the roll, which is kept in the nursery, and, when removed from the infant after a movement of the bowels, can be burned, thus avoiding the trials resulting from the objections of the nurse or the laundress to washing the napkins. If, however, the mother prefers the regular old-fashioned napkin, small squares of this gauze can be placed in the middle of the napkin, and this will in great measure obviate the more disagreeable part of the napkin- washing, as the square of gauze will hold most ot the movement and can at once be burned. The infant while in long clothes need not have any further covering for its legs, and need have nothing on its feet. There is no particular objection to little knit socks if the mother wishes to use them. After the nurse has put on the band and the napkin there are left three garments which are usually the clothes needed to complete the infant's outfit of long clothes. L.ofC 100 PEDIATRICS. Fig. 37. (Long Clothes.) A •w 1 ' x; /■* ii A ^ _^ Flannel band for early weeks. Shirt. Petticoat. ■ . m, a f / Dress. A, knit band ; B, napkin ; C, stocking. NORMAL DEVELOPMENT. 101 These garments are the shirt (Fig. 37 B, page 100), the petticoat (Fig. 37 C), and the dress (Fig. 37 D). Shirt (Fig. 37 B). — The shirt is a garment with long sleeves and high neck, cut almost as long as the outside white slip or dress. Unless it is knitted it is well to have it made of some soft, fine, all-wool material, with the seams finished on the outside to prevent irritation of the skin. It is made to button in the back. A fresh garment of this kind is also suf- ficient for the infant's dress at night, except during the early weeks of life. Petticoat (Fig. 37 C). — A flannel shirt cut all in one piece, as the shirt is, made of fine flannel, with no sleeves and with low neck, repre- sents the petticoat. It should be made large enough to go over the shirt, should be of the same length as the dress, and should also be made to button in the back. The taste of the mother can be gratified by any reasonable degree of embroidery which she may wish to put on this second garment, but the shirt should be perfectly plain. Dress (Fig. 37 D). — The outer garment should be made of some soft white material, such as nainsook, should be large enough to go over the shirt and petticoat, should not be starched, and is usually about one yard long from the neck to the bottom of the skirt. It should have high neck and long sleeves, and should button behind. .The advantage of this costume is that it is loose but warm, and that the three pieces which constitute it can be put on together, the infant having to be turned over only once before the clothes are buttoned. The other methods of clothing usually necessitate turning the baby over sev- eral times in the process of dressing. Before the infant has had its bath, these three articles of dress are to be arranged one inside the other, ready to be slipped on all three at once. This can be done with great celerity, and the dressing process can thus be gone through without the usual accompaniment of irritated cries which are so frequently heard in the nursery, and which are to be deprecated. When the infant is old enough to have its long clothes changed to short ones, which is at about the time when it learns to creep, the under-gar- ment can be replaced by a knitted or fine all-wool undershirt with high neck and long sleeves (Fig. 38 F, page 103) made short, with an additional white petticoat in winter if desired. The infant should now also have its feet and legs covered with long white wool stockings, which are kept in position by being pinned to the napkin (Fig. 37 E, b, page 100). When the child begins to walk, soft kid shoes should be used with the soles adapted to the natural curves of its feet, as explained on pages 104 and 105. Stockings. — A word in regard to the stockings is especially needed in reference to the older child in its third, fourth, and fifth years. It is a mistake to think that if we keep the feet and abdomen warm the legs can be left uncovered with impunity. Short stockings and bare legs, in my opinion, should be abolished, as a prolific source of catarrhal conditions. The argument is a poor one that certain children have been known to 102 PEDIATRICS. grow up well and strong with uncovered legs, or even that our ancestors were in the habit of depriving their children of suitable coverings for their necks and arms as well as legs, while they themselves were warmly clothed from head to foot. Our ancestors did and said many things which, to us, convict them of great ignorance. The stockings should be white. This is to insure freedom from poisonous dyes, which at times seriously affect the delicate skin of the young child. Colored stockings are a source of great gratification to lazy nurses and to those who wish to lessen the size of their laundry. There are three garments which are usually put over the shirt and are considered to complete the short clothes. These are the flannel petticoat, the white petticoat, and the dress, and they are to be made large enough to fit one over the other and thus to be put on all at once. Flannel Petticoat (Fig. 38 G, page 103). — The inner garment next to the shirt has a flannel skirt, a cotton waist, low neck, no sleeves, and is fastened with buttons in the back. White Petticoat (Fig. 38 H, page 103). — Next to the flannel petticoat comes a garment with a skirt of some soft white material, with a cotton waist, low neck, no sleeves, and also buttoned in the back. Dress (Fig. 38 I, page 103). — Finally, over all the other garments comes the dress, which is made with high neck and long sleeves, and is buttoned behind. Night-Dress (Fig. 38 J, page 104). — A regular night-dress can now be used, made of soft flannel, with high neck and long sleeves, and buttoned behind. An extra garment can in cold weather be worn under the night- dress if deemed advisable for the especial child. FEET. — In young children, although the foot may be well formed, it is very weak, so that the arch is easily broken down. The pad of fat, to which reference has been made under development, is a physiological protection against such breaking down. Children should not be allowed to walk until some time after they are ready to do so, always allowing, of course, that if they insist on walking they can seldom be restrained from doing so. As they get older, long walks with their parents should be forbidden, for it is through these long walks that the evils which have been explained are brought about. The child will get exercise enough at its play, and in doing so will not overtax the arch of the foot, or use its feet beyond the degree which nature intended. Children should not be told to turn the toes out too much, as this puts the arch in a position where the muscles give it least support. The average dancing-school master is a fair example of what over-zealous ignorance combined with the respected traditions of the past can do to children's feet. SHOES. — Children's shoes should be rights and lefts, like those of adults, as the present style of straight shoes gives no support to the arch during a very important period of its growth ; this, moreover, also tends to push the great toe towards the median line of the foot, so as to cause NORMAL DEVELOPMENT. 103 Pig. 38. (Short Clothes.) F | ! '* ! ' r 'i ki | ) '"1C Shirt. Flannel petticoat. White petticoat. Dress. 104 Night-dress. enfeebling of the muscles which have so much to do with the proper elasticity of the feet. We should, therefore, have shoes properly adapted to the child's foot, — shoes that will at once be comfortable and leave the feet free to develop and fulfil all their functions. The children's shoes as we find them in the stores have the two sides of each shoe symmetrical and equidistant from the middle line ; the right and left are told only from the arrangement of the buttons, and are frequently worn interchangeably. Now, the foot has no such median line on each side of which the parts are equally disposed ; and its two edges are very different, as a glance at the soles of a one-and- a-half-y ear-old child's feet shows (Fig. 39). It is Avell to note especially that the phalanges of the great toe do not naturally point towards the outer border of the foot : such a position, common as it is in the adult, must be considered as an acquired deformity which started, in all probability, with the first pair of leather boots. That this matter of forcing the first toe out of its normal position may bring Avith it very serious consequences is easily shown : as it inclines against the terminal phalanx of the second toe, it often crowds it back- ward, and finally makes it the distressing "hammer toe," which may even require a surgical operation for its relief. On the inside of the foot, as soon as the axis of the first toe is bent, we begin to find a bulging out of NORMAL DEVELOPMENT. 105 the metatarsophalangeal joint, which in later years, fostered by pair after pair of tight and ill-fitting boots, is capable of giving the most exquisite pain. Still more subtle in its working than this is the trouble that often comes from disabling the great toe from performing its full function. The elasticity of one's step depends largely upon one's power to press down Pig. 39. (Natural size, 1% years. Unsuitable shape for sole of child's shoe. Suitable shape for sole of child's shoe. firmly with the great toe and then raise the weight of the body over it as a support ; when this is lost by crippling the toe with ill-shaped boots, the muscles not only of the first digit but of many adjacent groups begin to atrophy. This soon leaves the internal arch of the foot without sufficient support, and the long series of woes incident to kt flat-foot' 1 is started upon. Therefore, for one and all of these reasons, let us demand that children's feet shall have at least the chance to develop properly in well-fitting anatomical shoes. SLEEP. — Infants and young children vary much as to the amount of 106 PEDIATRICS. sleep which they need and take during the day. At first they sleep almost continuously, especially if they happen to be somewhat premature. In a few weeks, however, they begin to have regular periods of rest, con- sisting of several hours' sleep, at first twice in the day, and later once. The more sleep they can be induced to take in the twenty-four hours, the better. As they grow older the amount of sleep which they take grows less, but in the first four or five years of life it is well to try to induce the child to rest quietly on its bed for at least an hour during the day. The number of hours that an infant or child sleeps varies so with the indi- vidual that precise rules cannot practically be given ; one simple rule holds true, — allow each child to sleep as long as it naturally can. WHEN TO GO OUT OP THE HOUSE.— If the infant happens to be born in the winter months and the weather is at all severe, it is better to keep it in a well-ventilated nursery than to run the risk of its vitality being lowered by exposure to cold. I believe that infants in our northern climate are exposed to cold far more than they ought to be, and that they need fresh, warm, dry air, rather than the cold and often damp air of our winter months. When they are born in a milder climate, or at a warmer season of the year, they can after the first few weeks be taken out in their carriages often twice a day. When the infant is five or six months old I am in the habit of giving the following directions to the mother as to when she shall send it out. I explain to her that it makes as much difference whether the air is damp or dry, and what the rate of the wind may happen to be, as does the number of degrees indicated on the thermometer. If the sun is shining, the air dry, and there is no wind, the infant can with- out harm go out for an hour in the middle of the day even at a tempera- ture of —6.6° to —3.8° C. (20° to 25° F.). Where, on the contrary, the air is damp, or the rate of the wind is great, it is better for the infant to remain in its nursery, and, at any rate, not to go out, if the temperature is below 0° C. (32° F.). The practice of allowing the infant to sleep in the open air in its carriage in every kind of weather is, I believe, a bad one ; but on the days when it is proper for it to go out, such as I have already described, it can without harm sleep in the open air. The nurse should be directed to protect the infant's eyes from the direct rays of the sun, and not to allow a strong wind to blow in its face. Where the weather has been too severe or damp for the infant to go out in its carriage for some time, it is advisable to have it dressed warmly and wheeled up and down in its nursery with the window open for fifteen or twenty minutes. To avoid too much draught, blankets can be placed over the cracks of the doors and the open fireplace while the infant is breathing the fresh air. The room being far above the ground, the damp- ness is avoided, and even a considerable velocity of the wind outside the house will in this way be unable to affect the air of the room, and will not make too strong a draught. Where it is possible, as is the case in certain -families who can afford such a luxury for their child, a solarium at NORMAL DEVELOPMENT. 107 the top of the house, especially in cities, is desirable and practical. Not only should an injudicious administration of cold air be avoided, but extreme care also should be taken in hot weather that the child is not exposed to too great direct heat from the sun, and it should never be kept in a hot atmosphere where currents of fresh air cannot have access. NURSERY-MAIDS.— The idea that the child should be taken care of by an old, experienced nurse is a vicious one. The experience of nurses, as a rule, is that of ignorance rather than of intelligence. Every mother, as she is presumably more intelligent than the nurse whom she employs, and is surely more interested in the welfare of her child, should personally supervise and unhesitatingly investigate all that the nurse does to the child. The nurse's ideas as to what is needed for the child's hygienic surroundings, food, and clothing can well be dispensed with. The mother, learning from the physician what is best for her child, should give her directions to the nurse and see that these directions are strictly carried out. A nurse between the ages of twenty and thirty-five is prefer- able to one who is younger or older. She should be neat, healthy, strong, cheerful, gentle, and patient. She should be willing to refer small details of the nursery routine to the mother, as well as those which appear of greater importance. The chief attributes of a good child's nurse, in my opinion, are a desire to obey implicitly the orders which she receives from her mistress, and a temperament in harmony with the sensitive nervous organization of her charge. In certain cities, such as New York, Philadelphia, Buffalo, and Boston, schools have been established for nursery-maids. An admirable school of this kind has been carried on for some years at -the Infants 1 Hospital in Boston, where the nurses are trained to be servants as well as nurses, the course lasting for one year. When intelligent girls trained in this way can be obtained, the preferable age is between twenty and thirty-five years. MOUTH. — A protest should be made against the way in which the nurse, and in fact almost every one who comes near the infant, put their fingers into its mouth on all occasions. It would seem as though the in- fant's mouth was considered by those who ought to know better as some- thing which was especially made to be felt. Infants are much more likely to have various diseases in their mouths than are adults, and prob- ably one reason for this is that dirt of all kinds is constantly being intro- duced into them. The fingers should always be thoroughly washed before entering the infant's mouth, and yet unwashed fingers are continu- ally feeling the baby's gums to ascertain if a tooth can be found. The nurse should be instructed that she is never to kiss the infant on its mouth, or allow any one else to. The germs of disease can well be transmitted in this way. It is partly through ignorance of doing harm. and partly through timidity on the part of the mother in prohibiting it. that a stop is not at once put to this bad habit oi' nurses and friends, and it is the physician's duty to warn mothers on this apparently trivial but 108 PEDIATRICS. really important question, and to tell them how certain infectious diseases, especially tuberculosis, can be transmitted in this way. SCHOOL. — Much ignorance of the child's nervous organization is shown by those who should best know how to care for it, at a period of life when its hygienic surroundings, both mental and physical, are ex- tremely important. No one system is good for all children. I am sure that I have seen the kindergarten system do harm to a number of children, although it seems to suit others. Each child should be gauged for itself, and not be forced into any general system, even if that system has proved to be good for the many. No time is lost, in my opinion, in sending children to school at a somewhat later age than is usually supposed to be neces- sary. I am continually having to take little children out of school who are fretful and have loss of appetite. Neither parents nor teacher seem to appreciate that the little, actively growing brain is overtaxed by too great stimulation and is protesting against such treatment by these general symptoms. Many a child is being dosed with tonics who merely needs rest from school. The parents should keep the most rigid supervision over their children while at school, and notice from their behavior whether they are mentally tired. This supervision should not be left to the teachers alone, however interested they may be in their little pupils. It seems hardly necessary to state that the school-room should be well ventilated, and that at stated intervals during the school hours the win- dows should be thrown open and the atmosphere of the room completely changed. This should not, however, be done with the children in the room. Attention should be paid not only to what the children eat at lunch, but to how and where the lunch is eaten. A child really needs nothing but dry bread and milk or water between its meals, so far as its nutrition and digestion are concerned. DEFECTS OF POSTURE. — We can best appreciate the importance of following nature as closely as possible in its methods of developing young human beings so as to perfect their various functions to the fullest extent by examining carefully a group of malformed children. Back. — The extreme flexibility and slow development of the spine clearly point out to us that nature intends to leave its function in abeyance and bring it into use slowly. If the young infant is allowed to sit or stand at too early an age, the superincumbent weight of the large head tends at once to exaggerate the physiological curves of the spine to a point where they may become pathological. During the first year of life the strength of the spinal column is slowly increasing. Not before the seventh or eighth month has it acquired suf- ficient rigidity to warrant the child's being allowed to sit up. Artificial methods, therefore, of making the young infant assume a sitting posture at a period of development when the spine should be comparatively straight should be deprecated. I have met with numerous instances where both parents and nurses were anxious to have the infants, at a very NORMAL DEVELOPMENT. 109 early age, sit for quite a long time strapped in small chairs. In like man- ner the same infants were encouraged to stand and walk long before the apparatus for locomotion was ready for use. One may ask, how many of these individuals developed a spinal curvature in later childhood ? Possi- bly the risk in a perfectly healthy child may be small. One often, how- ever, in early infancy, cannot determine which individual may become rhachitic, and where rhachitis is present the tendency to abnormal curva- ture is well known. We should, then, in our advice as to the proper physical management of the early years of life, be guided by our knowledge of the normal average development. Free play for the infant's legs, when lying on its back in bed, should be a point to be noticed and considered, since we know that pressing down the legs causes strain and curvature in the lower spine. Knowing the great lateral flexibility of the infant's spine, Ave should advise the nurse not to hold the infant continually on one side. Symmetry of development and free opportunity for natural movement should be our aim in the management of the infant from the very earliest period of its existence. Our knowledge of the great flexibility of the growing spine provides us at once with a most valuable means for treating lateral curva- ture in childhood, and we are continually seeing the benefit of encour- aging the promotion of elasticity by moderate pressure and bending. A case which was under my observation at the Infants' Hospital beautifully illustrates the truth of what has just been said. A feeble, rhachitic child, nineteen months old, was presented for treatment with a marked lateral curvature in the dorsal region, the convexity being towards the right, combined with decided rotation, following the type of the worst adult cases. The condition seemed to be purely the result of habit, the patient having been made, when very young, to sit up beyond the limit of endurance of the still undevel- oped bones and ligaments. The treatment was based entirely on the elasticity of the spine, and consisted simply of manipulation and recumbency, resulting in a very great degree of improvement both as to the curvature and the twisting. The improper treatment of the young subject's spine, as in infants, for instance, where they are carried altogether on one side, is well recognized as an important factor in the etiology of rotary lateral curvature. Remembering what has been said regarding the ossification of the dif- ferent parts of the spinal column, it will be understood that so long as an infant can be made happy in the prone position, whether in its nursery or in its carriage, it will be better for it to be kept in this position, always protecting the eyes when out in the open air from the strong light, and the face from the wind. During the first year when it begins to sit up in its carriage its back should be carefully supported by a pillow. Fig. 40 represents the harm which can be done by encouraging children to sit up before their spinal columns are sufficiently strong. The infant, six months old. had been made to sit in a chair for hours at a time, strapped in a position which allowed it to use its arms, but such as to render it impossible to tall back and rest itself. 110 PEDIATRICS. The exaggerated curve of its back corresponds to that which would be seen normally at birth. Such a curve is shown in Fig. 3 (1), page 23. If this infant had not been Pig Posterior spinal curvature from sitting too soon. made to sit until it had developed sufficiently to acquire the pysiological curve (2). it would not at this age show any spinal curvature. It had, however, through improper treatment reacquired the posterior curvature (1) of the early hours of life. As the child grows older, weak undeveloped muscles have a tendency to allow lateral and posterior curvatures to be produced. Habit, of course, has much to do with these faulty positions of later childhood. Figs. 41 and 42 represent a girl aged four and one-half years, with a lateral curva- ture, not from disease of the spine, but one which is usually explained as a result of superincumbent weight coming upon muscles which are unable to support it properly. On looking at her from behind, the curve which the line of the spinal column takes to the right in the dorsal region is quite distinct. On looking at this same child in front, the right shoulder is seen to be higher than the left, and the whole thorax is in a distorted position. These deformities are always more readily recognized by looking at the child in front and preferably across the room, as the outline of the chest and hips is much more clearly defined on the anterior aspect of the body than on the posterior. Posteriorly, in cases even of the slightest lateral curvature, one notices the difference in the level of the angles of the scapulas. This child stooped, and had what is commonlv called round shoulders. In any case of round shoulders lateral curvature should be thought of and carefully eliminated. Faulty attitudes in sitting and standing play a great role in producing these curvatures. We must, however, acknowledge that such spinal curva- NORMAL DEVELOPMENT. Ill hires have been differently explained on the ground that they are the result of a lack of development of all the tissues upon one side of the spine. Other explanations have also been given ; but in certain individual cases it is impossible to formulate any reasonable cause for the curvature. Fig. 41. Pig. 42. Lateral curvature of the spine. Child 4V 2 years old. Legs. — At birth the infant's legs are curved rather than straight, as is seen in Figs. 28 and 29, facing page 86. The natural tendency of the growth of the legs is to become straight, but if the child is encouraged to stand and walk too soon, especially if the bones have not been properly nourished, the weight of the head and trunk becomes too great to be supported by the legs, which curve outward in the form of an ellipse, a condition which is called "bow-legs." The deformity of ••knock-knee." in which the leg at the knee bends in rather than bows out, may occur from simple weakness, but is rare except in rhachitis, under which it will be more fully described. DIVISION II. FEEDING. GENERAL PRINCIPLES. Just as the highest aim of medical art should be directed to the prov- ince of preventive medicine, so the highest and most practical branch of preventive medicine should consist of the study of the best means for starting young human beings in life. They should be preserved from the perils which surround the early hours of their existence, and be given strength and vigor to resist the attacks which must inevitably be made on their vitality, and which are greater and more dangerous in inverse pro- portion to their age. With these objects in view, the preventive medicine of early life becomes pre-eminently the intelligent management of the nutriment which enables young human beings to breathe and grow and live. In fact, it is a proper or an improper nutriment which makes or mars the perfection of the coining generations. The feeding of infants is, then, the subject of all others which should interest and incite to research all who are working in the domain of pediatrics. The subject is a great one. and is worthy of the most careful study. The responsibility of dis- cussing so serious a question is a grave one. It should be taken up carefully. It should be dealt with broadly. "We must acknowledge that in the status of feeding, as it has existed up to the last few years, the average human breast-fed infant was more likely to live, other conditions being the same, than the infant which was fed by any other method. But Ave must remember that the latest investigations of this subject show very clearly that it is not human milk as a whole which is pre-eminently good, but that it is a varied combination of the different elements of the milk which makes it the best food during the first year of life. It is our prov- ince to study and make use of these elements of the food, which were once somewhat mysterious, but which are now rapidly becoming known through the work of patient and careful investigators. In reviewing the immense amount of literature which has accumulated on the subject of feeding, we find that the superiority of human milk to all other kinds of infant food in the early months of life is acknowledged so generally that it has become an axiom. On the other hand, the 112 FEEDING. 113 opinions expressed regarding artificial feeding in the past are so diverse and so opposed to one another that it is evident that much which has in former years been taught must be unlearned, or rather admitted to be untrue, before we can expect to make any decided progress in this most difficult subject. In our endeavor to copy nature we may hope that, as our knowledge increases, more and more light will be thrown upon those points which are now obscured by ignorance. It is, indeed, of the first importance that we should recognize our ignorance, and, watching every advance which science is making in this subject, be ready to sweep aside precon- ceived ideas which do not rest upon established facts, and thus by wise iconociasm build our knowledge on a surer basis. The great number of artificial foods used by physicians according to the fashion of the day only proves that artificial feeding has never arrived at that state of perfection where it could compete with human breast feeding. The difficulty in approaching the study of the subject has been that physicians as a class have regarded it too purely from a clinical stand-point. We know, for instance, how easily we may be misled by the apparently good effects of a medicament when perhaps on further in- vestigation, or in the light of some new discovery, we learn that the im- provement in the case was due not to the drug, but rather to circumstances entirely apart from it. The same rule applies equally well to the case of many foods and methods of feeding. To state concisely what I have already referred to, we should, in studying the form of nutriment which shall be suitable for an especial period of life, manifestly be guided by what nature has taught us throughout many ages. The researches of science at present, especially in the subject of infant feeding, are wisely directed towards learning to read the truths which nature presents to us. Great progress has been made in reading these truths. What we are also endeavoring to do is to copy them, and in regard to human milk a great advance has been made in our knowledge as to what we are to copy from it. The feeding problem is one which is surrounded with many difficul- ties on account of the great diversity of individual circumstances and idio- syncrasies. Certain infants thrive on peculiar mixtures which are not adapted to infants as a class. Many will not thrive on that food which nature has provided for them, and the well-being of an infant will depend much upon the circumstances by which it is surrounded, such as affluence or poverty, country or city life. The constituents of the nutriment which nature has provided for the offspring of all mammals in the early period of their existence is essentially animal and never vegetable. Human beings in the first twelve months of life are carnivora. It is therefore evident that an animal food, entirely and freshly derived from animal and not vegetable sources, has been proved to be the nutriment on which the greatest number of human beings live and the least number die. 8 114 PEDIATRICS. MAMMARY GLAND. — In regard to the early months of life, a knowledge of the changes which take place in the mammary gland from many causes is of vital importance and must be kept in view. The methods of modifying the milk in the mammary gland, however limited in their scope, should be carefully investigated and adapted to the indi- vidual infant according to its age and size and general physical condition. The mammary gland, in its perfect state, uninfluenced by disease or ner- vous disturbance, or by the improper living of the mother, is a beautifully adapted piece of mechanism constructed for the elaboration and secretion of an animal food. When in equilibrium it represents the highest type of a living machine adapted for a special purpose, — -mechanically, physio- logically, and economically. When from any cause this sensitive machinery is thrown out of equilibrium, its product is at once changed, sometimes slightly, but again to such an extent that the most disastrous consequences may follow when it is taken by the young consumer. The breasts of all mammals are elaborators and producers. They are not storehouses for preserving sustenance until it is needed. They are delicately con- structed mills, turning out, when demand is made for it, a product which has been directly formed within their walls from material which has been brought through their portals from various parts of the economy. The breast is a compound racemose gland, lined with glandular epithelium, which forms sugar, fats, and proteids, and these are mixed with water and salts from the blood. The epithelial cells are so finely organized, and so sensitive with their minute nerve connections, that changes of atmosphere, changes in food, the emotions, fatigue, sickness, the catamenia, pregnancy, and many other influences, throw their mechanism out of equilibrium most readily, and change essentially the proportions of their finished product. Then again this delicate mechanism adapts itself to the quantity of its product, elaborating a smaller or a greater supply, according to the demand actually made upon it by the consumer. The same breast will either supply the proper amount of milk demanded for the require- ments of the average age or a greater amount for the same age in case of a greater gastric capacity. Again, this machinery is regulated as to the time which it takes to produce the average food required for the different ages, a shorter interval of feeding being needed for the younger infant and a longer one for the older. This fact is made evident by the decided qualitative changes which result when the gland is called upon to produce its product at improper intervals. Thus, a prolonged interval lessens the solid constituents in their proportion to the water, while a shortened in- terval, by exciting the epithelial cells to frequent work, over-stimulates them, with the result of increasing the solids in their proportion to the water. In fact, too long intervals produce a product too dilute, while too short intervals produce a product too concentrated. The analyses of large numbers of specimens of human milk at different periods of lactation show us that not only do the constituents vary from month to month, FEEDING. 115 and even from day to day, but that this variation takes place as much in the early as in the later periods of lactation. We are not warranted, there- fore, in assuming that the milk grows stronger as its age increases, pro- vided that it still remains in normal equilibrium. The mammary gland acts both as a secretory and as an excretory organ, so that it cannot be classed as a metabolic tissue in the limited meaning which we now attach to these words. Yet the metabolic phenomena giving rise to the secre- tion of milk are so marked, so distinct, and have so many analogies with the metabolism which we meet in adipose tissue, that we must look upon the mamma chiefly as a secretory organ (Foster). This, however, is only within certain limits, for we know that at times foreign elements may be excreted from the gland. This at o'nce suggests the interesting question as to when the mammary gland is most likely to have what we might call its normal secretory function interfered with and to assume temporarily the function of an excretory organ. This seems to occur both before the gland has attained its equipoise, as during the colostrum period, and later when any of the above-mentioned influences occur which affect the gen- eral mechanism of the gland. In these instances we find the colostrum reappearing in the milk. Therefore in the beginning of lactation, during lactation when normal metabolism is interfered with, and as lactation draws to a close, we have analogous conditions in which the mammary gland instead of being a normal secretory organ becomes abnormal and more or less an excretory organ. During these periods of abnormal gland excretion we must remember that drugs can be eliminated by the milk more freely than when the gland is in equipoise. We assume, therefore, that the mamma during that early period of lactation, which essentially represents a condition of lack of equipoise, has a double function, partly secretory, partly excretory. The greater the excretory function of the gland is at any time in proportion to the secretory, the more abnormal will be the finished product ; while the nearer the gland approaches to a purely secretory organ, the more perfect and normal will be its product. The mechanism of the mammary gland is therefore in its most perfect condition after the colostrum period has ceased, and at a time when the general organism, both physical and mental, is freed from causes detri- mental to a perfect metabolism. General principles are vital in their importance when we come to study the subject of feeding in all its phases, whether the nutriment to be provided for the infant is to come directly from its mother, a wet-nurse, or an animal, or indirectly from the product of the mammary gland. These principles are, (1) That nature throughout all ages has clearly indi- cated by means of natural selection what the source of supply should be; that is, that the mother should during some early period o( its life supply food for her offspring from her mammary glands. (2) That when, owing to disease, over-civilization, or any causes which prevent the offspring from receiving its sustenance directly from the maternal mammae, some 116 PEDIATRICS. nutriment must be substituted which will correspond as closely as pos- sible to the natural food-supply. (3) That this substitution can be ob- tained most exactly through the product of the mammary gland of another woman. (4) That, owing to the strong analogy between human beings and all animals which suckle their young, we should in our efforts to copy good human milk make use not only of what we have learned from human beings, but also of what is known of lactation as it occurs in animals. This requires a knowledge of the investigations and experience of those who have studied commercially the breeding of animals and their food, and the production and modification of their milk. FIRST NUTRITIVE PERIOD. The nutrition of young human beings may be divided into three dis- tinct nutritive periods, corresponding to the degree of their development. The first period consists of the first ten or twelve months of life. The second period comprises the second and third years, and the third period the remaining years of childhood. The science of feeding depends almost exclusively, in addition to the general principles already referred to, on the knowledge of what elements of the food are required by the growing tissues in these nutritive periods, and also on the time when the various digestive functions are ready and able to dispose of them. The first nutritive period is essentially the only one in which human milk need be considered. There is a marked analogy between the nutrition of human beings and other mammals, and it is therefore necessary to understand the lactation of animals when we endeavor to explain that of human beings. I here wish to acknowledge my indebtedness to Mr. G. E. Gordon for placing at my disposal his practical observations on the feeding, breeding, and lactation of cows. The first nutritive period represents the first twelve months of life, and is obviously the most important one of the three. In this period the infant may be fed by a number of methods. It may be nursed by its mother, or a wet-nurse, or an animal, or it may be nourished by food especially prepared from the milk of one of these. I. MATERNAL FEEDING. The first of these methods, the maternal, is so far superior to any other which has ever been known that I shall assume that it is the best, and the one from which in almost every particular all others should be copied. Normal Maternal Conditions. — The assumption that the maternal is, when normal, the ideal source of infant food-supply presupposes many im- portant conditions concerning the mother and the function of her mam- mary glands. She should be strong and healthy, of an even, happy tem- perament, desirous of nursing her infant, and have time to devote herself FEEDING. 117 to this special duty during the whole period of her lactation. She should have a sufficient supply of milk, and should be willing to regulate her diet, her exercise and her sleep according to the rules which will best fit her for her task. These may be said to be the ideal conditions which we endeavor to obtain for an infant which is to be nursed under the most favorable circumstances. It is true that women who are far from vigorous nurse their infants with seemingly good results, and that a frail, delicate- looking mother may have an abundant supply of good milk. These are exceptions, however, which make the principles just stated all the more true. We must have some general principles to guide us in our endeavor to perfect the nutriment of infants as a class, or we shall surely in many instances do serious harm to the individual. Coxtra-Ixdicatioxs to Materxal Feeding. — With few exceptions, the mothers who have uncontrollable temperaments, who are unhappy, who are unwilling to nurse their infants, who are hurried in the details of their life, who are irregular in their periods of rest and in their diet and exercise, are unfit to act as the source of food-supply for their infants. Even if their milk happens to be sufficient in quantity, it will probably be so changeable in quality as to be a source of discomfort and even of danger rather than the best nutriment for their offspring. It is far better for such mothers not to attempt to nurse, but to adopt some other method of feeding. It is of still greater importance that mothers who are suffering from some chronic disease, or one which their infants may directly inherit, should give up all thoughts of nursing. When there is no question of disease in the mother, it is our duty to investigate, and, if possible, to counteract the other contra-indications to nursing, often only caused through ignorance of what to us seem very simple truths, but which to the young mother are enveloped in mystery. There is, then, a double necessity for studying in the closest detail the conditions which constitute normal lactation ; first, that, knowing what is normal, we should rec- ognize what is abnormal, and, by the intelligent use of our knowledge, render possible an apparently unsuccessful attempt to nurse ; secondly, that we may know exactly on what the normal and vital conditions of successful nursing depend, in order t that we may understand what we should copy in substitute feeding. Nursing. — The natural method of feeding is by sucking. The infant should be placed in a comfortable position in its mother's arms, with its head and back supported. It should be made at once to understand that it is to begin its meal as soon as the breast is offered to it, and continue, with, of course, breathing-spells, until the meal is finished. The mother should herself preferably be sitting, as she can thus best manage and control the infant if it is inclined to be restless. The formation of the lips and buccal cavity are adapted to the mechanism of suction. The breast is so organized that it provides a fresh supply of food at the required intervals. It prevents fermentation 118 PEDIATRICS. of the food before it enters the infant's mouth, while at the same time the suction incites to action both the necessary digestive fluids of the infant and the function of the gland itself. The gland avoids a vacuum by collapsing as it is gradually emptied, and allows the food to flow con- tinuously, thus obviating the tendency to exhaustion of the infant and prolongation of the nursing-time which necessarily accompanies a re- tarded flow of the milk. Finally, the breast is practically self-regulated as to the amount which it is required to provide according to the infant's age. A healthy infant should empty the breast with easy and uninter- rupted sucking in about fifteen to twenty minutes. Nipples. — In certain cases the mother's nipple is so small or depressed that it is a source of much annoyance to the infant, and at times this in- terferes so seriously with its obtaining the proper food-supply that its nutrition suffers, and some other method than nursing has to be substi- tuted. It is here that the ingenuity of the physician is taxed to its utmost. Every kind of device may fail, and it is necessary patiently to try one after the other before deciding to give up the nursing. Nipple-shields should be experimented with, and will sometimes obviate the difficulty. We should, however, always impress upon the mother the fact that the value of her milk as a food may be entirely destroyed if foreign elements are allowed to enter with it into her infant's mouth. This simply means extreme cleanliness of the glass shield and rubber nipple. When the nipples are very tender and cause great discomfort to the mother during the nursing, their condition frequently becomes so serious an obstacle as to prevent nursing altogether. This change, however, should not be thought of for at least several days, or until it is absolutely certain that the exquisite pain is more than the mother is willing or able to endure. It is often the case that after a little time of the greatest suf- fering from tender or excoriated nipples the whole difficulty will pass away and the mother be able to nurse her infant with comfort. Where the nipples show a tendency to be dry and hard, it is well to apply some simple ointment once or twice a clay during the last few weeks of the pregnancy. Astringents, as a rule, should not be used. Bathing with cold water before and after the nursing, and thus keeping the tissues in a healthy condition, appears to be as successful as the application of any medicaments. Mastitis. — Another trouble which may arise during the nursing period is a disturbance of the mammary gland itself, sometimes amounting merely to a stasis in its milk production, but again going on to inflammation. The latter is a serious matter, and should at once be placed in the hands of a skilful surgeon. The former condition requires great care in its manage- ment. Gentle massage from the periphery of the gland towards the nipple, amounting in fact to merely a delicate stroking with the ends of the fingers, is an important part of the treatment. The breast should be withheld from the infant for about twenty-four hours, and the milk from FEEDING. 119 time to time drawn in small quantities by means of a properly adjusted breast-pump. The breast should also be carefully supported by a swathe. If these measures are begun as soon as there are any indications of dis- turbance in the breast, these abnormal conditions soon disappear. The indications referred to consist in the appearance of hard swellings in place of the usual soft elastic condition of the milk glands. These swellings may occur without any especial pain, but on palpation they are usually tender to a greater or less degree. In regard to the relation of micrococci to inflammation of the breast, according to Zweifel and Doderlein there are in mastitis two varieties of organisms, the staphylococcus pyogenes aureus and the streptococcus pyogenes, but never the staphylococcus pyogenes albus. They admit that other varieties may perhaps be found on closer investigation, but at the same time they consider it striking that in all their cases there were never any local or general symptoms caused by the staphylococcus pyo- genes albus. although that they were virulent was proved by their inocu- lation of mice. There is not much doubt that these pathogenic organisms gain access to the gland through the nipple. The infant may not be able to hold the nipple with sufficient firmness on account of some abnormal condition of the nipple itself. Under certain circumstances, even when the nipple is well formed, the infant has insufficient suction-power to obtain its food, though the food itself may be perfectly adapted to its digestion. In these cases we often find that it cannot or will not be induced to obtain its food through a shield and rubber nipple, as shown in the following case : An infant, seven months old, was dying of starvation, as I had not been able to prepare for it a food which it could digest and thrive on. (This was before milk laboratories were established.) It was totally unable to nurse, although the breast- milk was a good one and agreed with it perfectly when it was introduced into its mouth with a spoon. The milk was pumped from the breasts at regular intervals and given to it from a bottle for over three months with the greatest success, the infant thriving, and at the end of that time being in a perfectly healthy condition. Breast-Pump. — In regard to the use of the breast-pump there is a great difference of opinion, but I believe that those who have opposed its use have been influenced to a great degree by what they have seen in their hospital practice, and also by the views of others who have, in like manner, met with unfortunate results in lying-in hospitals. It is well known that all inflammatory conditions about the breast are more likely to occur in hospitals than under conditions in which the woman is less likely to be exposed to pathogenic organisms. This should be taken into account when we are deciding whether or not to use a breast-pump. In my experience, acquired in a great degree from my private practice, where every precaution in regard to cleanliness and asepsis could be ob- tained, I have never met with any bad results from the use of the pump. Fig. 43 represents the form of pump which T have found safe and useful. The apparatus should be one which can be carefully cleansed, and 120 PEDIATRICS. should, therefore, preferably be made of glass. No one special pump will, in all probability, suit every case, and it is of importance that one should use the greatest care in adapting the pump to the individual. When applied to the breast it should cause little or no pain or discomfort. The part Avhich is adapted to the nipple is like an ordinary nipple-shield. This is attached to a glass bulb, into which the milk falls as it is drawn from the breast. The mechan- ism is very simple. A vacuum can be produced in , the glass bulb by means of suction through a rubber tube attached to a rubber bulb with its valve working back- ward. MILK. — The products of the mam- mary glands of all mammals is essentially the same. In all we find substances rep- resenting the great subdivisions of food- stuffs, — that is, fats, carbohydrates, pro- teids, and salts, — but there is considerable variation in the relative proportions in which they occur in the milk of different mammals, and, as regards their ultimate chemical analysis, much is still to be in- vestigated by the analytical and physio- logical chemists. It is primarily on the results of their work that the advances in the scientific feeding of infants and children are to be made. In general the composition of milk consists of fats, of carbohydrates in the form of lactose or milk-sugar, of proteids in the form of caseinogen (casein) and lactalbumin, of salts, extractives, and water. It is the combination of these various elements which makes the resulting product characteristic of the especial mammal. Formation. — The more recent investigations on the physiological action of the mammary glands tend to show that the actually dissolved constituents of milk do not have their source in a simple process of filtra- tion or diffusion from the blood, but are dependent upon a specific secretory activity of the glandular elements (Hammarsten). Evidence of this lies in the fact that milk-sugar is not found in the blood, that the lactalbumin is not identical with serumalbumin, and that the mineral bodies exist in milk in different proportions from those in the blood- serum of the same animal. According to Foster, milk is the product of the activity of certain protoplasmic cells, occurring in the epithelium of the mammary gland. These cells are rich in proteids and nucleoproteids, which seem to be the source of the casein or its mother-substance. The protoplasm itself becomes a constituent of the secretion (Hammarsten). Breast-pump. FEEDING. 121 When the milk is kept at 35° C. (95° F.) outside of the body, the casein- ogen is increased at the expense of the lactalbumin. When, in cows, the action of the cell is imperfect, as at the beginning and end of lactation, the lactalbumin is in excess of the caseinogen ; but when the cell possesses its proper activity, the formation of caseinogen is in the greater proportion. The fat of milk is produced within the protoplasm of the epithelial cells, and is set free by the destruction of the fat globules ; a portion of the fat is probably taken up by the glands themselves from the blood and eliminated with its secretion. That this is possible has been proved by the experiments of Winternitz, in which the passage of iodized fats in the milk was noted : and similar observations were made by Spampani and Daddi with sesame oil. Microscopically, the fat can be seen to be gathered in the epithelial cell in the same way as in a fat cell of the adipose tissue, and to be discharged into the channels of the gland either by a breaking up of the cells or by a contractile extension very similar to that which takes place when an amoeba ejects its digested food. A formation of fats from carbohydrates in the animal organism is now positively proved, and it is possible that the milk glands themselves also produce fats from the carbohydrates brought to them by the blood (Hammarsten). It is also well established that a part of the fat of milk is produced from proteid material : but the question in all these instances as to how much fat is produced by the secretory mechanism of the milk glands, and how much is obtained from other organs and tissues and eliminated from the blood by the milk glands, has not been determined. The origin of the milk-sugar is not known. That it is formed in the cell protoplasm is indicated by the fact that it is not found in the blood itself, and may be maintained in abundance in the milk of carnivora which are fed exclusively on lean meat. One of the nucleoproteids men- tioned above as occurring in the cell protoplasm yields a reducing sub- stance when boiled with dilute acids, and future investigations may show some relation between this substance and lactose. Nervous Disturbances affecting the Milk. — The secretion and elimi- nation of milk are very evidently under the control of the nervous system, which produces marked changes in both the quantity and the quality of the mammary product in proportion to the relative nervous excitability of the special mammal. Women are especially sensitive in this respect, and when living in the midst of our modern civilization, so harmful for the produc- tion of good nursing, present an exaggerated example of disturbance of the equipoise of the mammary gland. The chemistry of the equipoise and lack of equipoise of the mammary product appears to be closely con- nected with its proteid element. This element is known to be a com- pound one and decidedly complex, but for purposes of illustration we can safely say that the Avord proteid is a general term, which includes casein- ogen and lactalbumin ; also that these factors of the complete whole vary in their proportions to each other according as the mammary function is or 122 PEDIATRICS. is not in a state of equipoise. In the colostrum period, and probably in the analogous periods represented by the abnormal conditions already spoken of, the lactalbumin is in excess in proportion to the caseinogen, while as the equipoise of the function becomes more complete the casein- ogen is increased proportionately to the lactalbumin. Probably at the end of lactation, as in the beginning, we shall find this same condition of rich- ness of lactalbumin and deficiency of caseinogen. This increase of the the lactalbumin at the expense of the caseinogen explains how the excretory function of the gland at times becomes more prominent than the secretory. These nervous disturbances, however, may also cause an over-produc- tion of the total proteids, as shown by their percentages. In some cases also the fat has been found to be much reduced in its total percentage. Instances of this have arisen when, as observed by Zukowski, seasons of fasting with their accompanying excitement of the emotions have induced such a disturbance of the equilibrium of the milk that the fat has been found to be decreased to the low percentage of 0.88, with the result that the infant has become sick and given evidence of impaired nutrition. These same nervous influences in all probability have to a greater or less degree their analogy in the milk-product of all mammals. COLOSTRUM. — During the early days of lactation the mammary gland secretes a fluid which differs somewhat from that which is produced later. The milk at this period is called colostrum, and the period is called the colostrum period, on account of the presence in the milk of certain ele- ments called colostrum corpuscles. These cells measure from 12 to 22 ^ in diameter, and show a small, irregular, extensively degenerated nucleus. Their protoplasm contains large and small granules, which show the pro- teid reactions, and are not stained by acid, basic, or neutral dyes ; a few of the granules which stain by osmic acid are probably fatty. The cor- puscles have been described by Czerny as lymphoid cells, whose function is to absorb and reconstruct unused milk globules and to convey them from the milk glands into the lymph-channels. They disappear from the mother's milk in a week or ten days after birth. If they continue in the milk into the third week, or return at any time during lactation, they almost invariably cause disturbance of the infant's digestion, and become an indi- cation for a temporary suspension of nursing. If they persist for any length of time, the mother's milk is manifestly not suitable for the infant, and a substitute should be provided. Chemistry. — An analysis of colostrum milk of a cow by Harrington gave the following results : Fat i.7i Milk-sugar " . . . . 4. 90 Proteids 1. 72 Ash 0. 79 Total solids „ 9.12 Water , 90. 88 100.00 III. IV. V. 2.40 5.73 4.40 11.15 10.69 11.27 0.25 0.16 0.21 13.80 16.58 15.88 86.20 83.42 84.12 FEEDING. 123 The table which follows represents the analyses of live specimens of duman colostrum milk, also made by Harrington : TABLE 24. I. II. Fat 1.40 0.68 Milk-sugar and proteids . . . 9.44 11.53 Ash 0.17 0.31 Total solids 11.01 12.52 Water 88.99 87.48 100.00 100.00 100.00 100.00 100.00 The most recent study of human colostrum has been made by Wood- ward, who analyzed the colostrum of six nursing women, using in each instance the combined twenty-four hours' amount of the middle milk, and following each case from three to seven days. He concludes as a result of his investigations that colostrum corpuscles are not always found in the so-called colostrum-milk ; that when they are present the percentage of proteids is higher, and as they disappear the proteid per- centage drops. In all his cases there was a loss of weight in the infants varying from eight to twelve ounces, whether the colostrum corpuscles were present or absent ; when they were absent a high temperature in the mother was noted. The results of his analyses may be best seen in the following table : TABLE 25. General Average of Twenty -six Analyses. Color Yellowish. Keaction Alkaline. Specific gravity 1024 to 1034. 1029.5 Fats 2.0 to 5.3 per cent. 4.0 per cent. Proteids 1.64 to 2.22 per cent. 1.9 per cent. Ash 0.14 to 0.42 per cent. 0.2 percent. Total solids 10.18 to 13.65 per cent. 12.5 percent. Lactose (calculated) 5.6 to 7.4 per cent. 6.5 percent. Water 87.5 per cent. The observations of Townsend have shown that the infants of mul- tipara do not lose as much weight in the colostrum period as those of primiparse, and also that the shorter the colostrum period the smaller the so-called physiological loss of weight in the new-born. Colostrum is also supposed to have a laxative effect, and so to aid in removing the meconium. Whether this action is of any advantage to the infant is doubtful. The appearance of the colostrum corpuscles is simply an indication that the equilibrium of the mammary gland has not been established, or has been disturbed. It may be that the not infrequent disturbance of the infant's digestion in the early weeks o( nursing is pro- duced by an exaggerated abnormal condition occurring in the colostrum period, as well as by the return of the colostrum at irregular intervals. 124 PEDIATRICS. HUMAN MILK. — Beyond the general conditions affecting the mammary products of the mother, which have already been spoken of, I know of no way of increasing the flow of milk. I have little confidence in galactagogues in the form of drags or special foods, for their number betrays their inefficiency. The milk becomes lessened from many causes, some of which are identical with those which commonly produce any dis- turbance of its equilibrium such as have been mentioned. Certain drugs, such as belladonna, will in some women cause a notable decrease in the flow of milk, and must therefore be given with care during the nursing period. An active cathartic, and also a diet composed of solid food and a small amount of water, will also lessen the quantity of milk. Clinical Examination of Human Milk. — The quality of the mother's milk is of so much importance to the welfare of the infant that it is of the greatest practical assistance in the management of certain cases to know the results of an analysis of the breast-milk. This can be done exactly only by an analytical chemist. The methods of analysis used is too purely a chemical question to be of practical use in clinical work, but simple approximate clinical tests are often very desirable, even though they are less accurate, when the services of a skilled chemist cannot be obtained. To obtain a specimen for analysis the hands should be sterile, the breast and nipple should be carefully washed with sterilized water, and from 20 to 30 c.c. (5 to 8 drachms) of milk drawn by the breast-pump, which, being made of glass, can also be thoroughly washed. The milk should then be poured into a sterilized bottle, tightly corked, and kept on ice until the examination is made. The general methods of making the rough quantitative estimation of the constituents of the milk are as follows : Specific Gravity. — This is obtained by means of the hydrometer, for the use of which only 15 c.c. (J ounce) of milk are required. Pats. — In every case it is very important to know the exact percent- age of the fat, both from its being the most variable element and from its use in the determination of the percentages of the other elements. The most exact means for this purpose outside of the chemical laboratory is an apparatus called the Babcock Fat- Tester, which is shown in Fig. 48, and described on page 192. As this is not an expensive machine, it has seemed to me that in communities at a distance from an expert chemist, or where the people are unwilling to pay for a complete analysis, a Bab- cock machine could be owned jointly by a number of physicians and kept at some central place. The smallest amount of milk required for determining the percentage of fat with the Babcock machine is 17.50 c.c. Another less accurate method of estimating the percentage of cream is as follows : A glass-stoppered cylinder is filled with milk exactly to the upper line, which is marked 0. A pipette should be used for putting the last FEEDING. 125 few drops into the cylinder, care being taken not to allow the milk to run down the inner side of the tube, since this somewhat obscures an exact reading. The cylinder is then corked and allowed to stand for twenty- four hours at a temperature as near to 21.1° C. (70° F.) as is prac- ticable. A variation of a few degrees on either side of this point is unim- portant. If, however, the variations are wide, the rapidity with which the cream rises is somewhat modified. In the great majority of cases the lower line of the cream has become sharply defined at the end of twenty-four hours, and can then be re- corded. If this is not the case, the milk should be allowed to stand for six hours longer before reading the percentage. By comparing the percentage of the cream with that of the fat, as de- termined by a chemical analysis of the same specimen, it has been dis- covered that the ratio of the cream to the fat is very nearly 5 to 3, and for clinical purposes it can be so estimated. Proteids. — There is no known method of determining directly the per- centage of the proteids in the milk by a clinical examination, and a com- plete chemical analysis by an expert is the only one that can be accepted as accurate. It is possible, however, from a knowledge of the specific gravity and the percentage of the fat, to make an approximate calculation in regard to the percentage of the proteids, at any rate sufficiently close to determine whether in a given case they are near the normal, or are in very large or very small proportions. Holt has described a method in which the only instruments needed are a small hydrometer, a pipette, and a glass- stoppered cylinder graduated to one hundred parts and holding about 10 c.c. The specimen of milk for analysis should be taken from the " middle milk,' 1 and it is important that the milk should be freshly pumped and handled as little as possible, also that the graduated glass cylinder should be scrupulously clean, otherwise the milk will often sour before the cream has had time to rise. This is particularly true in summer. 15 c.c. (J ounce) is the amount of milk required for the test. In estimating the proteids certain suppositions must and can be fairly accepted : (1) Supposing the proteids to remain unaltered : if the percentage of fat be low, the specific gravity will be high, but if high, the specific gravity will be low. (2) Supposing the fat to remain unaltered : if the percentage of the proteids be high, the specific gravity will be high, but if the percentage of the proteids be low, the specific gravity will be low. If, therefore, the fat and the specific gravity be known, the proteids may be estimated by the following rules : (1) If the percentage of the fat be found to be high and the specific gravity high, that is, from 1033 to 1034, we may assume that the proteids are also of high percentage, otherwise the excessive fat would bring the specific gravity below the normal average. 126 PEDIATRICS. (2) If the fat be found to be of low percentage and the specific gravity high, we may assume the proteids to be nearly normal, since the high specific gravity is explained by the small proportion of fat. (3) If the percentage of fat be high and the specific gravity low, the proteids may be assumed to be normal, since the variation in the specific gravity is explained by the high percentage of fat. (4) If the percentage of fat be low and the specific gravity low, the percentage of the proteids is also low, since otherwise the small propor- tion of fat would make the specific gravity above the average. Of course it is only the wide variations in the proteids which can be recognized by these rules ; but these variations are often very impor- tant. We can then say that, knowing the specific gravity, and calculating the fats as three-fifths of the known percentage of the cream, we can judge whether the proteids are normal, very high, or very low in amount. Whereas only wide variations can be recognized by these rules, even these are often very useful. Holt asserts the estimation of the proteids of milk by this method to be as accurate as the estimation of solids by the specific gravity in examinations of the urine. Another method of estimating the percentage of proteids has been recommended by Woodward. Two " milk-burettes, " each of a capacity of 10 c.c, having a glass pinch-cock or valve and a narrow exit-tube about one inch long, each containing 5 c.c. of milk, are subjected to a tempera- ture warm enough rapidly to sour the milk — 35° to 37.8° C. (95° to 100° F.). They are allowed to remain in this temperature until a distinct pre- cipitate can be seen, which is in from eighteen to twenty-four hours. At the end of this time the milk has distinctly separated into an upper layer of viscid yellow fat, and a lower layer of fluid milk, quite opaque above, transparent below, and clinging to the sides of the tube. At the bottom there is a granular precipitate. The burettes are then cooled in water, the milk serum withdrawn into two graduated tubes, and 10 c.c. of Esbach's solution (picric acid, 5 gm. : citric acid, 10 gm. ; water, 500 c.c.) is added up to the 15 c.c. mark. The mixture is then stirred with a glass rod and placed in a hand centrifuge. The amount of centrifugation required is in direct proportion to the care used in separating the fat, and should be continued until there is a constant reading. This can be quickly ac- complished if the fermentation of the milk in the tubes is watched and the separation of the casein is made as soon as the precipitation is formed. The reading expresses in percentage the amount of total proteids in the milk. Sugars and Salts. — These may for clinical purposes be assumed to be about constant in all human milk, and in fact are practically shown to be by a large number of exact chemical analyses. Microscopic Examination. — The mere microscopic examination of milk beyond the determination of the presence or absence of colostrum cor- FEEDING. 127 puscles and foreign matters, such as pus, blood, and epithelial cells, is too uncertain and misleading to be in any way depended upon, the chemical analysis being the only practical method which can be recommended. The truth of this statement was lately impressed upon me when a physician skilled in the use of the microscope sent me a specimen of woman's milk which he stated was rich in fat, but which the analysis showed to have only a little over one and a half per cent, of this element. The presence of an undue amount of yellow coloring matter is at times very misleading. I have also seen human milk which had a greenish color, evidently produced by some of the micro-organisms which are known to occur in cow's milk, but the nature of which is not yet fully determined and which under the microscope are not represented by anything abnor- mal. CLINICAL SIGNIFICANCE OF THE CHEMISTRY OF HUMAN MILK. — There is no doubt of the great value of an expert chemical ex- amination of the milk in cases where an infant is not thriving, although apparently receiving a sufficient quantity of milk from its mother. On the other hand, we must remember that a chemical analysis will never give any information regarding the quantity of the milk, and it often hap- pens that when such an analysis has proved the quality to be good, the infant is not thriving because the quantity of the milk is very small. The symptoms which indicate that it is the quantity of milk which is at fault rather than the quality are that the breasts at the nursing time are soft, and that only a small quantity of milk can be extracted from them by the breast-pump. A period of nursing longer than the usual fifteen to twenty minutes before the child is satisfied should make us suspicious that the milk is lacking in quantity. We can also determine the actual quan- tity of the milk which the child has imbibed at an especial nursing by means of weighing, as described on page 59. A number of observations at different nursings in the day must, however, be made before a correct conclusion can be reached by this latter procedure. Konig, Forster, Meigs, Harrington, and others have analyzed the milk of a large number of women of all nationalities. An average of their results is expressed in the following table : TABLE 26. Average Human Milk. Reaction Amphoteric or slightly alkaline. Specific gravity 1028 to 1034. Water . 87 to 88 per cent. Total solids 12 to 18 per cent. Fats 3 to 4 per cent. Milk-sugar 6 to 7 percent Proteids 1 to 2 percent. Total mineral matter 0.1 to 0.2 per cent. Reaction. — According to Hammarsten, woman's milk is amphoteric in reaction instead of alkaline. Courant has shown by delicate chemical 128 PEDIATRICS. tests that the relation between the alkalinity and acidity in breast milk is as 3 to 1. Specific Gravity. — The specific gravity varies normally to a consider- able degree on account of the variations in temperature to which the milk happens to be exposed at the time when the specific gravity is taken. When, however, the milk has its average normal composition, and the temperature to which it is exposed is 15.5° C. (60° F.), its average spe- cific gravity is 1031. "Water. — One of the most important chemical facts to be remembered for clinical purposes is the very large proportion of water which is found in normal human milk, for it shows it to be a highly diluted food by which the best results can be obtained in infant feeding. It also indicates the care that should be taken not to overtax the comparatively slight power of absorbing a concentrated food which exists in the early months of life. Fat. — The fat of human milk is made up chiefly of palmatin, stearin, and olein. About two per cent, of the total fat consists of the glycerides of butyric, caproic, caprylic, and myristic acids. The production of animal heat is so very important a part of the infant's well-being that it is not sur- prising we should find so large a percentage of fat as well as of sugar in the food which is provided for it. The presence of fat in the milk is not only for the purpose of nutrition, but also as a means for the maintenance of bodily heat. This latter function of the fat cannot with impunity be trifled with, and is essential for active metabolism. A proper amount of fat is probably of great aid in the regulation of the faecal discharges. An amount of fat proportionate to the proteids is presumably necessary, or at least of great aid, in their proper digestion. We should naturally expect that unless the standard percentage of fat, or at least a near approach to it, existed in the mother's milk, trouble would be likely to arise with her infant, and this corresponds with my experience in cases in which the special ingredient which has interfered with the success of the nursing has been the fat. I have found clinically that when the fat was much lessened the nutrition suffered, that the digestion was not good, and that there was a tendency to constipation, while when its percentage was decidedly above the standard the digestion was weakened, there was a tendency to diarrhoea, and in con- sequence a resulting poor nutrition. These clinical observations at once suggest that in the management of infant feeding we must recognize the existence of two important con- ditions. One of these is the digestion of the infant, the other is its nutri- tion. These two requirements for a successful lactation are based on the facts that the milk may be easily digested but not nutritious, and that it may be highly nutritious but difficult to digest,. so that it is the equilibrium of these two conditions which produces a perfect infantile development. It is especially important that the percentage of fat in an infant's food should be within the limits of the normal variations which are found in the milk of healthy nursing women with healthy infants. For, although FEEDING. 129 it is admitted that a large percentage of surplus fat is frequently found in the faeces of infants whose digestion and nutrition are normal, and whose food is human milk, yet we have no more right to conclude from this that a small percentage of fat is sufficient for nutrition, or that a large surplus will be eliminated by the faeces, than we have to assume that there is too much oxygen in the blood because we find a certain surplus of oxygen in the arterial blood which is returned to the lungs in the pulmonary veins. In fact, it is far more probable that nature introduces a certain percentage cf fat into human milk with a purpose which can be accomplished only by that percentage, so that it is an error to change this percentage beyond the variation which commonly occurs in average human milk. Sugar. — The form of sugar which is found in human milk is called milk-sugar, or lactose, and has the highest percentage of all the elements constituting the total solids of the milk. The sugar is more digestible than the fat, but does not have so much potential energy — that is, so much heat-producing power in a given weight — as does the fat, which is to the sugar as 2.4 to 1. The conversion of milk-sugar into lactic acid gives rise to many of the changes occurring in milk. Proteids. — Although there have been a great many different opinions expressed as to the average percentage of the total proteids in human milk, Ave are led at present to believe that it is normally one or two per cent. Proteid is a general name including caseinogen and lactalbumin, which in its general features resembles ordinary serum-albumin, but the ultimate chemistry of these elements is still obscure. We recognize that this lactalbumin is present in small and variable quantities when the mammary gland and its secretion are in a normal condition, while at the time when the glandular function is being established, and during periods of glandular disturbance, it becomes proportionately larger in amount. According to Konig, who, in his comparative analysis of the caseinogen and lactalbumin in human milk, estimates the total proteids at 1.82, the caseinogen has a percentage of 0.59, while the lactalbumin is 1.23. The proteids, as a whole, are a valuable source of information to us when we are determining whether the milk is normal or abnormal, and in arranging an infant's food the relative proportions of the caseinogen and lactalbumin should be borne in mind. Mineral Matter. — The mineral matter, which is sometimes called the ash and sometimes the salts, has an average percentage of from 0.1 to 0.2. Up to the present time, although a certain number of analyses of the min- eral matter of human milk have been made, yet the results, for various reasons, have been deemed unsatisfactory. So large a quantity of milk is needed for a reliable determination of the percentage of each element which makes up the total amount, that this in itself has been an important reason for failure in accuracy. The determination of the mineral matter of cow's milk has not been attended with the same difficulty, and its per- centages have been estimated with comparatively reliable results. It has 130 PEDIATRICS. always been supposed that there is a radical difference between the per- centages of the mineral matter of cow's milk and that of human milk. The exact knowledge of the percentages which exist in the latter has become of still greater importance since such decided advances have been made in the modification of the elements of the former. With the view of making some advance in this difficult question, and of providing for the milk- modifiers of the future a more exact basis for perfecting a substitute food resembling as closely as possible the product of the human breast, I un- dertook, in the spring of 1893, to procure an unusual and sufficient quantity of human milk for analytical purposes. In the course of a few weeks, by means of the concerted action of numerous assistants, I col- lected five and a half liters (about six quarts) of human milk, which is an unusually large quantity for experimental purposes. This milk was im- mediately reduced to its mineral constituents in the laboratory of Dr. Charles Harrington. The analysis of this large amount of mineral matter was then made by Dr. Harrington and Dr. L. P. Kinnicutt, with the fol- lowing results : The Mineral Matter of Human Milk. Unconsumed carbon 0. 71 Chlorine 20. 11 Sulphur 2. 19 Phosphoric acid 10. 73 Silica 0. 70 Carbonic acid 7.97 Iron oxide and alumina 0. 40 Lime 15.69 Magnesia 1.92 Potassium 24. 77 Sodium 9.19 Oxygen (calculated) 6.16 100.54 Composition of the Mineral Matter calculated from the above Analysis. Uncombined carbon 0. 71 Calcium phosphate 25. 35 Calcium silicate 1.35 Calcium sulphite 2.11 Calcium oxide 1. 72 Magnesium oxide 1.91 Potassium carbonate 24. 93 Potassium sulphite 8.04 Potassium chloride 12.80 Sodium chloride 23. 13 Iron oxide and alumina 0.40 102.45 A closer approximation to the relative proportions of the salts in the form in which they occur in milk, calculated from the above analysis, may be stated as follows : FEEDING. 131 Calcium phosphate 23.87 Calcium silicate 1.27 Calcium sulphate 2.25 Calcium carbonate 2.85 Magnesium carbonate 3.77 Potassium carbonate 23.47 Potassium sulphate 8.33 Potassium chloride ■. 12.05 Sodium chloride 21. 77 Iron oxide and alumina 0.37 100.00 In comparing the previous analyses which have been made, and which can be found in Konig's Nahrungsmittel, II., 2 e Auflage, with this new analysis, we must remember that the previous analyses were made some years ago. In the last few years the processes which have been employed have been so much more exact that these results must be considered far more trustworthy than those made at an earlier date. It is not remark- able, therefore, that distinct differences should be found between this new analysis and the analyses which have hitherto been made, and pre- sumably this last analysis is the correct one. It has been made with the greatest care, and by means of the most improved technique, by two eminently competent and well-known chemists, who in their work have acted as controls on each other. In this way great precision has been attained. The residue obtained from the evaporation of about six quarts of woman's milk was extracted with naphtha to remove the fat, and then ignited at a very low temperature so as to prevent the volatilization of the chlorides. The ignition was accomplished by placing the residue from the naphtha extraction in a platinum dish which was supported on a platinum coil inside of a larger platinum dish, the latter being heated with a free flame. Even at this low temperature a partial change in the com- position of the ash took place, the sulphates being reduced to sulphites, but not to sulphides, as the ash on being carefully tested showed that sulphides were not present. All the carbonates of calcium and all the carbonates of magnesium were reduced to oxides. The ash also contained seven-tenths of one per cent, of unconsumed carbon. In woman's milk, naturally, there would be no free carbon. All the calcium that did not exist as phosphate would be in the form of sulphate and carbonate, not of sulphite and oxide as found in the ignited ash. The magnesium would exist as carbonate, not as oxide, and the potassium as sulphate, carbonate, or chloride. No sulphite of potassium would be present. The chief differences between this new analysis and all previous ones are as follows : (1) The phosphoric acid is less than half as much as previously re- ported. 132 PEDIATRICS. (2) The magnesium is also less than half as much. (3) Silica and alumina are present. They have not been returned in any previous analysis. Assuming the truth of the statement that the constituents of the mineral elements of human milk are subject to great fluctuation according to age and other causes, it is right to assume that the mineral matter ex- amined by Harrington and Kinnicutt, being the product of a large number of women, is a fair average specimen. The conclusions which we can draw from these chemical analyses are far from precise, owing to the variations which may occur and to the in- sufficient number of reliable analyses which have so far been made, but they enable us to work more intelligently. Variations in Milk. — We are led to expect that we shall find that when the milk is poor and does not agree with the infant there is an excess of proteids and a diminution of fat beyond what we have so far been able to determine as the normal average percentages of these two elements. Again, when a variation takes place in the milk it is more likely to be found in the fat and proteids, as already stated, than in the sugar or the mineral matter. It is also important to have a number of analyses made, on different days and at different times, in order that the error of an especial or temporary variation may be corrected. The im- portance of the assistance which can be gained from these analyses is, in my opinion, very great, and many more analyses should be made than we are now in the habit of deeming necessary. The question of expense should not for a moment be considered by those who can afford to have analyses made, for not only will real benefit come to their own children through money spent in this way, but these analyses, when published and collated, will prove of great value for the proper regulation of the feeding of infants in all classes of society. An error for which we must always allow may interfere with the true analysis of the milk which the infant has actually received in its stomach at the end of the nursing, and is one which must necessarily invalidate the information which we receive from our analysis. This subject has already been referred to in speaking of the changes which arise from slight causes and influence the special specimen which is being analyzed. Thus, we should recognize that the milk varies considerably in its percentage of fat and total solids in the different periods of a nursing, and that the composition of the milk which the infant has in its stomach may differ very widely from the composition of a specimen taken directly before or after the nursing. Harrington's analyses of the three periods of a milking will illustrate the meaning of what has just been said, and although they were made from the milk of a cow, yet knowing the closely analogous conditions existing in human and in animal milk, we shall find them equally valuable in explaining the corresponding changes met with in woman's milk. They are represented in this table (Table 27) : FEEDING. 13 TABLE 27. 1 Fore-milk" Fat, 3.88 Total Solids. 13.34 15 40 "Water. 86.66 84.60 82.87 Mineral Matter. 0.85 0.31 0.82 'Middle milk" 6.74 • Strippings" 8.12 17.13 Reiset and Peligot have also made analyses of the first, second, and third portions of ass's and cow's milk, with the result of showing not only the increase of solids at the end of a milking, but also that this in- crease is mostly of the fat, and to a lesser degree of the proteids, and that a short interval of nursing increases the solid constituents in proportion to the water, the reverse of this being true when the intervals are long. Heidenhain explains this physiological phenomenon by saying that his in- vestigations point towards the fact that during the pauses between the milkings the cells of the glands are growing. During this time a propor- tionately small amount of solids and a proportionately large amount of water are secreted, while the irritation of milking causes increased activity of the milk-cells, with a corresponding increase in the solid secretion and a lessening of the water. Harrington's analyses of woman's milk showing the " strippings" of a two-hours interval and the " fore-milk" of a twelve-hours interval are also of considerable interest : ' ' Strippings, " " Fore-Milk, ' ' 2-hours Interval. 12-hours Interval. Total solids 15.32 10.14 Water 84.68 89.86 100.00 100.00 With these chemical and physiological facts before us, we are forced to acknowledge that we must be very circumspect in the conclusions which we deduce from such analyses of human milk as have been made up to the present time. An error in these conclusions, when a correct chemical analysis has been made, is less likely to occur from the sugar and the mineral matter than from the proteids and the fat. Reasoning from the strong analogy which must exist between human milk and cow's milk, and being aware of the great variations which occur in the latter, we may assume that human milk is liable to vary in its com- position considerably with different milkings on the same day, and also with the milkings of the same hours on different days, so that at present we are not in a position to state that our knowledge of human milk is sufficiently exact to justify an attempt to formulate a table to show the composition of woman's milk at different periods of her lactation, however valuable such information may in the future prove to be. We must also understand that human milk of normal quality, and proving to be equally nutritious to the special infants that are fed on it, may vary considerably in the percentages of all its elements, and in the combinations of these percentages. This feet is well illustrated in the following table, showing the analyses o( fourteen 134 PEDIATRICS. specimens of human milk all differing in the combinations of their dif- ferent elements : TABLE 28. (Harrington.) Human Br east- Milk Analyses. [Mothers healthy, and infants all digesting well and gaining in iveight.) I. II. III. IV. Y. VI. VII. Per Cent. Per Cent. Per Cent. Per Cent. Per Cent. Per Cent. Per Cent. Pat 5.16 4.88 4.84 4.37 4.11 3.82 3.80 Milk-sugar 5.68 6.20 6.10 6.30 5.90 5.70 6.15 Proteids^ 4.14 3.71 4.17 3.27 3.71 1.08 3.53 Mineral matter . 0.17 0.19 0.19 0.16 0.21 0.20 0.20 Total solids. ... 15.15 14.98 15.30 14.10 13.93 10.80 13.68 Water 84.85 85.02 84.70 85.90 86.07 89.20 86.32 TcXXOO 100.00 100.00 100.00 100.00 100.00 100.00 VIII. IX. X. XL XII. XIII. XIV. Per Cent. Per Cent. Per Cent. Per Cent. Per Cent. Per Cent. Per Cent. Pat 3.76 3.30 3.16 2.96 2.36 2.09 2.02 Milk-sugar 6.95 7.30 7.20 5.78 7.10 6.70 6.55 Proteids 2.04 3.07 1.65 1.91 2.20 1.38 2.12 Mineral matter 0.14 0.12 0.21 0.12 0.16 0.15 0.15 Total solids 12.89 13.79 12.22 10.77 11.82 10.32 10.84 Water 87.11 86.21 87.78 89.23 88.18 89.68 89.16 100.00 100.00 100.00 100.00 100^00 100.00 100.00 All these specimens of milk were obtained from healthy mothers, and in every case the infant was thriving. In a number of these cases, how- ever, when one of the infants which was doing well on its own mother's milk was fed with one of the other combinations, it soon became sick, and had to be changed back to the one adapted to its digestion. Human milk may, then, be considered to represent not an especial food but a combina- tion of foods, and its fat, sugar, proteids, and mineral matter to represent these different foods. In other words, we find by experience that the digestive capabilities of infants differ, just as do those of adults, and that nature provides a number of varieties of good human milk adapted to the varying idiosyncrasies of infants. BACTERIOLOGICAL EXAMINATION.— Although human milk is usually considered to be sterile, except in some cases in which the woman is diseased, yet Cohn and Neumann have examined the milk of forty-eight healthy women and have found bacteria in forty-three cases. These or- ganisms were mostly represented by the staphylococcus pyogenes albus, with a few of the staphylococcus pyogenes aureus and the streptococcus pyogenes. They found fewer bacteria when the breast had been emptied a short time previously, and more when there had been a stagnation of the milk in the breast. More bacteria were also found in the first few drops than in the last ones, and from their experiments they concluded that the bacteria enter the nipple from without. The conclusions deduced from their experiments, as well as from the experiments of others who have met with similar results, seem to show practically that bacteria can FEEDING. 13 1 enter the ducts of the nipple and penetrate to a greater or Jess distance; also that the milk in its course from the gland to the nipple washes out the bacteria, and that we can in this way account for the presence of these organisms in the milk which is first drawn from the breast, and their absence from that which comes later. MANAGEMENT OP POOD IN EARLY DAYS OP LIFE. Young animals at birth begin to receive their nourishment immediately, and a corresponding increase in their weight takes place from the first day of life. The human infant in like manner should begin with its nursing early, getting what it can from the breast until the full supply of milk has come. In this way it will not be so likely to have a large initial loss of weight to regain, a condition by which it is often handicapped at the very beginning of its career, when there is most danger to be apprehended from a depression of its vitality. Every day, every hour, is of the utmost im- portance in the early days of life, and provided it can be done without detriment to the condition of the mother, the sooner the infant is put to the breast the better it will be. During the first twelve hours of life, and in most cases during the first twenty-four to thirty-six hours, owing to the inability of the mother to supply milk for her infant, scarcely any food is, as a rule, obtained. If during this period the infant is restless and evi- dently hungry, 5 to 10 c.c. (1 to 2 drachms) of a sugar solution may be given at intervals of two or three hours. This solution should be made by dissolving milk-sugar in sterilized water, and its strength should be from five to six per cent. If the mother's milk is delayed still longer, something additional must be given to the infant, and in these cases the following prescription is useful : Prescription 2. Fat 1.00 Sugar 5.00 Proteids 0. 50 Reaction slightly alkaline. 10 feedings, each 30 c.c. ( 1 ounce). To be heated for thirty minutes at 75° C. (167° F. ). Intervals of Feeding. — The younger the infant the greater the meta- bolic activity, and hence the greater need of frequent feeding, for food is required not only for repair of waste, but also for the infant's rapid pro- portionate growth. This, with the increased demand for additional animal heat, makes essential the regulation of the intervals of feeding according to the age. The intervals constitute a very important part of the management o( breast feeding, when the quantity is regulated by the breasl it sell'. These intervals should be definitely stated to the mother at different times throughout the nursing period, and should be adhered to. The following table represents the intervals for an average breast-ted infant, but it should be understood that the intervals of feeding should be made to correspond to the stage of development of the individual. 136 PEDIATRICS. TABLE 29. The day feedings are supposed to begin at 6 A.M. and to end at 10 P.M. Age. rom birth to 4 weeks " 4 to 6 " " 6 to 8 Intervals. .... 2 hours ....2 " ... 2i " Number of Feedings in 24 hours. 10 9 8 Number of Night Feedings. 1 1 1 " 2 to 4 months . . . . .... 21 u 7 " 4 to 10 " 3 " 6 " 10 to 12 " ....3 " 5 When the milk has begun to be produced in the breast, the infant should be fed once in two hours during the day and once during the night until it is six weeks old. The day feedings are usually reckoned from 6 a.m. to 10 p.m. This interval of two hours should be adhered to, allowing that exceptional circumstances may arise in which the physician must judge according to the individual case, until the sixth or eighth week is reached, when the intervals may be made two and one-half hours, and the number of feedings in the twenty-four hours eight. At about the fourth month the intervals can be made three hours, and the number of feedings six. When the infant is two or three months old, the night feeding can be omitted. The number of feedings at ten months may be reduced to five. Allowing the mother to have as many hours of continuous sleep at night as possible is especially important, in order that she may not be exhausted by the lack of that regular and sufficient rest which is of the utmost necessity for the production of a normal milk. Irregularity in nursing, too frequent nursing, and too prolonged inter- vals often so disturb the quality of human milk as to transform a perfectly good milk into one entirely unfitted for the infant's powers of digestion. Thus, too frequent nursing lessens the water and increases the total solids in human milk, making it resemble in a certain way condensed milk; while too prolonged intervals result in such a decrease of the total solids as to render an otherwise good milk too watery and unfit for purposes of nutrition, however well it may be digested. The lesson that may be drawn from these facts is that some general rules for the feeding intervals should not only be recommended but enforced. The mother should neither injure her infant's digestion by nursing it too frequently, and thus giving it a too concentrated fluid, nor, by neglecting to feed it often enough, interfere with its nutrition by giving it a food that is too diluted. Regimen of Lactation. Diet. — The diet of the nursing mother should not essentially differ from what would be considered to be a healthy one for her at any time. There is no special diet which, under all circum- stances, is best for all nursing women during the period of their lacta- tion. In the early days of the puerperium there is, as a rule, more danger of overfeeding than of underfeeding the mother. The tendency is to give too much meat and solid food, with the result that when the FEEDING. 137 secretion of the milk is being established the total solids are increased to a degree beyond the capacity of the still undeveloped digestive function of the infant. Infants in the early days and weeks of life thrive better on a milk that shows a high percentage of water in proportion to that of the total solids. A rule which has in my experience become almost an axiom is that the age of the individual infant is in inverse proportion to its powers of absorbing solid food, and in direct proportion to the need of a large amount of water in its food. A light and plentiful diet should therefore be given to the mother while she is confined to her bed. This diet should consist of milk, gruels, soups, vegetables, bread and butter, and after the first week a small amount of meat once during the twenty- four hours. When the mother is able to go out of the house again, and has resumed her usual habits, the quality of the diet can be very much increased, and she can have the usual variety of food represented by meats, vegetables, milk, fruits, and cereals. There are no special kinds of food which are contra-indicated, provided we keep the food within the limits of the ordinary articles which commonly represent a plain but nutritious diet. It is very important for the nursing mother to have her meals at regular intervals, and during the early part of the lactation to take food somewhat more frequently than when she is not nursing. The additional meals, as a rule, should be made up of milk or cocoa. There does not seem to be any advantage in adding any special beverages, such as beer, malt, or stimulants, to her diet. She should receive as much milk as is compatible with her digestion, and should drink a plentiful supply before retiring at night. This wide range of food for the nursing mother has been recommended with a purpose. The food of the nursing woman is without doubt closely connected with that which she provides for her infant. Various substances are eliminated by the mammary gland, and we should therefore impress upon mothers the importance of a carefully arranged diet when they are nursing. Certain vegetables, and sometimes fish, will in individual cases affect the milk and cause discomfort to the infant. We must, then, in every case, seek to determine which article of diet may cause disturbance in the special woman's milk secretion, and eliminate that article. We should, however, be very careful not to prohibit this special article of diet from the regimen of a large number of women to whom it might be of benefit rather than of harm, simply because it has affected the milk of a few women. For the average woman a plain mixed diet, with a moderate excess of fluids and proteids over what she is nor- mally accustomed to, will, as a rule, give the best results. Exercise. — Exercise has so constant an influence on the changes which take place in the daily secretion of the milk, that the mother should be encouraged to be out of bed and to walk about her room as soon after her confinement as is possible without injuring tier physical condition. Exercise is so important for promoting the proper elaboration and equi- librium of the milk secretion during the entire period of lactation, that it 138 PEDIATRICS. should always be insisted upon, and regular hours for walking should be as definitely arranged during the day as the hours for eating. The exer- cise must, however, be in accordance with the strength of the special woman, for fatigue has the same deleterious influence on the production of the milk as has lack of exercise. DISTURBED LACTATION. — The disturbances which are liable to occur in the course of lactation are frequent and varied. They should be studied carefully and recognized at once when they occur, or the continu- ation of the lactation may not only be interfered with but be prevented entirely. When colostrum corpuscles are found after the first two weeks of life the milk should be looked upon with distrust, and special efforts should be made to discover the reason of their persistence, and to prevent the dangers which are liable under these circumstances to arise. These dangers may be not only from combinations of the milk elements which are incompatible with the infant's digestion, but also from the disturbances which may arise from the free mammary elimination of foreign material. Drugs. — We know that during periods of mammary disturbance there is a much greater possibility, than when the gland is in a normal condition, of the direct transudation from the blood of such inorganic substances as arsenic, antimony, lead, iodide of potash, mercury, and others, taken by the mother. Well-authenticated cases come to our notice from time to time in which injury has been done to the nursing infant in this way, and in which even death has occurred from the elimination by the breast-milk of certain organic substances, such as colchicum and morphine. The greatest variety of substances have been found in the milk, but no definite rule as to the amount of this elimination has yet been established, so that our knowledge of the existence of this process is valuable as a prophylactic against harm, rather than as a means of direct benefit to the infant in disease. We must also recognize the clinical fact that this elimination may occur at any time during the nursing period in the breasts of women who, so far as we can ascertain, are in a perfectly healthy condition. Thus, every practitioner has at times doubtless observed the laxative effect on the infant of such drugs as compound liquorice powder given to the mother ; and a case has lately come to my notice where an infant vomited for weeks while taking the milk from the breast of its mother, who was unusually well and strong, but who was in the habit of drinking a considerable quantity of porter daily. After the porter was omitted the vomiting ceased at once, and did not return. These facts warn us that the use of drugs during the period of lactation should be far more limited than at other times, and that the medicinal treatment of disease in infants is exceedingly inexact. Saline cathartics may not only act unfavorably on the infant through the mammary excre- tion, but may lessen very decidedly the flow of the milk, and even stop it altogether. FEEDING. • 139 Menstruation. — In deciding whether a return of the menstrual period necessarily contra-indicates the continuation of nursing we cannot adopt and follow an inflexible rule, but must be guided by what seems best for the individual case. Infants are at times affected so seriously by the alter- ation in the constituents of the milk which occurs once in four weeks that their nutrition is markedly interfered with, and a change to a more stable food is indicated. Again, the only disturbance which may arise is a tem- porary and slight digestive attack for a day or two, which apparently does not materially affect the infant, and makes us hesitate to run the risk of depriving it of a food on which it thrives during twenty-six days out of twenty-eight. It is better not to be too hasty in concluding from the bad symptoms in the infant that we should at once withdraw it permanently from the breast, for the catamenia may appear once, and then not again for a number of months, the infant's powers of digestion in the mean time becoming so much more fully developed that they are unaffected by the milk of the catamenial period. Even when the catamenia recur regu- larly, the disturbance which may have been great at one period may for many reasons fail to recur at the next ; so that the question is reduced to whether the composition of the milk shows a recovery of the equilibrium of its constituents within a few days, or remains affected to such a degree as to endanger the integrity of the infant's nutrition. My own experience is in favor of allowing the infant to continue with the breast, unless it is decidedly contra-indicated by circumstances such as have just been mentioned. I have seldom met cases which could not without permanent injury be tided over the small amount of temporary digestive disturbance which may arise. There have, as yet, been too few analyses made during the catamenial period to justify us in drawing any definite conclusions as to the chemical status of the question ; but the probability is that the milk will be found to be deficient in fat and to have its proteids increased, following the general rule of disturbed mammary secretion, and that consequently it is in a condition to interfere temporarily with both digestion and nutrition. Pregnancy. — A much more serious question arises when the nursing mother becomes pregnant ; for here the almost universal clinical experi- ence is that the infant, for various reasons, cannot continue to be fed by its mother, it being unusual for a woman to have sufficient vitality to nourish properly her living child and growing foetus. The danger of reflex miscarriage from the continual irritation of the mammary gland by nursing I personally have had no experience with, but this is mentioned as one of the dangers contra-indicating the continuation of nursing by a pregnant woman. We must, however, here also not judge hastily, but take all the circumstances of the case into consideration before deciding on a measure of such vital importance to both child and foetus. 11' the mother remains strong and vigorous, and the analysis of her milk shows no deterioration, while the infant is a delicate one just beginning to thrive on its rightful 140 ' PEDIATRICS. supply of natural food, or if it is during a hot period of the year, and especially when a wet-nurse or feeding from a milk-laboratory cannot be employed, it will often be wiser to take some risk and continue the nursing for a certain time, perhaps six or eight weeks, and then, according to circumstances, gradually to substitute another food. Almost every case will differ in the questions to be decided, and must be judged on its own indications and contra-indications, always, however, recognizing the accepted rule that lactation and pregnancy are usually incompatible. Management of Disturbed Lactation. — The nursing mother is inclined to believe that if she feels well and strong her milk must be good for her infant under all circumstances. She therefore frequently transgresses the rules which are necessary for keeping her milk in equilibrium, and she should be made to understand that sometimes abnormal variations are liable to arise, however good her general health may be. She is simply fulfilling a task demanded by nature from those who bear children, and her duty, when once she has undertaken to nurse, is to prevent as much as possible these variations by regulating her life to a normal standard and avoiding excitement. Both of these requisites of a normal lactation come within the province of the physician to explain as he would any other branch of rational medicine. He should impress upon her that emotional mothers do not make good nurses, and that the physiological influence of the emotions on the nervous system, with its resulting changes in the mammary secretion, has necessarily a much wider range in women who are subjected to the customs and vicissitudes of modern life than it has in those who live in a more natural way. The following table shows the percentages and combinations which are likely to occur in abnormal milk : TABLE 30. Showing typical analyses of a normal, a poor, an over-rich, and a bad human breast-milk. Normal Milk. Over-rich Milk. Bad Milk. (Healthy life Poor Milk. (Rich feeding ; (Pregnancy. as to exercise (Starvation.) lack of exer- Disease, etc.) and food.) cise.) Fat 4 1.10 5.10 0.80 Sugar . . 7 4.00 7.50 5.00 Proteids = . . 1.50 2.50 3.50 4.50 Mineral matter 0.15 0.09 0.20 0.09 Total solids 12.65 7.69 16.30 10.39 "Water 87.35 92.31 83.70 89.61 100.00 100.00 100.00 100.00 The terms poor and bad milk are merely relative, and in common use do not have a definite meaning. I have adopted the terms for the pur- pose of simplicity and to distinguish a milk which can be restored easily to a normal condition from one in which the difficulty of such restoration is very great. By a poor milk I mean one which represents a condition of lack of nourishment or starvation in the mother, but one which can easily FEEDING. 141 be changed by the proper feeding of the mother. In this case the normal mechanism of the mammary gland has not been interfered with. By a bad milk I mean one which represents a profound disturbance of the mechanism of the mammary gland produced by many causes, disease, pregnancy, and especially extreme nervous conditions in the mother, and one which cannot be easily changed to a good milk. The following are some of the rules which will be found of use in managing a case of disturbed lactation : General Principles for Guidance in managing a Disturbed Lactation. To increase the total quantity Increase proprotionately the liquids in the mother's diet, and encourage her to believe that she will be enabled to nurse her infant. To decrease the total quantity Decrease proportionately the liquids in the ( Rarely necessary. ) • mother's diet. To increase the total solids Shorten the nursing intervals ; decrease the exercise ; decrease the proportion of liquids in the mother's diet. To decrease the total solids Prolong the nursing intervals ; increase the exercise ; increase the proportion of liquids in the mother's diet. To increase the fat Increase the proportion of meat in the diet and of fats which are in a readily digestible and assimilable form. To decrease the fat Decrease the proportion of meat in the diet. To increase the proteids Decrease the exercise. (Very rarely indicated.) To decrease the proteids Increase the exercise up to the limit of fatigue for the individual. In attempting to formulate rules we must understand that we are dealing with a subject of which very little is known definitely. I can, therefore, at present only state my experience in a large number of cases, and give some general idea of how we can recognize whether we are deal- ing with a bad or poor milk rather than with a normal variation of a good milk. This knowledge of the variations which take place in human milk is of the utmost clinical importance during the period of lactation, for it is the only means by which we can decide definitely and intelligently many vital questions in this period. Instances have continually been brought to my notice where infants have been allowed either to continue with their mother's milk when they were not thriving on it, simply because it was mother's milk, or, on the other hand, have been weaned from their mothers for what would evi- dently have been insufficient reasons had the case been thoroughly under- stood. In both instances a proper knowledge of what can be done with human milk — that is, with the management of its different constituents by increasing or decreasing their relative proportions — would have been of benefit to both mother and child, and in some cases would have saved the life of the latter. This lack of knowledge, or rather lack of adaptation o( 142 PEDIATRICS. the knowledge which we possess of this branch of medicine is, to say the least, reprehensible, and in other branches of our art, which are more intel- ligently and carefully studied, would be deemed inexcusable. Physicians are continually stating to their patients that human breast-milk is the best food for infants, and at the same time are content to ignore the very principles which would make their statements true. We should under- stand that when we speak of the superiority of breast-milk as a food, we mean good average breast-milk and for the average infant. In all these cases of disturbed lactation we must determine whether the symptoms in the infant are really caused by a disturbance of the milk- supply. We ascertain first whether the supply of milk is sufficient in quantity by the methods already described. We then investigate the quality of the milk. A chemical analysis shows us whether the percent- ages of the different elements are (1) normal or (2) abnormal. If we find them to be normal, we know that it is not the milk which is disturb- ing the infant, and we must seek for the cause of the disturbance in other sources beyond the breast. If we find the percentages to differ decidedly from those of average human milk, we must determine whether it is the va- riation from the normal average percentages or combinations of percentages which is producing the trouble, or whether these percentages are really well adapted to the infant and the cause of the trouble is to be looked for else- where. This can be done only by changing the different percentages and their combinations and watching the result. If we find them abnormal, we can usually determine whether it is one or several of the elements which are producing unfavorable symptoms, and we should endeavor by our treatment to change the percentages of these elements so as to cor- respond first to the normal average percentages, and then, if this is not sufficient, to reduce them to lower percentages than the average until the infant's digestive functions have recovered their equilibrium. We must not forget in applying these principles that the cause of the disturbance of the milk may exist in some abnormal condition of the mother, whether physiological or pathological, and that this cause must first be removed or we shall fail to regulate the milk. A sedentary life, with abundance of rich, mixed food, provided the woman has a strong, healthy digestion, appears to increase the total solids and to decrease the water. This increase is almost always in the fats and proteids rather than in the sugar and mineral matter ; in fact, the marked variations in human milk are almost always shown in the fat and proteids, and hence our attention must almost invariably be directed to correcting these elements. This is fortunate, as we know of no special treatment, except on very general principles, by which we can alter the pro- portion of sugar or salts to the other constituents. A meat, or rather a nitrogenous, diet and fat in an easily digestible and assimilable form in- crease the fat in breast-milk. The proteids are more difficult to deal with. They have a tendency to increase in very bad and in very rich milk. The FEEDING. 143 problem which we have to solve is almost always how to decrease them, no matter what the milk is. Our knowledge, unfortunately, concerning a sure means of reducing the proteicls is very limited. Practically, how- ever. I have found that when the woman is in good health it is physical exercise which we must insist upon, preferably walking in the open air and within the limits of fatigue. A walk of from one to two miles twice daily I have found to be about what the average healthy woman in New England needs to reduce the percentage of the proteids in her milk ; but the amount of exercise must be carefully regulated according to the physical capabilities of the individual. Bearing in mind these simple rules, and having determined, by means of an analysis or analyses, the cause of the special disturbance, it is often possible to regulate the nursing period in cases in which a lack of this knowledge would necessitate weaning. In this way also serious harm to the infant may be avoided. The following tables represent the changes which took place in the milk in certain cases of disturbed lactation. TABLE 31. ( Hum an Mi Ik.) Showing the influence of a luxurious life on a poorly fed but healthy ivet-nurse. Normal. Two days before change of food. Fat , , ... 4.00 0.72 Sugar 7.00 6.75 Proteids 1.50 2.53 Mineral lxiatter . ,.. 0.15 0.22 Total solids 12.65 10.22 Water, .„, 87.35 89.78 100.00 100.00 III. IV. tich food and little exercise a month. but for Food and regula 5.44 5.50 6.25 6.60 4.61 2.90 0.20 0.14 16.50 15.14 83.50 84.86 100.00 100.00 TABLE 32 ( Human . Milk ) Showing a bad milk and one which it was impossible to manage on account of the continued recurrence of the same cause, uncontrolled emotions. Normal. Fat ... 4.00 Sugar .....,, 7. 00 Proteids 1.50 Mineral matter 0. 15 Total solids 12.65 Water, 87.85 100.00 Emotions causing dis- turbance in infant's digestion. 0.62 5.80 4.21 0.20 10.83 89.17 100.00 144 PEDIATRICS. Showing TABLE 33. [Human Milk.) milk possible to manage, because the mother , though excitable, was able and willing to control her emotions. Fat Sugar Proteids Mineral matter. . . Total solids Water Normal. Infant doing badly. Colic. Mother before treatment. Infant doing well. Mother after treatment. Wet-nurse pro- vided but not used 4.00 1 62 3.20 3.04 7.00 6.10 6.40 6.60 1.50 3.54 2.52 2.32 0.15 0.17 0.18 0.12 12.65 11.43 12.30 12.08 ■ 87.35 88.57 87.70 87.92 100.00 100.00 100.00 In the above case the mother was very nervous and wished to nurse her infant, but thought that she could not, as she had been discouraged by her nurse and physician. She was then told that she could nurse in a week, if in the mean time she took proper food and exercise and withdrew the infant from the breast. This she did, and had her breasts regularly pumped, with good results. TABLE 34. (Huma?i Milk. ) Showing the effect of the catamenia on human milk. Normal Catamenia, Seven Days after Forty Days after Second Day. Catamenia. Catamenia. Eat 4.00 1.37 2.02 2.74 Sugar 7.00 6.10 6.55 6.35 Proteids 1.50 2.78 2.12 0.98 Mineral matter. . . 0.15 0.15 0.15 0.14 Total solids 12.65 10.40 10.84 10.21 Water 87.35 89.60 89.16 89.79 100.00 100.00 100.00 100.00 TABLE 35. (Human Milk.) Showing a milk in which the proteids, which were disturbing the infant, could not be reduced until the mother was made to walk comfortably, a?id thus without fatigue. Eat Normal. 4.00 7.00 1.50 0.15 . 12.65 . 87.35 Infant and Motl no very with colic vomiting. ler taking exercise and rich food. 3.05 Su°;ar.. . 6.10 Proteids 3.89 Mineral matter. . ids 0.16 Total sol Water. . 13.20 86.80 100.00 100.00 Infant as before. Mother walking- Infant doing well. two miles daily, Mother walking but having blis- two miles. Easy ters from uncom- shoes, no blisters. fortable shoes. 0.65 3.34 5.25 6.30 3.82 2.61 0.18 0.16 9.90 12.41 90.10 87.59 100.00 100.00 FEEDING. 145 TABLE 36. {Human Milk.) Showing how a milk can be managed while the nursing is continued. Infant two \\ r eeks Normal. old, with serious general nervous symptoms and pain. Mother eating much meat and taking Mother walking and eating less meat. Infant entirely well. Infant four months old, with pain and diar- rhoea. Mother not walking so much. Infant doing well. Mother walking two miles daily. Milk diluted one- fifth. no exercise, Fat 4.00 3.44 2.09 3.98 3.19 Sugar 7.00 5.60 6.70 7.00 5.60 Proteids 1.50 3.96 1.38 2.22 1.78 Mineral matter 0.15 0.20 0.15 10.32 0.19 0.16 Total solids. .. 12.65 13.20 13.39 10.73 Water 87.35 86.80 89.68 86.61 89.27 100.00 100.00 100.00 100.00 100.00 As is seen from the last analyses, the infant did not do well until the mother began to exercise, and at four months it was again affected by apparently the high percentage of the proteids. The infant was consid- erably under the weight corresponding to that of the average infant of four months. It was found to nurse twenty-five minutes at a time, and by calculation from its weight before and after nursing, it was found to take from 80 to 120 cc. (20 to 30 drachms). This amount being larger than the probable size of its stomach demanded, the time of the nursing was reduced to twenty minutes, and 20 cc. (5 drachms) of sterilized water were given in the middle of the nursing, thus changing the percentages in the milk to the figures which are represented in the last column. This calculation is on the basis of 100 cc. (25 drachms) to each nursing. So long as this method of feeding was adhered to, the infant did well. It was evidently a case in which the infant could not digest over two per cent, of proteids. TABLE 37. [Human Milk.) Showing that even for a long interval the breasts may be pumped and the result be a successful nursing. Normal. Fat 4.00 Sugar 7.00 Proteids 1 . 50 Mineral matter 0. 15 Total solids 12.65 Water 87.35 100.0(T Infant showing nervous Infant showing no uric symptoms and much acid and thriving. Mother walking two miles and nor eating much meat. 2.67 6.60 3.18 0.17 uric acid. Mother taking no exercise and much rich food. 5.71 4.00 4.29 . 0.19 14.1!) 85.81 100.00 12.62 87.38 100.00 10 146 PEDIATRICS. In this case the infant was withdrawn from the breast temporarily, and the breasts pumped for twenty-seven days. When the analysis presented the figures seen in the last column, the milk was treated by diluting it, as in the previous case, and the infant was put back to the breast. TABLE 38. [Human Milk. ) Showing the value of retaining the breast-milk by managing even an unpromising case. Infant with colic and failing. Infant put on Mother no ex- bottle. Breasts Exercise in- ercise, nursing pumped every creased to two Eating much irregularly, four hours. miles. Small meat. Exer- Normal. irregular and Moderate ex- amount of cise the same, improper ercise. — one meat, sweet food. mile. Full Nervous, wor- regular diet, ried condition. Tranquil. Fat 4.00 0.34 3.24 2.79 4.84 Sugar 7.00 5.40 5.45 5.05 6.00 Proteids 1.50 3.61 3.95 3.66 3.42 Mineral matter... 0.15 0.18 0.16 0.20 0.17 Total solids 12.65 9.53 12.80 11.70 14.43 "Water 87.35 90.47 87.20 88.30 85.57 100.00 100.00 100.00 100.00 100.00 The last case represents a bad milk from the failure of the healthy mother to conform to the rules of lactation. This bad milk, represented in the second column, had to be made into a rich milk by regular feeding before any attempt could be made to alter the ratio of the constituents. The proteids were then reduced somewhat by exercise, and, after the breasts had been pumped for two weeks, the analysis showed the percent- ages as represented in the last column. The milk was then diluted with sterilized water, and the infant was put to the breast and did well ; in fact, was carried through an attack of retro-pharyngeal abscess with this breast- milk. The decrease in the total quantity of the milk is of ordinary occurrence at any time during lactation, but it is most common among civilized races at about the eighth to the tenth month. When it occurs early in the lac- tation it is very disheartening to the mother if she is desirous of continuing her nursing. She becomes fearful that the flow of milk may stop alto- gether, and the nervous influence thus brought to bear on the mammary gland tends to increase the disturbance. We should therefore encourage her to believe that the milk will return. The following case illustrates what has just been said : The mother was much discouraged because her milk lessened in quantity early in the lactation, and she was convinced that it wo.uld not return. She had been taking, without my knowledge, a disproportionately small amount of fluid in her diet. There was an element in this case which the intelligent nurse brought to my notice, — namely, that the infant was not vigorous, and when put to the breast sucked feebly and called upon the gland for very little milk. Reacting to this lack of stimulus, the FEEDING. 147 gland, although in a normal condition, secreted only the small amount demanded by the infant, and the milk lessened day by day. Treatment was instituted on the sup- position that the mammary gland is practically self- regulating as to the amount of food which it will elaborate at a given nursing. If it happens to be called upon to nourish twins, it will increase the amount of its supply. If the infant which is put to it has a small gastric capacity, it will produce the amount needed for that capacity. I assured the mother that the milk would return, and I treated directly the mammary gland itself. An increase was made in the amount of liquid in the mother's diet, and the breasts were, after each nursing, pumped gently, skilfully, and thoroughly. The breast-pump supplemented the feeble action of the infant, and when more work was required of the gland it began to produce more milk. The increase in the liquid diet supplied the gland with materials to work with, and its mechanism ceased to be dis- turbed by the nervous influence emanating from the mother. She became cheerful when she found the milk returning, while the infant, now that the milk could be procured more easily, demanded more, sucked more vigorously, and thus satisfied the sensitive mechanism of the mammae. The next case points to the possibility of our being at times too hasty in the decision to deprive an infant of its mother's milk. The mother, a rather delicate primipara, twenty-five years of age, was delivered of a boy seven pounds in weight. Within four hours puerperal convulsions set in, from which she recovered, but was left with albuminuria 0.25 per cent, and casts. The latter disappeared in a few days, but the albumin, although somewhat dimin- ished, continued ; and the patient, naturally of a calm disposition, was in a highly nervous condition, fearing that she could not nurse her infant, but decidedly opposed to having a wet-nurse. The milk appeared in considerable quantity on the fifth day, but the infant did not thrive, and, although it gained somewhat in weight, was very fretful, slept very little, and looked ill, so that the attending physician became alarmed, and after treating it for its dyspepsia without much success until it was five weeks old, and finding that there was still about 0.25 per cent, of albumin in the mother's urine, decided with me that the breast-milk should be withheld until we could determine the cause of the trouble, and an analysis was accordingly made, with the following result : Fat 1.62 Sugar 6.10 Proteids , 3. 54 Mineral matter 0. 17 Total solids 11.43 Water 88.57 100.00 This analysis suggesting the probability that the large amount of proteids was causing the disturbance of digestion, and that the small amount of fat was not suffi- cient for nutrition, the attending physician was very anxious to procure a wet-nurse ; but while we were endeavoring to get a proper one, we decided to empty the mother's breasts with the breast-pump every day, thus relieving her from the worry of attempt- ing to nurse her infant and seeirfg it fail to gain. She also obtained in this way un- disturbed nights and a great deal of out-door life. The infant was in the mean time placed on a substitute food, which was digested very well, and. as it ceased to cry. the mother's mind became tranquil, and the albumin in her urine in a few days was reduced to a trace. The treatment was carried out for a week, the milk continuing 148 PEDIATRICS. to flow freely, and an analysis (I.) was then made of the mother's milk and also of that of a healthy wet-nurse (II.) whose infant was thriving on its mother's milk. I. II. Mother. Wet-Nurse. Fat 3.20 3.04 Sugar... 6.40 6.60 Proteids 2.52 2.32 Mineral matter 0. 18 0. 12 Total solids 12.30 12.08 Water 87.70 87.92 100.00 100.00 The two milks being equally good, it was decided to allow the infant to begin to take one nursing daily from its mother, although the proteids were still about one per cent, higher than the infant seemed likely to digest ; it was given to its mother, nursed well, seemed satisfied, digested its meal without trouble, and at six months was still being nursed and was thriving. The next case illustrates the principle that too frequent nursing lessens the water and increases the total solids in human milk, making it re- semble in a certain way condensed milk. It also illustrates what has been stated concerning the two important questions to be considered in the management of a normal lactation, — namely, that the digestion as well as the nutrition must be regarded. This case is one of the numerous in- stances of the same kind which have come to my notice, and also empha- sizes the fact that infants are often weaned from the breast when there is not the slightest necessity for it. The mother, a healthy primipara about twenty-two years old, had nursed her infant for six weeks, during which time the infant was fretful, suffered much from colic, and never seemed satisfied. There was, however, a continual gain in weight, although the faecal discharges showed evidence of the food not being properly digested and were numerous and watery. By advice of the attending physician, the infant was weaned. The mother came to me for advice in regard to placing her infant on a substitute food. On inquiry I found that this infant had been nursed almost continu- ously night and day, with intervals usually of only one hour, and it was evident that the frequent nursings had resulted in producing a concentrated milk which the in- fant's gastro-enteric tract was rebelling against and was not digesting, although suffi- cient food was being absorbed to prevent up to this time any interference with the general nutrition. This infant, then six weeks of age, was deprived of its supply of good human milk in the middle of the summer simply because the important matter of changing the intervals had not been thought of as a means of improving the milk and relieving the pain and apparent hunger. There seems to be no doubt that if the milk in this case had been properly managed it would have agreed perfectly with the infant. I would also add in connection with this case that when the digestion is not carried on properly the nutrition must soon suffer, and it is only in the early weeks of a disturbed digestion that, as a rule, we find the nutrition to be unimpaired. The next case is one of a multipara who was under my care at the City Hospital, and who up to the time of her entrance had been nursing her infant, which was thriving. The patient stated that her milk had always been abundant and of good color up to the time when she was separated from her infant, which was twelve hours FEEDING. 149 previously, as she had to be away from home for that time. At the end of twelve hours the breast was found to be so distended that the breast-pump had to be applied. The milk was drawn with great ease, almost flowing of itself, and in considerable quantity, but it no longer resembled the milk of the previous nursings which had been at the proper intervals. On the contrary, it was clear, with very little color, the total solids were reduced to a minimum, and it no longer would have nourished the infant. The treatment of this case was of course to pump the breasts every three hours until the infant could again be nursed. As an illustration of the harm which may come to an infant from the percentage of fat in its mother's milk being too high, and also of the means to employ either to increase or to decrease the fat in breast-milk, this case will be of interest. The mother was a healthy primipara. She had plenty of milk, but the infant suffered from colic and had very frequent watery dejections. She was eating a great deal of meat three times daily and not taking much exercise, so it was naturally sup- posed from the symptoms of the infant and the diet of the mother that an over- percentage of fat was one of the elements which were disturbing the lactation, and that a high percentage of proteids would also be found. The analysis proved this supposition to be correct : Primipara. Healthy ; eating much meat ; not taking much exercise. Fat 4.96 Sugar 6.60 Proteids 3.29 Mineral matter 0. 17 It was therefore decided to reduce the meat to a minimum, which was done, and three days later an analysis gave the following figures : Eating little meat. Tat 1.73 Sugar 5. 70 Proteids 3.71 Mineral matter , 0. 13 The milk was found to be lessening in quantity. The infant's dejections were less numerous and had more consistency ; but it was not gaining, and continued to have pain. In fact, the analysis showed a poor milk, or even a bad one, as represented by the usual combination of a low percentage of fat and a high percentage of proteids. The woman was consequently made to eat a moderate amount of meat, and to exercise more, and three or four days later the analysis showed an improvement in the fat : Eating moderate amount of meat ; taking more exercise. Pat : 'IA'1 Sugar 5.50 Proteids , 3;55 Mineral matter 0. 15 The infant now began to gain in weight, but continued to have colic, as was expected from the high percentage of proteids. The exercise was still further increased, and a later analysis showed a decided lessening of the proteids. 150 PEDIATRICS. Exercise still further increased. Fat - 2.35 Sugar 6.25 Proteids 2.69 Mineral matter 0. 15 The infant then began to have regular movements, of good consistency, and no longer had pain j it also gained regularly in weight, and looked well and strong. The mother regulated her diet, exercise, and sleep in accordance with the requirements of her infant, and her milk again became abundant. We shall, of course, often fail in our attempts to manage the percent- age of fat in this way, but this case illustrates exactly the changes which it is usually necessary to produce in order to alter a high fat percentage. The proteids also being high, there was an over-rich milk to deal with ; taking away the fat-producing element reduced the fat to a low percentage ; exercise reduced the high percentage of proteids, and a combination of sufficient meat and exercise finally produced a milk which could be di- gested. This next case illustrates a number of points in the management of lactation. A high percentage of the proteids was creating the disturbance in the infant, and it was their final reduction through treatment that per- mitted the lactation to go on. The mother, a remarkably healthy and vigorous multipara, living in the country, had a plentiful supply of milk. Her diet consisted mostly of vegetables, and she did not take much exercise. The infant was not thriving, having had continued attacks of colic, with frequent vomiting, and it did not gain in weight. The analysis showed a bad milk, which was contrary to what we should usually expect to find in the milk of a mother who was in such perfect health as this one was. Fat 0.52 Sugar 6.80 Proteids , 2.48 Mineral matter 0. 15 Total solids , 9.95 Water 90.05 100.00 The mother was instructed to eat meat and walk two miles every day. One month later, as the infant had not improved, another analysis was made, which showed that the milk was in a worse rather than a better condition. Fat 0.45 Sugar 6. 15 Proteids 2.47 Mineral matter 0. 16 Total solids 9.23 Water 90. 77 TooToo It was found that the mother had eaten meat but once a day. and in small quantity ; also that she had not walked much. I then insisted on her eating meat three times a FEEDING. 151 day. and walking three miles. This she did for two weeks, when the infant was found to have gained slightly in weight, but to still have colic and vomiting. Another analy- sis showed an increase in the fat. Fat 1 53 Sugar _ 4 6.68 Proteids 2. 48 Mineral matter , # 0. 16 Total solids 10. 85 Water 89.15 100.00 During the next two months the walking was continued, and the meat increased in quantity. The infant continued to vomit and to have colic until the mother was made to ride on horseback every day, when the pain ceased, and from that time the infant gained steadily in weight, and was well and strong during the rest of the lactation. An analysis made two and one-half months after this procedure showed that at last the pro- teids had been reduced to come within the limits of the infant's digestion, and that the fat, although still having a low percentage, had been increased sufficiently for the infant's nutrition. Thus a bad milk was finally changed to a good one. This infant evidently could not digest a percentage of proteids approaching 2, but fortunately could be nour- ished on a low percentage of fat. Fat 2.01 Sugar 6.90 Proteids , 1. 54 Mineral matter 0. 17 Total solids - 10.62 Water 89.38 loo. 00 The next case was that of a poor milk. The infant was four months old. It was perfectly well and was digesting well, but had not gained for three weeks. The mother was producing from her breasts a suffi- cient quantity of milk, but the analysis showed that this milk had to be modified within the breast by a regulation of the diet of the mother : Fat 1.29 Sugar 6. 05 Proteids 2.93 Mineral matter 0. 12 Total solids ' 10.39 Water 89.61 100(H) She was consequently made to eat an increased amount of meat, and in the course of a few weeks the infant was thriving and gaining in weight. The next case was that of a wet-nurse whose infant was digesting- well, gaining in weight, and happened to be of about the same age as that of the infant whom she was hired to nurse. In order to see if this nurse's milk would agree with the foster-infant, the nurse and her infant were brought to the house of the foster-child, and were comfortably lodged and plentifully fed. 152 PEDIATRICS. Twenty-four hours later both infants began to have colic and green faecal discharges. An analysis of the milk showed a high percentage of proteids : Fat 3.19 Sugar 6.40 Proteids 3.11 Mineral matter „ 0. 15 Total solids 12~85 Water 87.15 100.00 The nurse was then given a lighter diet with a greater proportion of liquids, and was made to walk one mile twice daily. By weighing the infants just before and just after a nursing, it was found that they took from 90 to 120 c.c. (3 to 4 ounces) in fifteen min- utes. The infants were then allowed to nurse for ten minutes. 30 c.c. (1 ounce) of sterilized water was next given to them, and they were then allowed to nurse for ten minutes longer. In this way it was estimated that they were receiving in their stomachs 120 c.c. (4 ounces) of food in which the percentage of the proteids was under 2.5. The infants ceased to have colic, and the faecal discharges became normal. The nurse's infant was then sent away. Two weeks later the foster-infant was thriving, and, as another analysis of the milk showed a sufficient reduction of proteids, the sterilized water was omitted. Fat 2.87 Sugar 6. 25 Proteids 2. 90 Mineral matter 0. 15 Total solids 12. 17 Water 87.83 100.00 During the rest of lactation the infant digested well and gained fairly in weight. The following case was that of a perfectly healthy primipara, whose infant digested her milk well and gained in weight. The case shows how at times an infant can thrive on what appears to be too high percentage of some of the solids in the milk. The analysis of her milk was as follows : Fat... „ 4. 11 Sugar „ „ . . 5. 90 Proteids . . 3.71 Mineral matter. .~ 0.21 Total solids .-. 13.93 Water. 86.07 100.00 In contrast to this case was the following one in which the infant was evidently thriving. The mother was delicate and frail, and the infant was fed by a healthy-looking wet-nurse. In the early part of the lactation the infant did not thrive, and, as the mother was so delicate, it was not deemed advisable to attempt to improve the quality Fig. 44. Colostrum milk from cow. (Photo-micrograph.) Fig. 45. Colostrum milk from woman. (Photo-micrograph, t FEEDING. 153 of her milk. The interesting point in connection with this case is the inability of the infant to digest a poor milk and its ability to digest perfectly well the wet-nurse's milk, which in its analysis showed a very high percentage of fats and of proteids and a low per- centage of sugar : Fat 4. 72 Sugar , „ 4. 05 Proteids 4. 74 Mineral matter „ 0,19 Total solids , , 14.20 Water 85,80 100.00 In the following case it was found impossible to change the percentages of the elements in the milk. The woman had a moderate quantity of milk, and nursed her infant for two or three months. The infant did not gain, it had colic, and at times vomited. The analysis showed that it was in the class which I have designated as "bad :" Fat 1.61 Sugar „ . . . 4. 67 Proteids 4.07 Mineral matter. 0. 17 Total solids 10.52 Water 89.48 100.00 An increase of meat in this mother's diet and more exercise had no effect on the percentages of the elements of her milk, and the infant was therefore weaned. Soon after beginning to take a substitute food from the milk-laboratory the infant ceased to have colic and gained in weight. The percentages of the elements in the substitute food which produced such an immediate change in the infant's condition were as represented in this prescription : Fat 3.50 Sugar , 7.00 Proteids ■ , 1.00 It was merely necessary to raise the percentages of the fat and sugar, and reduce that of the proteids, in order to produce this rapid and satisfactory result. The next analysis is that of a woman's milk, which is instructive for a number of reasons : Fat 2.30 Sugar 6.65 Proteids 2.57 Mineral matter 0. 12 Total solids 11.64 "Water 88.36 100.00 The percentage of fat is low, and that of the proteids is rather high. The infant, with the exception of being somewhat constipated, was always well, gained in weight, 154 PEDIATRICS. and showed no digestive disturbance during the lactation. This was remarkable, as the mother's catamenia returned regularly during the lactation from the time that the infant was four months old. There was considerable flowing at the time of the cata- menia, and the mother was habitually constipated and did not have a very good appe- tite. The infant did not seem to be affected by any of these conditions. The analysis of this milk was made from a specimen of the "middle milk," which was taken between the catamenial periods. It may be of interest, in connection with what has been said concerning the variations in the milk which may arise from emotional causes and menstruation, to report the analysis of a milk of a mother and a wet-nurse where these influences appeared to produce certain chemical changes. The mother, a healthy but rather delicate primipara, the period of whose pregnancy had been supervised by me with the greatest care, but whose temperament was subject to extremes of despondency and excitement, was delivered, after a short and easy labor, of a healthy boy. She was exceedingly anxious to nurse her infant, but within a few hours after its birth she was seized with an uncontrollable fear that she would be unable to do so. In spite of all the assurances to the contrary which could be given to her, and the plen- tiful supply of milk which in due time came in the breasts, she remained in a very nervous, despondent condition. As the infant began to show decided signs of indi- gestion, I thought it best, before proceeding further, to investigate the composition of the milk. The analysis resulted as follows, and plainly showed the necessity of not persisting further, as it was evidently much altered from unavoidable nervous con- ditions, which seemed likely to recur through the whole of her lactation : [Mother's Milk.) Fat ........ 0.62 Sugar , 5. 80 Proteids 4.21 Mineral matter, ............:. ....... 0.20 Total solids 10.83 Water '. 89. 17 100.00 Under these circumstances, a healthy wet-nurse, whose own infant was strong and thriving, was employed, and the foster-infant immediately began to gain in weight and ceased to show any digestive disturbance. After a month, however, it was found not to have made its weekly gain, to be unusually restless, and to be having frequent faecal discharges. It was then discovered that the wet-nurse was menstru- ating, and on the second day the following analysis of her milk was made : ( Wet-Nurse. ) Fat 1.87 Sugar 6. 10 Proteids 2. 78 Mineral matter , . . 0. 15 Total solids 10.40 Water 89.60 100.00 The catamenia lasted about four days, and did not return for some months. The infant after the first twenty-four hours showed no disturbance whatever, soon began to gain, and was not affected by the subsequent occurrence of the catamenia. An analysis, made one week after the catamenia had ceased, showed a decided change for the better ; that is, increased fat and decreased proteids. Forty days after the FEEDING. 155 catamenia a still greater improvement was found in the milk, as was anticipated from the thriving condition of the infant. The change in the percentage is shown in the following analyses : Seven Days Forty Days after Ca- after Ca- tamenia. tamenia. Fat 2.02 2.74 Sugar 6.55 6.35 Proteids 2. 12 0.98 Mineral matter 0.15 0.14 Total solids . , . . . 10.84 10.21 Water 89. 16 89. 79 100.00 100.00 The following case is of considerable interest with reference to what has been said in regard to the incompatibility of pregnancy and lactation. Unfortunately, a full consideration of the condition of the milk cannot be presented, as it rapidly disappeared from the breast after the first analysis was made. and. before another specimen could be procured, had disap- peared entirely. The milk was taken from one of my patients who had been pregnant for three months and at the same time was nursing an infant nine months old. Fat 7.64 Solids, not fat 6.04 Total solids 13.68 The infant at the breast was not thriving. It had been digesting its mother's milk perfectly and had been gaining in weight until the pregnancy had existed for some weeks. At the time the analysis was made the infant's digestion had evidently been weakened, and as a result it had ceased to thrive and was rapidly losing in weight. This analysis will be found to illustrate several facts. In the first place, it repre- sents a very rich food. The total solids are even greater than appear in most cow's milk, and the fat is almost double the percentage which is considered normal in both human and cow's milk. It also shows that a food may be unusually high in the percentage of its total solids and yet not of a character suited for the nutrition of an infant. The explanation of this fact is that although for a time an infant may digest fairly well a rich food, yet that nature has provided that the percentages of the elements in its food should remain within certain limits. If these limits are transgressed, either by giving too low or too high a percentage of any of the solids in the food, the nutrition will be interfered with. In the latter case the digestive function of the infant actually becomes weakened, and the strong food soon begins to act as a foreign body. The absorption of the food is next interfered with, and the infant starves as readily on the strong food which cannot be absorbed as on the weak food in which the needed elements are lacking. This analysis also represents a condition which, in the majority of cases of preg- nancy, occurs after the first six or eight weeks, — namely, a much disturbed mammary equilibrium. The percentage of fat in proportion to that of the solids not fat is so entirely different from the percentages of the different elements in a normal milk that we may say that this milk of pregnancy represents a condition of profound disturbance. This especial analysis must not be taken as a standard one for the milk of preg- nant women, for, in all probability, analyses of milk under these conditions differ very widely, yet invariably show an absence of the normal percentages. 156 PEDIATRICS. Prolonged Lactation. — In healthy women the milk towards the end of a normal lactation has a tendency to return to the condition which we notice at the very beginning of lactation : that is, the product of the mam- mary gland becomes unstable and the percentages show a poor or a bad milk. In rare cases I have met with women whose milk remained of fair quality and who could continue their nursing into the second year with- out apparent detriment to themselves or to their infants. There is, how- ever, no reason for thus continuing the lactation, even if the mother is healthy and the milk good, for at the end of the first year, human milk, whether good or bad, is not a food which is adapted to the corresponding stage of development of the infant's digestive organs. Unmodified cow's milk and starch in some form are much better adapted to the stage of de- velopment of the digestive organs of the second year, and should therefore at that time be substituted for human milk. Mixed Feeding. — It not infrequently happens to nursing women, when their general health is not in a normal condition, that the supply of milk, while good in quality, is not sufficient in quantity to satisfy the infant, and the question arises whether the mother's milk should be entirely given up, or whether it should be supplemented by other food. My experience is in favor of assisting the mother to nurse her infant during the earlier months of its life. When the substitute food can be carefully regulated, and when the mother's milk is of good quality, this method is superior to that of withdrawing the mother's milk and feeding the infant exclusively upon a substitute food. We have, on the one hand, a better opportunity for regulating the mother's milk, by increasing or diminishing the number of the substitute feedings, and, on the other hand, if the mother's milk agrees with her infant, an excellent opportunity for making our substitute food correspond to what nature has provided. In arranging a mixed feeding we should in every case first have an analysis made of the mother's milk, and, if her milk has been agreeing with the infant, make the substitute food correspond to the maternal. It is also well to have an analysis of the mother's milk made at an early period of her lactation, as soon as the mammary gland has acquired its equilibrium and when the infant is thriving. This is a very important precaution, which may be of great use to us at a later period when the mother's milk may from many circumstances be disturbed or entirely lost. When such an accident happens, we know exactly what the composition of the milk was on which the infant was thriving, and can at once arrange a proper substitute food. The following cases illustrate this statement : An infant was thriving on the milk of a healthy wet-nurse. One day, without giving any warning, the nurse left the house and never returned. The infant had to be put on a substitute food, as another nurse could not be procured. It was left in the middle of the hot weather without the food which had been so well adapted to its FEEDING. 157 digestion. Unfortunately, the precaution of having an analysis made of the wet- nurse's milk had not been taken, and it was some time before I was able to substitute a food which would agree with the infant. The second case was where the mother's milk, after careful management, had be- come fitted for her infant, and where the infant was thriving. One day the mother received a nervous shock from seeing the arm of another of her children dislocated. Within a few hours the milk entirely disappeared from her breasts and did not return. The analysis of her milk, which had been previously made, provided me with a guide by which I could at once have a substitute food prepared which would correspond to the food which the infant had been receiving from its mother. This was done, and the infant continued to thrive, showing no bad symptoms from the change of food. There are certain points to be considered in mixed feeding. First, if the mother's milk is agreeing with the infant, the substitute food should be of the same composition. Second, if the mother's milk is fully digested by the infant but is lacking in certain nutritive qualities, the absence of which prevents the infants nutrition from being normal, we should, after the first week, alter the composition of the substitute food so as to make it fulfil the requirements of nutrition by increasing the percentage of that special element in the substitute which is deficient in the composition of the maternal milk. The times at which the substitute food should be given will depend upon the number of feedings which are found to be necessary in addition to the maternal feedings, and we should carry out the same principles in this mixed feeding that have been laid down for the general manage- ment of human breast-milk. If the mother's milk is lacking in quantity we should make the intervals between her nursings longer, and introduce one or two substitute feedings according as the age of the child requires shorter or longer intervals. If, on the contrary, the mother's milk is abundant, but either too strong or too weak, we should make the intervals of her nursing correspondingly long or short, In this way, with an accu- rate knowledge of the percentages which exist in the mother's milk, and with our power to change these percentages in substitute feeding, Ave can usually in a week or ten days regulate the substitute feeding of the infant to such a degree that the mother's milk will also agree with the infant, and the infant will thrive again. WEANING. — There is no doubt that in a considerable number of cases occurring in the practice of physicians among civilized nations the mother's milk appears to be entirely unfit for her offspring, and it be- comes a question whether the infant shall be withdrawn from its mother's breast temporarily or entirely. In such an emergency the careful and repeated analysis of the milk will enable us to determine this question wisely. I am convinced that a large number of infants are deprived of their natural food and weaned on insufficient grounds. We thus assist to keep up the resulting high mortality figures, and I believe that these figures will be sensibly reduced when, in consequence of our taking a more enlightened 158 PEDIATRICS. view of the subject, we increase the number of infants who are fed during the first three or four months of life upon a suitable breast-milk. A particular reason among many for waiting at least three or four months before weaning is presented by the fact that the stomach, after growing rapidly, has by the fourth or fifth month become a more perfect receptacle both as to size and to function. A number of nursing women find that at variable periods in the course of their lactation their milk begins to fail, and they are forced first to lessen the number of their nursings and then to wean entirely. The time, then, when the infant should be weaned almost always settles itself, without our intervention, at varying periods. The period of lactation, and the one which might be called physiologically normal, can, when the breast-milk remains of good quality and quantity, be carried through the first year with benefit. We have certain guides which aid us in determining the proper time for beginning to wean. Physiologically, we know that certain functions, such as that which converts starch into glucose, are but slightly developed in the early months of life, and that they are only gradually established during the first year, and not, as a rule, perfected and in a con- dition in which we can call upon them with impunity until the last two or three months of that year. A sign which aids us in judging the progress of this development of the functions is the appearance of the teeth, call- ing our attention to the fact that nature is preparing the infant to digest and assimilate a form of food different from that which it has thus far received by sucking. The presence of six or eight incisors corresponds usually in the normally developed infant to the full development of the pancreatic secretion. A most valuable index which assures us that we need not be anxious to change the infant's food during the first year is the continuous increase in its weight, which, with a general healthy condition, results from a nor- mal lactation. We must allow, however, for certain variations which in special cases are as important as is the rule to terminate the lactation at a definite period. The period of lactation may be curtailed or lengthened by a month or two according to the season of the year, the development of the teeth, or the condition of the child from illness or convalescence. Under such circumstances it may be wiser to feed the infant from the breast during the heated portions of the year, and to wean it in cool weather, before or after the hot season, according to the individual case. An interdental period is also preferable to a dental period, on account of the possible disturbances which may arise in the latter and interfere with the proper actions of the new functions to which reference has been made. In these exceptional circumstances, when there is any uncertainty as to the character of the milk which the infant is taking, a chemical analysis should be made at once, and repeated several times at intervals of a few days. These latter months, though not so difficult to manage intelligently as the early period of the infant's life, are much more likely to need care- FEEDING. 159 ml supervision than the middle period, which, from its usually uninter- rupted tranquillity, has been called the period of normal nutrition. When on account of an insufficient supply of milk in the mother the infant has for some time become accustomed to several meals of a substi- tute food daily, the matter of weaning becomes a very simple one, for we know that we have a food which will agree with it ; but when we have to begin to wean directly and to adapt a food to the infant's digestive capa- bilities, as in cases of sudden failure of the milk or of sickness in the mother, this procedure becomes much more intricate, and is at times fraught with considerable danger. It is in these cases that an analysis of the milk made when the mother was in good condition often proves to be of great assistance. The method of weaning which I have adopted, and have found to be the safest and best, i& the one which I have been enabled to use since having a milk-laboratory at my command. My rule is, provided that the infant is thriving or digesting its mother's milk well, to order from the laboratory a substitute food the percentages of the elements of which are very similar to what the infant has been taking from its mother. After a few days, if this food is agreeing with the infant, a change should be made in the percentages of the different elements, with the object of gradually combining these percentages in such a way as to correspond to the per- centages of the elements of unmodified cow's milk. This is easily and precisely accomplished. For instance, supposing that the infant is re- ceiving from its mother a milk in which the percentage of the fat is 4, of the sugar 6.50, and of the proteids 2, we should begin by giving the same percentage of fat (4), a lesser percentage of sugar (5.50), and an increased percentage of proteids (2.25). After a few days, if this milk is digested well by the infant, the fat can be made 4, the sugar 4.50, and the proteids 3. In a few more days, if this food is digested well, plain cow's milk, with lime-water sufficient to make it slightly alkaline, can be given. The milk which is now received from the farms connected with the laboratories is practically so free from bacteria that it need not be pasteurized in the winter months ; and often, also, in the summer, it will remain fresh, except in exceptionally warm weather, or when it has to be transported a long distance. If this still agrees with the infant, cow's milk without lime-water can be given. Unless under very exceptional circumstances, sudden weaning is to be deprecated, though of course we must admit that it is sometimes done with impunity. The safest method, so long as we cannot judge beforehand which infants will be likely to be unfavorably affected by sudden weaning, is to take plenty of time and gradually ascertain by frequent changes the food best adapted to the case. The infant should be gradually accustomed to this food, omitting the breast-feedings one by one, until finally we are sure that we have a substitute food on w T hich it will thrive. At the tenth or eleventh month, provided that the weaning of the infant is deemed 160 PEDIATRICS. desirable at so early a period, and after having accustomed it to take plain cow's milk, starch in some form can also be given. It will be necessary to determine how much of this new element may be introduced into the infant's diet, carefully adapting the amount to its amylolytic function, which varies in different infants, and which has but lately arrived at its full development. When these changes have been accomplished, the breast can with safety be entirely withdrawn. The danger of injudicious weaning is illustrated by the following case : A delicate infant, backward in its development, digesting well, and a little over one year old, was suddenly deprived of the plentiful supply of breast-milk of its healthy mother and fed on oatmeal gruel. Vomiting and prostration immediately began, and continued until the oatmeal was omitted and the breast-feeding resumed, when the infant began to thrive again. Three weeks later the mother, through igno- rance, suddenly and without any preparation fed it again on oatmeal gruel. On the following two days the infant vomited incessantly and was much prostrated. Several changes were then made in its food, but the symptoms grew worse, and the mother, who was now very uneasy about the infant, again put it to her breast, with, how- ever, this time a disastrous result, as her milk from nervous influences was so changed in its quality that it acted like a poison on the infant, who fell into a condition of col- lapse. A wet-nurse with a healthy infant four months old was immediately procured, and after several days of complete prostration the foster-infant began to revive, and later was gradually weaned without trouble. It may be well to add, for the encourage- ment of physicians who have cases of this kind to deal with, that after the mother's milk had poisoned the infant, and when I first saw it, the skin was gray and cold, the fontanelle sunken, and the eyes fixed, yet recovery took place. Under the same cir- cumstances equal success in the treatment would probably be obtained by writing for a milk prescription to contain fat 2.50, sugar 5, proteids 0.50. This, of course, would be an exceedingly weak food for an infant twelve months old, but it would be the safest combination to begin with, and could be increased in strength as the infant recovered. n. DIRECT SUBSTITUTE FEEDING. "WOMEN. — When for any reason it is impossible or inadvisable for the mother to nurse her infant, some other food must be substituted for the maternal. The milk of another woman approaches the mother's in its characteristics most closely, and should be obtained unless contra- indicated. It is generally supposed that the mother's milk, as a rule, is more likely to be suited to her infant's digestion than the milk of another woman ; but we have as yet too few cases where direct investigation by means of chemical analysis of the two kinds of milk has been made to lay down actually as a fact what we can merely grant as a supposition, that an idiosyncrasy in the mother's milk mil find an analogue in her infant's digestive , powers. The reverse of this proposition has also been held to be true, that at times some idiosyncrasy in the mother's milk will make it radically unfit for her infant. The probability is that analyses will show either that these varieties of milk are poor ones, or that the infants have unusually weak digestive powers. FEEDING. 161 The fact that every mother cannot provide as good a milk for her infant as can be supplied by another woman finds its analogy in the ina- bility of some Jersey cows to rear their own calves. The following case illustrates how at times an idiosyncrasy of diges- tion in the infant corresponds to some unusual percentage in its mother's milk : The mother, a primipara, was healthy, but of a highly nervous temperament. The infant was thriving, but, as a measure of precaution in case of mammary disturbance at a later period of the lactation, an analysis was made of the milk, with the following result : Fat 5. 16 Sugar 5.68 Proteids 4. 14 Mineral matter 0.17 Total solids 15. 15 Water 84.85 100.00 The report made by Dr. Harrington in connection with this analysis was, "The precipitated curd is quite similar in its appearance to that obtained in the analysis of cow's milk." The mother was advised on general principles to take more exercise, and ten days later another analysis of the milk was made : Fat 4.88 Sugar 6.20 Proteids 3.71 Mineral matter 0.19 Total solids 14.98 Water 85.02 100.00 The second analysis was so similar to the previous one that, in conjunction with the perfect digestion and health of the infant, it was concluded that this infant had an idio- syncrasy of digestion which enabled it to thrive on what would in most cases cause extreme disturbance. This view of the case proved to be correct, as the infant, which was under my care for a number of months, continued to thrive. A comparison of this analysis with that of the milk of the wet-nurse on page 164, where the high percentage of proteids caused vomiting of thick curds by the infant, will show a striking similarity of the two milks. There is no doubt that in the majority of cases a milk such as is represented by these two analyses would be totally unfit, and would not only cause marked indigestion but often more serious results, such as convulsions. The following case presents an illustration of the reverse of the sup- position that the mother's milk will suit her infant's digestion better than the milk of a wet-nurse : This infant was being nursed by its mother and showed continual disturbance of its digestion. At times it would be constipated, and again it would have attacks of colic with watery discharges. The colic was the most prominent symptom, and the 11 162 PEDIATRICS. child, though looking fairly well, was not gaining in weight. An analysis of the mother's milk showed that the percentage of fat was from 2 to 3. the sugar was of about the normal percentage, and the proteids varied from 3 to 3.50 per cent. The mother was of an extremely nervous temperament and was unwilling to carry out the rules for the management of her milk, which were absolutely necessary in order to reduce the high percentage of proteids, which evidently caused the disturbance. A wet-nurse was therefore procured, the analysis of whose milk was as follows : Fat 2. 96 Sugar 5.78 Proteids 1.91 Mineral matter 0. 12 • Total solids 10.77 "Water 89.23 100.00 The infant on taking this new milk ceased to have colic, but was more constipated and did not gain in weight. It was therefore decided that it would be wise to increase the percentage of the fat in the nurse's milk. This was done by giving her considera- bly more meat to eat and making her take moderate exercise. The infant within a week began to gain in weight and to sleep well, the bowels ceased to be constipated and were moved naturally every day. There was also a plentiful supply of milk. Another analysis of the milk was then made, with the following result : ♦ Fat 3.31 Sugar 6. 45 Proteias 2.36 Mineral matter 0. 16 Total solids 12.28 Water 87. 72 100.00 This last analysis is of great significance. The increase in the percentage of the fat evidently regulated the faecal movements. The total solids increased from 10.77 to 12.28, and the plentiful supply of milk made the infant gain, especially as it now was digesting perfectly. It was evident that it could digest a milk with a percentage of pro- teids below 2.50, while it was a percentage of 3 in the mother's milk which prevented her from carrying on her lactation. In this case it will be seen that the milk of another woman was far preferable to that of the mother, and that the idiosyncrasy of a high percentage of proteids in the mother's milk did not find its counterpart in an idiosyncrasy in the proteid digestion of her infant. "WET-NURSES. — The general question as to whether a wet-nurse shall be employed is one which is of serious import, and must in each in- stance be decided by giving full weight to all of the many circumstances which are involved in the case. Foster-feeding, when all the conditions are good, is superior to substitute feeding. The reverse of this statement, however, must always be kept in view, that- a poor nurse, whether from temperament, or age, or general health, or the quality of her milk, had bet- ter be set aside when the conditions are favorable for a successful substitute feeding. It is perhaps better that the nurse's milk should correspond in FEEDING. 163 ago somewhat nearly to that of the infant she is to suckle, but a difference of some months in age may not be a contra-indication, as we are not yet in a position to say definitely that the milk differs sufficiently in different months to make this a reason of importance in choosing a nurse. A fee- ble child will nurse more easily and probably have better care from a multipara than from a primipara. The preferable age of the nurse is be- tween twenty and thirty years. Her other requisites are a condition of good health and a quiet temperament. It will save much trouble and often obviate the frequent necessity for changing if before her engagement we have made a chemical analysis of her milk ; in fact, all the points which have been already referred to for a successful maternal nursing are of equal significance in the case of a wet-nurse. The general health of the wet-nurse should be carefully investigated, as women suffering from constitutional syphilis or any chronic disease are manifestly unfit for nursing. At the same time we should be careful, un- less decided symptoms of disease are present, not to set aside the milk of a delicate-looking woman until it has been analyzed. The wet-nurse in the case just described, whose milk proved to suit the infant better than did its mother's, was a frail, delicate-looking woman, but healthy. The mother, on the other hand, was a large, strong-looking woman, but of a very nervous temperament. The rapid progress which is being made in the detection of the bacillus tuberculosis, not only in the sputum but also in the milk and in other secretions, may in the future be of much prac- tical importance in the determination as to whether a woman should nurse an infant or not, but the present state of our knowedge is only suf- ficiently advanced for us to state that this bacillus has been found in the secretion of the mammary gland of cows which have responded to the tuberculin test, and whose milk has been proved to be pathogenic in animal experimentation. Diet. — The same general principles that have been stated in speaking of the diet of the mother should be applied to that of the wet-nurse. We should be extremely careful not to change suddenly the customary diet of a healthy nursing woman on purely theoretical grounds. For many years the mistake was made of keeping women on too low a diet in the early period of lactation, with the consequent delay in the establishment of a sufficiently nutritious milk-supply, and a corresponding initial loss of weight in their infants. Where, however, we are especially likely to en- is in permitting a healthy, hard-working wet-nurse, accustomed to a some- what coarse but nutritious diet, to adopt totally different habits of exercise and a diet to which she is unaccustomed, rather than to have her continue her usual mode of life. This sudden change of habits frequently results in loss of health to the nurse, with its accompanying deterioration in the quality of her milk, or at least a change in its quality so as to make it an unfit food for her foster-child. A notable instance of too radical a change of habits was brought to my notice by a case seen in consultation. 164 PEDIATRICS. A wet-nurse had been procured for an infant ten days old. An analysis of her milk, two days before she began to nurse, is shown in the following table. Her milk was digested well for two or three weeks, during which time she was fed on an abun- dance of good food and rich milk. The infant then began to vomit thick curds iden- tical in appearance and toughness with the curds of cow's milk. Another analysis was made, which showed the amount of total solids to be increased in a most marked degree, the percentage of proteids corresponding far more nearly to that of cow's milk than to that of woman's milk. The nurse was then given plainer food and skimmed milk, and the infant ceased to vomit. The infant and nurse continued well and strong during the whole year, the infant making a weekly gain in weight. Analysis I. Analysis II. Analysis III. Two days before Rich food for Food regulated and change of food. a month. milk agreeing with infant. Fat 0.72 5.44 5.50 Sugar 6.75 6.25 6.60 Proteids 2. 53 4. 61 2. 90 Mineral matter 0.22 0.20 0. 14 Total solids 10.22 16.50 15.14 Water. 89. 78 83.50 84.86 100.00 100.00 100.00 Animals. — In parts of France, notably in Brittany, infants are put directly to the cow's teats, and sometimes with good results. I know of one family of eight children, all of whom were nursed by the family cow, and all of whom grew up healthy and strong. Yet the undesirability of feeding human beings directly from the udders of animals is so manifest that this method need not be discussed. EX INDIRECT SUBSTITUTE FEEDING. General Considerations. — I have laid great stress upon the importance of feeding infants during the early months of life by means of human milk. We know, however, that the necessity will often arise for supplying the infant with food not from the human breast. In all probability the em- ployment of substitute feeding will increase rather than decrease as our civilization advances. With this prospect before us, and appreciating the difficulties which in a large number of cases are liable to arise when we attempt to adapt a substitute food to the wants of an infant, it manifestly becomes a duty to endeavor to reduce the high mortality figures usually resulting from artificial feeding. With this purpose in view, we should care- fully investigate different methods of feeding and adopt some more uniform plan for starting human beings in life ; for diversity and not uniformity is now the rule. While inherited diseases contribute a certain proportion of the deaths which occur in infants, yet diversity of method in feeding is the most prolific source of disease in early infancy. The group of symptoms which for want of a better name is designated as difficult digestion occurs most frequently in the three periods in which the infant's digestion is likely to be tampered with, — namely, in the early weeks of life, when experi- ments are being made to determine what food will be best to start FEEDING. 165 with : next, when, in addition to the irritation arising from the beginning of dentition, new articles of diet are added to the original food ; and, thirdly, at the time of weaning, when there is often a sudden and entire change, in the character of the food. The proper management of the first of these periods is of the greatest importance, because it is the time when the stomach is in its most active period of growth, and when the function of digestion is being established, and following the rule of functional estab- lishment, is in a state of unstable equilibrium. We should recognize the fact that the problem of substitute feeding is not a simple one. We cannot reiterate too often that the question which commonly is supposed to be a simple one, and the one which in the great majority of cases is alone considered, — namely, ''Which food shall we give to the infant?"— is a misleading and insufficient one. The problem is a combination of factors of which the kind of food is only one, and I per- sonally have long been convinced that the neglect to investigate thoroughly and carry out in detail the combination of these by no means insignificant general factors has had much to do with our failures in subsitute feed- ing in the past. It would seem, also, that the present is a most opportune time for raising a note of warning against allowing our enthusiasm over any one especial theory to warp our better judgment. There will surely be a reaction which will relegate to its proper place every theory built upon single factors of the problem before us, and which is actually doing harm by keeping in the background other theories which, each in its own sphere, as a significant part of a complete whole, may be of very great importance in the successful solution of the general problem. An error of oversight of one-eighth in a mathematical problem is not so great as one of one-fourth, but nevertheless the correcting of the greater error will not prevent an oversight of the smaller from completely destroying a correct result. Until lately it has been the quality of the food which has been monopolizing to too great a degree the attention of the medical profession. Then it was sterilization in feeding which became prominent. A German writer on substitute feeding has stated that the physiology and pathology of infantile digestion depend not on the chemical but on the biological character of the food. If we are not on our guard, this exaggeration of each single factor will prevail, and by its influence will blind us to much good work which in other directions has already been done, and which we cannot afford to ignore. Not that I would for a moment be under- stood to underrate the value of feeding an infant on a sterile food, for it has for years proved of very great benefit in my practice and that of others, but I predict that by just so much as we enhance the value of this one important part of the whole at the expense of the others, just so much farther shall we be from an intelligent comprehension of the whole subject. To feed an infant one month old with six ounces of acid cow's milk every four hours, no matter how thoroughly such a mixture has been sterilized, would be a radical offence against well-known anatomical and physiologi- 166 PEDIATRICS. cal laws. We should investigate and endeavor to copy, each in its turn, the various devices which nature makes use of, for we must admit that we are not in a position to improve on nature's method. It is certainly wiser and more economical not to spare expense and trouble in arranging the infant's diet, for the period of active growth of an organ is the time when its function is readily weakened, and when once weakened, the digestive function is a prolific source of annoyance and ex- pense in childhood and adolescence. Cheap foods and cheap methods of feeding, unless they are the best that can be procured, should not be tol- erated in the early feeding of infants. We often, however, see a food recommended for a young infant because it is cheap and easily prepared, in spite of the fact that its well-known lack of nutritive ingredients should stamp it as unfit for use. In discussing the treatment of disease we advocate what is best, with- out reference to what it costs, and then, in the special case where expense is an element which has to be taken into consideration, we endeavor to adapt our treatment to these considerations, and approach as nearly as possible to our first standard. In like manner I believe that we are doing wrong to the public if we allow ourselves to be handicapped in so difficult a question as infant feeding by the cry of expense. Infant feeding is an expense which is vital to the welfare of the human race, and Ave can, without being accused of extravagance, safely relegate to the province of the manufacturers of patent foods the recommending to the public of foods which if judged by the amount that is offered in bulk are cheap, but which when judged by their nutritive properties are extremely ex- pensive. Our scientific knowledge and clinical investigations have not yet en- abled us to follow nature exactly, and we therefore have not yet obtained an ideal method of substitute feeding. We must, nevertheless, go as far as the present state of our knowledge will allow, thus gaining a little ground every year ; and we must be especially careful not to be led astray by the fictitiously brilliant results which are reported from time to time in favor of certain foods. Instances are continually occurring where one food will fail and another, when substituted for it, will succeed, and yet these successes are merely temporary, and the disturbances of nutrition and mortality resulting from the use of various infant foods ahvays re- mains far above those which occur from the use of human breast-milk. Source of Food. — Having decided to substitute some food in place of woman's milk for the infant, we must decide from what source the ele- ments of this food shall come. The food which approaches most nearly in every respect the product of the human mamma is that produced by the mammae of other animals. The reason for this is that the food which all mammals provide for their offspring is an animal one, and consists of the same elements, although the mammary product of different animals varies in the percentage of these elements. FEEDING. 167 Assuming, then, that average human breast-milk is the safest standard for us to copy, Ave are impressed with the fact that although a vegetable diet would often seem far the easiest method of procuring nourishment for young infants, yet nature has persisted in providing an animal one. We should therefore be very careful not to introduce into our substitute diet a vegetable element, which, as judged by our standard, must be a foreign element. Milk is the food which our reason tells us should be given to the young infant, and a milk which will approach as nearly as possible to the average human milk. The milk of various animals has from time to time been recommended as the best substitute for human milk, the recommendation being based on their analyses approaching more or less nearly the composition of human milk. The milk, however, of all animals has to be modified to correspond to human milk ; and when we begin to modify, it is as easy to change the percentages of the different constituents to a great degree as to a small. The fact that the milk of any particular animal approaches in its analysis nearly to that of the human breast is not of much significance, other considerations being far more important ; and it is most important of all that we should use one which can be obtained easily by the people at large. This at once settles the question that it is the milk of the cow to which we must turn our attention, even though cow's milk may differ in its composition from human milk to a greater degree than does the milk of the ass or the mare, whose milk approaches, so far as is shown by analyses, most nearly of that of all animals to human milk. If, how- ever, the ass and the mare should be employed for dairy purposes to the same extent that the cow has been, there is every reason to suppose that their milk might change in its composition and their comparatively unde- veloped mammary glands increase in size, just as has been the case with the cow, an animal which for thousands of years has been used for the production of milk, and which probably did not in the beginning give such an over-production of the mammary secretion as is the case now. It is, then, from the public demand, and by breeding, that cows have been made to produce so much more milk than is necessary for the support of their young. Not only quantitative but qualitative differences exist in animals according to the development of their mammary glands ; and, as Martiny has shown in his collection of statistics on this subject, the con- dition which determines the quantity and the quality of the milk depends on the development of the organ which produces it. A further exemplification that cow's milk is practically the universal source of the substitute food-supply for infants in most civilized commu- nities is the fact that the various foods, patent or not, all depend for their basis on cow's milk, and that without this addition of milk they would show but an insignificant percentage of many of the most important in- gredients of the food. Logically we should not speak of the various foods as such, but merely as adjuvants to cow's milk. If this is thoroughly 168 PEDIATRICS. understood, much misapprehension regarding the apparently successful results of innumerable foods will be done away with. Another reason for using cow's milk in preference to all others is owing to the fact that the cow can be kept under more strict control than any other mammal. THE COW. — Having chosen the cow for our primal milk-supply, we must next consider whether any special breed is better adapted than others for accomplishing our purpose. To do this we should first examine chemically and microscopically the elements of the milk of those breeds which can be employed best throughout the civilized world. It has been found that the finer breeds of cows from the Channel Islands are more liable, when transported from their home to countries where the climate is more severe, to contract diseases, such as tuberculosis, than are the animals represented by the Durham, Devon, Ayrshire, and Holstein breeds. Among the breeds of cows which should be used for infant feeding at the farms connected with the laboratories are the following. The Durham, or Shorthorn, represents the best type of cow for this purpose. She has great constitutional vigor, great capacity for food, a perfect digestion, a placid temperament, and yields a large quantity of rich milk, of which the analysis is as follows : Per cent. Pat 4.04 Sugar 4. 34 Proteids 4.17 Mineral matter 0.73 Total solids 13. 28 Water 86.72 100.00 Another breed, the Devon, has the same general characteristics as the Durham. The cows are gentle and vigorous, and give a moderate quantity of milk of medium quality, the analysis of which is as follows : Per cent. Fat 4.09 Sugar 4.32 Proteids 4.04 Mineral matter 0.76 Total solids 13.21 Water 86.79 100.00 Another breed is the Ayrshire, whose constitutional vigor is great, but whose temperament is nervous. The cows are not so hardy as the Dur- ham, but are very free from disease. They yield a large supply of milk with the following analysis : FEEDING. 169 Per cent. Fat . , 3.89 Sugar .............. 4. 41 Proteids 4.01 Mineral matter , 0. 73 Total solids 13.04 Water 86.96 100.00 Another breed which is of a thorough dairy type is called the Holstein- Priesian. This cow represents the most perfect milking animal known, having every characteristic of a cow suitable for laboratory purposes, but her milk is so light in its total solids that it is not so profitable as the other breeds. She yields a larger quantity of milk than any other known breed, although the analysis shows it to be poorer in quality. The follow- ing is the analysis : Per cent. Fat 2.88 Sugar ; 4. 33 Proteids 3.99 Mineral matter 0. 74 Total solids 11.94 Water • 88.06 100.00 Another breed is called the Brown Swiss grade. The cows are very vigorous, healthy, and docile, and yield a fair supply of milk of about the richness of the Devon, the analysis of which is as follows : Per cent. Fat 4.00 Sugar 4.30 Proteids 4.00 Mineral matter . 0. 76 Total solids 13.06 Water 86.94 100.00 Finally, we can make use of the little Bretonne cow, known all over Europe as the " cow for the family.' 1 Cows of this breed have all the characteristics of the good domestic cow which have already been men- tioned. They produce a medium amount of milk, large, however, in pro- portion to their size. Some of the marks which distinguish the breeds of cows best adapted for infant feeding are : (a) constitutional vigor, (b) adaptability to acclima- tization, (c) notable ability to raise their young, (d) freedom from intense inbreeding, (e) a distinctly emulsified fat in the milk, (/) a preponderance in the fats of the fixed glycerides over the volatile glycerides. The vola- tile glycerides do not exist in the mammae, but are formed in the milk soon after -the milking. In some breeds, as in those of the Channel Islands, this change occurs more quickly than in others. Such breeds as the Jer- sey, Guernsey, and any others in which intense inbreeding has been car- 170 PEDIATRICS. ried on and in which acclimatization has not been perfected, should not be used for infants and young children. These breeds, of course, do not represent all of those available for substitute feeding, for we may mention many others equally good each in its country. For example, the Kerry of Ireland, the Red Polled of England, the Dutch Belted and the Flemish, also the Flamande and the Cotentine of France, the Nor- man breed of Normandy, besides the Brown Swiss just spoken of, and the Simmenthal, sometimes called Bernese, of Switzerland, also the Chia- nina of Italy, and the Allgauer of Germany. The native cow of this country, the " Red Cow," through many generations of neglect and ex- posure in winter, has undoubtedly acquired an impaired digestion and does not respond readily to appropriate changes of food. Care of the Cow. — A cow whose milk is to be used for purposes of infant feeding should be properly housed and well cared for, as the do- mestic cow is an animal peculiarly sensitive to her surroundings, and her product is correspondingly liable to be thrown out of equilibrium. The milk product of a herd of healthy cows is much less liable to the varia- tions so injurious to the infant's digestion than is the milk of any one cow. It is especially to be noticed how much easier it is by proper care to control exaggerated nervous influences upon the cow's product than upon the woman's. This at once suggests to us the question. Where and how shall cows be taken care of? The cow is a sensitive animal, easily yielding to conditions good or bad in which she is placed. She is liable to contract diseases communicable to man. and especially to infants, and she is a ready vehicle for the trans- mission of obscure and often untraceable affections of a septic character. Her surroundings are such as to favor infection, and her attendants are often the means of conveying to the milk many of the transmissible dis- eases, such as scarlet fever, diphtheria, and tuberculosis. The ordinary cow is allowed to range over wide pastures which are sometimes overflushecl with herbage and sometimes parched by drought, and which nearly always contain noxious weeds, which she seems eagerly to seek. Again, she is forced to drink from stagnant pools and polluted streams, and at other times suffers for want of water for many hours to- gether. She is also frequently exposed to storms. Cows cared for in this way are not those which provide the best milk for substitute feeding. These are the adverse conditions which surround the ordinary cow during the summer. In the winter she is crowded in the stifling atmosphere of a close barn with the manure of the whole winter kept underneath the floor on which she stands. Her head is usually confined in a narrow stall. The fodder intended for the winter's supply is kept above her head, and is continuously contaminated by the foul odors of the barn. She is turned out to the watering-trough at periodical intervals. Thus she cannot be said to be cared for in a manner conducive to the equable function of her mammary gland. FEEDING. 171 For cows to be used for the purpose of infant feeding a barn is needed where each cow shall have at least twelve hundred cubic feet of fresh air. The food should be kept where it cannot be contaminated. The manure should be as carefully removed from the barn as if it were a human dwell- ing. The cow should have freedom for her head and limbs in wide stalls. Large, dry. sunny exercise-yards should be provided for her. Her food should always be brought to her and selected with great care. Pure water should be provided, and suitable cups or troughs containing running water should be in her stall. The bedding should be fresh and free from mould or from any soil productive of bacterial growth. Methods should be used to get rid of all the usual foul odors and free ammonia so com- monly produced in barns. Cows should be carefully guarded against fright, the worrying of dogs, and unusual excitements of all kinds, which cause serious disturbance of the lacteal functions of domesticated cows, in contradistinction to those of cows in a more natural condition, as, for in- stance, the cows in a semi-wild state on the plains of Montana, Texas, Australia, and the Pampas of South America. Excitement does not ap- parently injure the lactation of these cows, while it inevitably throws out of equilibrium the milk of the well-cared-for dairy cow. If the same care should be applied to regulating the woman's life as can be employed in the barn, we should encounter fewer difficulties in human breast-feed- ing. The feeding of the cows should have for its object the production of an even, nutritious, digestible milk and the careful avoidance of over- stimulation of the lacteal secretion. The exact chemical analysis of any one ration used for feeding cows for our purpose must be carefully consid- ered in accordance with the ratio of the digestible nutrients of the food, and this must of course be arranged practically from the recognized food tables. A great variety of food is necessary in feeding cows, but in the transition from green foods to dry, or the reverse, much care is needed to graduate the change, as disturbance in the equilibrium of the mammary gland is rapidly followed by injurious effects on the consumer. In past times, before I could rely as I do now on this carefully managed change of rations, the spring of the year with its flush pasturage and the fresh grass following the autumn rains were fruitful sources of infantile digestive disturbance in my nursery practice. All these links in the chain which constitutes a successful substitute feeding are of great importance. The cows must be kept clean by groom- ing and the necessary washing, the precaution always being taken to rub the moistened parts dry. The milkers should be dressed in clean, freshly sterilized white suits and caps. Their hands and arms should be thoroughly scrubbed before milking. The hands in milking should be kept dry. The milking-stools should be made of metal so that they can be sterilized. The milk should be drawn with some force, simulating the action of the calf, and at each milking every drop of milk should be drawn out. The milk should be drawn into sterilized pails and carried inime- 172 PEDIATRICS. diately from tne barn to the milk-house, which should be a sufficient dis- tance from the barn to be free from odors. No means yet known to science can prevent some few bacteria coming into the milk during the milking-time, though it is possible to reduce the number so greatly as to make the milk practically sterile for the purpose of infant feeding, par- ticularly if the second half of the product of the udder alone is used and milked into sterile tubes. The first half probably contains many bacteria, which, entering from without, have reached the lower portion of the teat. The major part of the bacteria present in the milk are such as cause the usual acid fermentation which we recognize in the common souring of milk, but there are many species of bacteria which ought to be prevented from gaining access to the milk, arising from mouldy hay, straw, or fodder, partially decayed roots, and the natural decay of the wood-work of the barn and adjoining buildings. These latter varieties, which are found to be especially inimical to the preparation of substitute foods, cause in some cases the alkaline fermentation and other abnormal conditions of milk. Every barn apparently has its own set of bacteria, and the flora in Amer- ica do not exactly resemble the analogous European species which have so often been described. The bacteria which are found in cow's milk do not necessarily come from external sources, whether they be of the cow herself or of her sur- roundings, but may also come from some part of the milk tract between the udder and the end of the teat. These conclusions, it may be said, are made with reference to healthy cows. Infectious mammitis, to some extent, seems clearly to be carried by the hands of the milkers from cow to cow. This also points to the fact that bacteria may find their way to the ducts through the teats. Tuberculin Test of Cows. — It is very important that certain precau- tions should be taken to prevent the use of cows which are affected with tuberculosis. It is probable that three per cent, of the cows whose milk is used for food are tuberculous. Where tuberculosis is developed to such a degree in the cow as to be dangerous to the consumer of the milk, the disease can be usually detected by a skilful veterinarian by means of the physical examination which is employed in cows. But. as it is a disputed question at present as to when the milk of a tuberculous cow becomes affected, it is wiser to adopt all measures of precaution known to science. Of these measures the one which is most efficacious in detecting even the incipient stages of tuberculosis is the "tuberculin test." All the cows in use at the farms of the milk-laboratories are subjected to this test, and unless a negative reaction is obtained they are isolated from the rest of the herd. Care of the Milk. — After the cows are milked, the milk should be carried quickly from the cow to the milk-house, which should be at least a hundred yards from the barn and completely isolated from all other buildings. To prevent the milkers from going into the milk-room, the FEEDING. 173 milk at the forms connected with the milk-laboratories is poured by means of a block-tin pipe through the wall of the milk-room into a large ice-lined block-tin tank, which is also the mixer for the milk of the entire herd. In the spare of four minutes, by means of an ice-jacket, the milk is cooled from 33.88° C. (93° F.) to below 4.44° C. (40° F.). This is to rapidly remove the heat, which is conducive to bacterial growth. The milk passes through eight thicknesses of sterilized gauze on its way to the tank. The milk-room is practically clean from a bacteriological stand-point, for the walls and floor are kept wet with clean water, and all dust is ex- cluded. The air which enters the milk-room is washed with sterilized water as it enters. Part of the milk is then passed through the separator, while part is drawn into sterile jars for transportation. No one is allowed to enter the milk-room except the man in charge, and he is carefully trained to be absolutely clean in person, taking special care of his hands, face, and hair. While in the milk-room he wears freshly sterilized white clothes. In the milk-room the jars are sealed, packed in ice, and in a few hours delivered at the laboratory. After milk has been treated with these precautions, I have had re- peated bacteriological examinations made on its arrival at the laboratory, with the uniform result that it has proved to be comparatively sterile, and at times it has contained either no colonies of bacteria or only one or two. No antiseptic can, without danger to the infant, be used about the cow, while all the mechanical devices heretofore tried to take the place of manual milking have inevitably tended to impair the lacteal function of the udder. CHEMISTRY OF COW'S MILK.— We have spoken of milk in general, and of certain points in connection with the chemistry of human milk in considering the subject of maternal feeding. In indirect substitute feeding, which involves a consideration of the principles governing the modification of cow's milk, it is of the first importance that the physician should acquaint himself with the chemical, physiological, and bacterio- logical characteristics of the food with which he is dealing. The failure to appreciate the importance of such a knowledge is responsible for much of the ill-founded criticisms of those who oppose the methods of percentage feeding, and the failure to obtain satisfactory results by those who have attempted to adopt percentage feeding without understanding its funda- mental principles. It is, therefore, well worth our while to consider in more or less detail certain points bearing on the chemistry of cow's milk. Average Analysis. — The following averages are from analyses by such well-known chemists as Konig, Forster, and others : Reaction Slightly acid. Specific gravity 1029-1083 Water 86-87 per cent. Total solids 14-13 174 PEDIATRICS. Per cent. Pat , „ „ .'. 4.00 Sugar 4. 50 Proteids 4.00 Total mineral matter 0. 70 Chlorine 18.45 Sulphur 0.41 Phosphoric acid 27. 98 Iron oxide and alumina , . . 0.44 Lime 23. 17 Magnesia 2.63 Potassium 53.00 Sodium .* 4.49 Reaction. — Perfectly fresh cow's milk is generally amphoteric in re- action, but on exposure to air becomes more and more acid, owing to the formation of lactic acid by the action of certain micro-organisms upon the milk-sugar. The relative proportion of the acidity and alkalinity of the amphoteric reaction varies in different cows and at different times during the period of lactation, and is undoubtedly influenced by the character of the food on which the cow is fed. Experiments seem to show that the milk drawn from cows fed on the better grasses in a half-ripe condition is much more alkaline than when the cows are fed on dry fodder and grain, which increase the acidity of the milk. These experiments are of great interest as showing that not only can the product of the cow, so far as its reaction is concerned, be made to correspond to that of human beings by means of perfectly natural feeding and under perfectly normal conditions, but that this alkaline modification can be produced to such a degree that one-third of the milk is sufficient to destroy by its alkalinity the acidity of the remaining two-thirds. It is doubtful, however, if it is desirable to attempt to modify the reaction of milk for infant use by any such method of feeding. The importance of the subject lies in the well-recognized fact that the infant's digestive functions have been from time immemorial better adapted to the digestion of an alkaline or a neutral fluid than of an acid one. Whether the moderately alkaline reaction of human milk is an important factor in the problem of infant feeding is a question which future investi- gation alone can completely prove, but with our present knowledge we are not prepared to dispense with even the least important of the many factors which make up this problem. At any rate, we should be very suspicious of a breast-milk which shows an acid reaction. In the preparation of an infant's food from cow's milk, according to the latest experiments by means of modification, the best results have been obtained by making the reaction of this food correspond to that of normal human milk. This, up to the present time, has been done best by the addition of an alkali, which is the only foreign element that it has been found necessary to employ. As it is wise in preparing a mixture for substitute feeding to make such a mixture approach as closely as possible in both taste and reaction to FEEDING. 175 woman's milk. Harrington's experiments made at my request (Table 39) with lime-water and ordinary cow's milk twenty-four hours old are im- portant. Lime-water was the alkali used in these experiments because it is the most simple adjuvant which we can use for making cow's milk alka- line, the amount of lime contained in it being so small that its addition in even considerable quantity does not materially alter the amount of the total mineral matter. As small an amount as one-sixteenth part, when added to ordinary milk, will render it alkaline, so that for making an acid milk correspond in its reaction to woman's milk, lime-water is of great value, as it apparently does not produce any other changes in the milk. In addition to this, the taste of a mixture which is made from ordinary cow's milk, so as to correspond to the composition of woman's milk, is strikingly like that of woman's milk if it contain one-sixteenth part of lime-water. Harrington has made an estimate by actual experiment of the amount of lime-water which is needed to produce an alkalinity in a mixture such as has been just mentioned which would correspond to the alkalinity of human milk. This table (Table 39) shows the results of his experiments. TABLE 39. Amount of Lime- ■ ^ Water in Mixture. Reaction. 25 per cent Strongly alkaline. 12. 5 per cent Still strongly alkaline. 6.25 per cent Slightly but distinctly alkaline, and corresponding to woman's milk. It must be remembered that these proportions of lime-water are those required for ordinary milk twenty-four hours old, a much smaller propor- tion being needed to produce the same results when the milk is collected and handled with the precautions insisted upon at the farm connected with the milk-laboratories: Specific Gravity. — The specific gravity of cow's milk varies from 1.028 to 1.034, and does not differ materially from that of human milk. Milk-Fat. — The fat of milk occurs as minutely divided globules, held in suspension in the milk-plasma, forming a fine emulsion. It is defi- nitely proved that all of the fat occurring in the milk is contained within these globules, but whether the globules are purely fat is a disputed point. According to Storch, the globules are surrounded by a slimy substance called " stroma substance," which, by his analyses, is shown to be neither casein nor lactalbumin, but a nitrogenous material containing fourteen per cent, of nitrogen and a reducing substance on boiling with mineral acids. The fat is composed for the most part of the neutral palmitin, olein, and stearin, and the triglycerides, myristic, butyric, and caproic acids, with traces of other unimportant fatty acids and extractives. The percentage of fat in the average cow's milk and in the average human milk is practi- cally the same, i.e., about four per cent. The glycerides of the fatty acids composing the fat in both cowl's milk and human milk have been deter- 176 PEDIATRICS. mined, yet our chemical and clinical knowledge of the nutritive value and digestibility of these, separately or collectively, has not arrived at a point where we can practically make use of this knowledge, and we therefore direct our attention to regulating in a milk modification the percentage of the fat as a whole. Fig. 51, page 204. a photomicrograph of a thin layer of milk, shows the minute globules of fat permeating the transparent medium. This fat is simply held in suspension, which enables us to separate it easily by mechanical means. It is, in fact, in the condition which marks the milk as an emulsion. Milk-Plasma. — The milk-plasma is the fluid in which the fat globules are suspended. It contains the caseinogen, lactalbumin, lactogiobulin, milk-sugar, and various extractives, such as urea, creatin, creatinin, hy- poxanthin, lecithin, cholesterin, citric acid, and certain mineral bodies and gases. Clinically, we cannot, in our present state of knowledge, state the significance of the presence of these bodies, though they undoubtedly are factors in the general metabolism of the body. The milk-sugar, caseino- gen, and lactalbumin are, on the contrary, of the first importance, and their nature should be clearly understood. Milk-Sugar or Lactose. — The sugar of milk in all mammals is of the variety called milk-sugar or lactose. It is a simple and uniform element to deal with. Its percentage in cow's milk is about 4.5, and in woman's milk about 7. Regarding the kind of sugar which should be used in making up a sub- stitute food, we have certain questions to consider which would seem to be important. Cane-sugar has been, and still is, a favorite form with which to regulate this part of the solid constituents of the food. The reasons given for using it have been its preservative qualities, as seen in the manufacture of condensed milk, and the theory that it is not liable to set up excessive so-called lactic acid fermentation, with its consequent disturbance of diges- tion, as has been supposed to be the case with milk-sugar. Cane-sugar in a concentrated form, as it is found in condensed milk, seems to act as a preservative, but when it is diluted, as in its administration to the infant, cane-sugar ferments very readily, and in this respect has no advantage over milk-sugar. Reasoning from analogy, we should say that as milk- sugar is the only form of sugar found in the milk of mammals, it is there for some good purpose, and that it is needed for the accomplishment of some process which takes place after the food has been swallowed. Roth cane- sugar and milk-sugar are converted into glucose either in the intestine or in the process of absorption from the intestine. There seems, however, to be some difference in the degree to which they can be used for pur- poses of nutrition before they are converted into glucose. So far as is known, whether in plants or in animals, cane-sugar is merely a reserve, and cannot be used directly for nutrition. Milk-sugar, on the other hand, is probably not merely a reserve, but may possibly be utilized in the econ- FEEDING. 177 omy also for nutrition. Thus, Bernard has shown that seven grains of milk-sugar dissolved in an ounce of water could be injected under the skin of a rabbit without the subsequent appearance of sugar in the urine, while under the same conditions and in the same amount cane-sugar was found to be eliminated as foreign matter by the kidneys. Milk-sugar undergoes no direct alcoholic fermentation except when ex- posed to certain unusual ferments, but it changes readily to lactic acid in the presence of nitrogenous ferments. The lactic acid fermentation may be checked by heating the milk. Cane-sugar, on the other hand, easily undergoes alcoholic fermentation, but changes to lactic acid less readily than milk-sugar. Cane-sugar, moreover, takes on the butyric acid fer- mentation more readily than does milk-sugar. The bacillus lactis aerogenes (Escherich) is present in normal digestion, and acts on the milk-sugar to produce an organic acid which drives out the more noxious forms of bacteria, which by their presence would interfere with normal digestion. When milk-sugar is converted into glucose and galactose, we physiologi- cally have a gradual conversion into lactic acid, which may aid in the digestion of the proteids, thus giving us a very valuable addition to the means at our command for rendering modified cow's milk digestible. Jeffries says, in reference .to the different actions of the various kinds of sugar in the digestive tract, that it is important to note that starch, dex- trin, inulin, cane-sugar, and dextrose afford material for the butyric acid fermentation, while milk-sugar does this only after completed hydration. Escherich, in speaking of Briegers bacillus, says, " Milk is coagulated with sour reaction first after several days (eight to ten) at the body tem- perature. With exclusion of air this bacillus cannot grow either in milk or milk-sugar solution, but will in grape-sugar. We thus see that the milk-sugar offers less danger of the butyric acid ferment, which we know makes much trouble at times in the body, and that under certain conditions of the intestine it should be exempt from the assaults of Brieger's bacillus. When we consider that by means of heat we can practically put an end to the lactic acid fermentation, which may have begun to act upon the milk before it enters the stomach, it would seem that Ave are justified, on both physiological and bacteriological grounds, in using the same animal sugar in substitute feeding that is found in the infant's natural food, instead of introducing a vegetable sugar, which in milk is a foreign element. The dangers from lactic acid are, at any rate, much exaggerated by writers on this subject. ProteidB. — The proteids of normal human milk belong to the nucleo- albumins, and have quite a wide range in their variation ; still, it is now well recognized that their average normal total percentage is very much below that of cow's milk. Assuming that the percentage of proteids in human milk is 1.5, or between 1 and 2, it can be stated that the relation 12 178 PEDIATRICS. of the percentage of the proteids in cow's milk and in human milk is as 4 to 1.5. The proteids represent the nitrogenous elements of milk They con- sist of two distinct elements, caseinogen and lactalbumin (for clinical pur- poses it is not necessary to consider the lactoglobulin as separate from the lactalbumin), which together make up the total percentage of pro- teids in both woman's and cow's milk. These two elements differ greatly, however, in their relative proportions to each other in the two milks. This difference is shown in the following figures taken from Konig : Woman's Milk. Cow's Milk. Per Cent, Per Cent. Caseinogen 0. 59 2.88 Lactalbumin 1.23 0.53 Total proteids 1.82 3.41 According to the observations of other investigators the proportion of lactalbumin in whey is one per cent. (Bulletin 28, United States Depart- ment of Agriculture), which gives a higher percentage than in the figures quoted from Konig. Another analysis of whey by Hammarsten gives the percentage of lactalbumin as 0.86. Thus it is seen that of the total nitrogenous constituents of milk which are classed under the general term proteids, and of which the caseinogen and lactalbumin are parts, the coagulable proteids or caseinogen in cow's milk are proportionately larger in amount than in human milk, so that under the same conditions a larger curd will be formed with the former than with the latter. The question whether the casein in all milk is the same, or whether there are several different caseins according to the difference in the species of mammals, has not been determined. The casein is precipitated from its solutions by acids, but the precipita- tion is retarded by the presence of neutral salts. It is soluble in small excess of hydrochloric acid, but is again precipitated by a large excess. This acid coagulation of milk is to be clearly distinguished from the coagulation which takes place as a result of the action of the rennet fer- ment, by which the milk, when fresh, coagulates into casein and " sweet whey" without any change in its reaction. Mineral Matter. — The mineral matter of cow's milk has been ana- lyzed with comparative care and success. The total salts obtained by the analyses of Konig was 7.1 parts in 1000 parts, or 0.71 per cent. According to Soldner, the potassium, sodium, and chlorine are found in the same quantities in whole milk as in milk-serum. Of the total phosphoric acid, 36 to 56 per cent., and of the lime, 53 to 72 per cent., is not in solution. A part of the lime is combined with the caseinogen ; the remainder is found united with the phosphoric acid as a mixture of dicalcium and tricalcium phosphate, which is kept dissolved or suspended by the caseinogen. The bases are in excess of the mineral acids in the milk-serum, and the excess FEEDING. 179 of the former is combined with organic acids. At present the percentage of the mineral matter in cow's milk does not enter into the clinical modi- fication of milk, but a more extended knowledge of the subject may in the future be found to be of importance. The differences between the constituents of the mineral matter of human milk and of that of cow's milk are as follows : in cow's milk there are more lime, magnesia, potassium, much more phosphoric acid, and less chlorine and sulphur. Water. — There is about one per cent, less of water in cow's milk than in human milk. Chemical analyses invariably show so large an amount of water in human milk that it is evident that the infant is intended to take, and can best assimilate, a very dilute food. We must bear this fact in mind in preparing a substitute food, as the precaution of supplying a thoroughly diluted food is of extreme importance in managing the infant's feeding both in health and in disease. Total Solids. — There is about one per cent, more of total solids in cow's milk than in human milk. These solids in the milk are held partly in solution, partly in semi-solution, and partly in suspension. Attendants. — So much has been said about, and so many physicians are in favor of, diluting cow's milk with such attenuants as barley-water and other cereal waters, that a clear understanding should be had as to the true position which such attenuation should hold in infant feeding. One of the objects which physicians expect to attain Avith cereal at- tenuants is that in some mechanical way the attenuant breaks up the coagulated proteicls into finer particles than when the milk is simply diluted with water or lime-water or solutions of sugar. Barley-water seems to be the best attenuant for this purpose, and in comparing the coagulum obtained by the dilution made with this cereal with that made with water, lime-water, or sugar-water, it is found to be somewhat finer in the former than in the latter. The barley-water should be made as directed on page 239. A decoction of barley-water made in this way contains rather less than one per cent, of starch. This proportion of starch does not add materially to the nutritive value of the mixture, and must merely be looked upon as a foreign element which is never found in human milk. If, as has also been recommended by certain physicians, this starch in the cereal attenuant is dextrinized, the attenuant becomes a solution of sugar, and has no more mechanical effect on the coagulum than sugar in water. The use of cereal attenuants, excepting when they have a higher starch percentage for purposes of nutrition, is chiefly confined to the practice of those physicians who have not made an extended study of the finer possibilities comprehended in laboratory modification, and have failed to appreciate that the older methods of treating the coagulum of row's milk are not needed in the newer. Human milk never contains starch : the amylolytic function of the infant is not fully developed in the early months of life, and should not be taxed in the process of its development. 180 PEDIATRICS. The small additional mechanical effect of cereals on the coagulum is in- significant in comparison with the more rational methods of treating the coagulum ; these are truths which the medical profession will acknowledge when the laboratory system is better understood and laboratory methods still further perfected. The newer and more rational methods just referred to of dealing with the coagulum are not only to dilute sufficiently with water, but so to treat the total proteids in the mixture that the relative proportion of lactalbu- min and caseinogen shall approach as nearly as possible to that which is supposed to exist in the proteids of human milk. In this way the pro- portion of caseinogen being very much lessened, the resulting coagulum of casein will be much smaller, and practically so fine that any mechanical attenuant becomes useless. If cow's milk is diluted with simple water 1 part to 3, the resulting coagulum is a little larger than the coagulum of human milk. If. how- ever, the dilution is 1 to 4, the resulting coagulum is finer than that of human milk. In either case, however, the size of the coagulum must differ still further if the high percentage of caseinogen in the cow's milk proteid is reduced to the relative caseinogen percentage of human milk proteid, according to the total proteid of the mixture and the lactalbumin correspondingly increased. Cow's Milk as compared with Woman's Milk. — We may in concluding the subject of the chemistry of cow's milk summarize the principal points of difference between cow's milk and human milk in the following table ; TABLE 40. Woman's milk directly from the Cow's milk as ordinarily received, breast. about twenty-four hours old. Reaction Amphoteric. (More alkaline Slightly acid. t than acid. ) Water 87 to 88 per cent. 86 to 87 per cent. Mineral matter 0.20 per cent. 0.70 per cent. Total solids 13 to 12 per cent. 14 to 13 per cent. Eats 4.00 per cent, (relatively poor 4.00 percent. in fatty acid.) Milk-sugar 7.00 per cent. 4.50 per cent. Proteids 1.50 per cent. 4.00 per cent. Gaseinogen (Konig) 0.59 percent. 2.88 percent. Lactalbumin (Konig) ... 1.23 per cent. 0.53 percent. Coagulable proteids Small proportionally. Large proportionally. Coagulation of proteids by acids and salts With greater difficulty. Curds With less difficulty. Curds small and flocculent. large and tenacious. Coagulation of proteids by rennet Does not coagulate regularly. Coagulates readily. Action of gastric juice . . Proteids precipitated hut easily Proteids precipitated hut dissolved in excess of the gas- dissolved less readily. trie juice. BACTERIOLOGY OF COW'S MILK.— A few matters concerning the bacteriology of cow's milk can best be considered in connection with FEEDING. 181 the subject of substitute feeding. Respecting this question Dr. J. A. Jef- fries very aptly remarks that "it is a curious fact that, while older people are chiefly fed on sterilized food, — that is, cooked food, — infants are fed on food peculiarly adapted by its composition and fluid state to offer a home for bacteria." It is manifestly very important to use a milk for modification which is as free as possible from bacteria. In the milk commonly used in cities the number of bacteria to the cubic centimetre amounts to a million or more. Ten thousand bacteria per cubic centimetre is considered the maximum for good milk. In the year 1899 a daily examination of the milk pro- duced by one of the farms connected with the milk laboratory in Philadel- phia was made at the Pepper Laboratory. The average for 334 days was 1530 bacteria per cubic centimetre; and this number fell in the autumn and winter to 1150 to 1195 per cubic centimetre. These figures show how. with especial care at the farms, milk can be radically changed in re- gard to bacteriology. In some experiments made by Jeffries agar-agar cultures were made before and after the different fluids were sterilized, and the colonies of bacteria were counted. His results coincide with those of previous ex- perimenters. — namely, that steaming for fifteen minutes is sufficient to kill the developed bacteria, while a second steaming is necessary for complete sterilization. Out of one hundred and twenty lots of milk steamed but once, all but four or five showed distinct signs of change within a month, while the majority of those steamed twice did not change at all. Jeffries's experiments also show that spores develop slowly, and, in- deed, rarely form in milk, which, as he says, is an excellent medium for growth, while spore-formation among bacteria, like seeding among higher plants, is a phenomenon of impaired growth. He also explains the pres- ervation of some of the milk steamed but once by the absence of any enduring spores from the start. In an article of very great interest and value to the practising physician, " On the Bacteria of the Alimentary Canal' 1 Jeffries has reviewed, at my request, the work done by the various dacteriologists : " Miller, De Barry, and Escherich have shown that living bacteria are to be found in the stomachs of men and animals, and the former author has also clearly proved that bacteria can pass through the stomach into the intestines and live for a considerable time. ... Of the morphology and biology of the forms found in the stomach little is known. The field is a new one, and the species have not been sufficiently described to en- able others to recognize them with certainty. Miller has found five kinds which give off carbonic dioxide and hydrogen gas, lactic, acetic, and butyric acids being formed. ... Of the flora of the intestines much more is known than of that of the stomach. The researches of Brieger. Vignal, Stahl, and Escherich have now proved that a large number of species may occur in the feces. Brieger isolated two new kinds : one a micrococcus, 182 PEDIATRICS. which turns grape- or cane-sugar into ethyl alcohol, with a trace of acetic acid ; the other the well-known Brieger's bacillus. This species occurs in the faeces in vast numbers, ferments sugar, and decomposes albumins. Vignal isolated ten species from the faeces, six of these also being found in the mouth. Of these some produced acid fermentations and gas, but un- fortunately they were not sufficiently studied to show their effects on digestion. . . . Escherich studied especially the faeces of infants, and found a large number of kinds of bacilli, among them a small bacillus capable of converting milk-sugar into lactic acid, carbonic dioxide and hydrogen gas being evolved, either in the presence or absence of air, a facultative anaerobic species, his bacillus lactis aerogenes. Escherich established, by the examination of a large series of cases, the fact that the kinds occurring in the faeces vary with the food, — that is, the intestinal contents. . . . Starting at birth with the sterile meconium, consisting of mucus, epithelium, and the like, infection by the mouth and rectum quickly occurs, and in a short time almost any form may be found, but chiefly such putrefying forms as proteus vulgaris. " With the suckling of the infant and the substitution of the refuse of the milk and secretion of the digestive tract for the meconium, a sharp transition occurs. Instead of the generally distributed forms causing de- composition, only two kinds are regularly found, bacillus lactis aerogenes and Brieger's bacillus ; the first chiefly in the upper parts of the intestine, the second in the lower parts. Passing on to the period of mixed diet, quite a number of forms appear, among them the streptococcus coli gracilis, the putrefying green fluorescing, a tetrad coccus, and several kinds of yeast. This brings us to the pith of the subject : Why are the flora so limited in the milk-eating infants and so diverse in others ? What drives the forms found in the meconium out ? That they can live there is clear, as shown by their presence the day before. Again, w r hat prevents forms so common with meat diet from gaining a footing ? It is not the milk alone, for milk is an almost universal food for bacteria, and all the kinds found in the intestines thrive in it. " According to Escherich, the bacillus lactis aerogenes and the milk diet keep out the other forms. "Formerly," continues Jeffries, "even before the action of ferments and putrefactive processes Avere clearly understood, the significance of this question was seen. The chyme is a mass admirably adapted for putre- faction or fermentation, yet ordinarily but little of either occurs. It is an alkaline or, as in the milk-fed, acid mixture, rich in albumins, fats, and the starch group, amply provided with water and warmth. Such a mix- ture outside the body at an equal temperature would quickly decompose. It was generally held that some preservative action was exerted by the digestive juices ; Bidder's and Schmidt's dogs with biliary fistulae were supposed to explain the whole. These dogs, deprived of their bile, be- came emaciated, and suffered from diarrhoea and decomposition of the in- FEEDING. 183 testinal contents. Thus it seemed clear that in the absence of the bile decomposition occurred, — that is, that the bile was a powerful germicide or germ-inhibitor. During the last few years, however, different results have been obtained in cases of biliary fistula. Rohmann's dogs did not suiter from diarrhoea or putrefaction in the intestines, hence it is clear that the bile is not the cause of prevention. The diarrhoea, if present, is due to the large amount of fat passed on to the lower intestines. •• Maly and Emich ascribed value to the bile acids, especially the tauro- cholic. basing their results on crude methods ; and Lindenberger, really leaving the subject, attributed the action to the organic acids in combina- tion with the bile. -All this argument and belief in the decided germicidal action of the bile occurred in the face of the well-known fact that bile itself will de- compose. " From a bacteriological stand-point, Miller has shown that a ten per cent, solution of bile, if anything, favors growth. Macfadyen has studied bile, bile salts, and bile acids in varying strengths. The only positive results were got with the acids ; these arrested the development of bac- teria if sufficiently strong, especially taurocholic acid. Neither acid had much effect, and least of all on the forms causing putrefaction. Proteus vulgaris was only arrested by a strength of from one to two per cent. The pathogenic forms were arrested by a much smaller quantity, from one to one-half per mille. ••It is thus clear that other causes must be sought for. One of these is to be found in the lack of oxygen in the intestines, as pointed out by Escherich and strangely forgotten by others. There is certainly very little free oxygen in the chyme, if any ; not only is it scarce in the food at the start, but is taken up by the chemical changes during digestion, and also by the intestines. This clearly must be a potent factor, for the majority of bacteria require a fair supply. Accordingly, many bacteria are found in the faeces which will grow in the air, as shortly stated by Macfadyen, and the mass of those isolated in the air are able to grow without it. " This apparent contradiction, the absence of oxygen in the intestines, and the presence of both aerobic and anaerobic bacteria, is probably ex- plained by the ability of the aerobic kinds to draw oxygen from oxyhem- oglobin. They thus breathe through the intestines, as it were, when in close contact with the walls, while the anaerobic kinds live in the mass of the chyme, and do not, so far as we know, reduce oxyhemoglobin. - Escherich, though he points out the absence of oxygen, does not seem to give it full value, or rather forgets the subject in treating of the action of his lactic acid bacillus. As before stated, this form is regularly found in great numbers in the upper part of the intestines of milk-fed children. Here it converts a considerable part of the milk-sugar into lactic acid, and thus prevents the other forms from growing, — most forms being suscepti- 184 PEDIATRICS. ble to an acid reaction, and especially to the organic acids. The action of salicylic acid is known to all, and recent experiments, of which Mac- fadyen's (the last) are the best, show acetic, butyric, and lactic acids to be efficient germ-inhibitors in strengths of from one to one-half mille accord- ing to the species. " In milk-fed infants another point is the comparative inability of bac- teria to attack casein, so that the bacteria are literally starved. "We may therefore conclude that the bile acids, lack of oxygen, lack of suitable albumins, and the presence of organic acids are the causes of immunity from the putrefying and fermenting kinds of bacteria to which we are exposed. Certain forms are probably limited by the lack of water, — that is, of a fluid state, — doing poorly if unable to swim freely about. It must not, however, be supposed that bacteria are scarce in the intestines ; on the contrary, they form a large part of the dry substance of the fseces. •• The ferments act by the production of various acids, chiefly derived from the milk-sugar. In small amounts, as in the case of the bacillus lactis aerogenes, the acid seems to be of benefit, and certainly does no harm, as it regularly occurs in healthy breast-fed infants. In large amounts, however, it must tend to over-acidify the contents of the intestines and interfere with the action of the digestive fluids." MILK - LABORATORIES AND PERCENTAGE FEEDING.— General Considerations. — When human milk that is suited to the indi- vidual infant cannot be obtained, or if obtained cannot be regulated by modification, it is desirable to substitute for it the combination of ele- ments which such a human milk represents. To accomplish this we must have materials which, while closely resembling the elements of normal human milk, are easily obtained. Physiological experiments on the mammary gland show that the albumin of the milk is not directly an exudation from the lymph-vessels supplying the mammary gland, but that it is actually modified in the gland itself. We thus see that the mammary gland, besides being an elaborator for infant nutrition, is also a modifier. This suggests to us that the modification of milk is not contrary to nature's method of pre- paring food for infants. Following, therefore, nature closely, we have learned that the proper modification of absolutely pure and fresh milk is the vital principle which should underlie our efforts to perfect a substitute food. The infant at the breast receives for its nutriment a fluid which is fresh, sterile, amphoteric, or faintly alkaline, which has a temperature of 36.7°-37.8° C. (98°-100° F.), furnished in an amount proportionate to the age and size of the consumer. It is this fluid which we have to copy in every possible detail when we undertake to prepare a substitute food. We should also consider as foreign matter, to be carefully avoided, any element which we know is not to be found in the milk we are copying. FEEDING. 185 The analyses of human milk teach us that there is a great capacity in different infants to assimilate a variety of proportions of the same nu- tritive elements. In all probability the infant needs a variety in its food somewhat to the same extent as does the adult. In order, therefore, to copy nature closely, we must have some means of preparing a food not only for the many but for the individual, and when introducing new methods for preparing a substitute food we must recognize the necessity of providing for many prescription possibilities. In this busy age of scientific rational medicine physicians all over the world demand, first, means of saving time, and second, exact methods of work, which in themselves soon become time-savers. In every branch of our art the tendency is growing year by year to systematize the detailed and laborious work of the individual for the common practical use of the profession at large. The subject of substitute feeding should be reduced to a more exact system, and an effort should be made to rescue this important branch of pediatrics from the pretensions of the owners of proprietary foods and the hands of ignorant nurses. With this end in view, I have given my professional assistance to the establishment of a system of milk-laboratories where the materials used shall be clean, sterile, and exact in their percentages. These laboratories have been placed under the control of educated, intelligent men in whom we have the same confi- dence that we have conceded to the pharmacist, and we can write direc- tions for infants' foods and send them to these laboratories just as, in the treatment of disease, we write our prescriptions for the division of one drug or the combination of several. As the pharmacist has nothing to do with the various methods of treating disease, so the milk-modifier is simply required to carry out the directions and ideas of the physician. No special school of medicine need be represented. No special method of feeding need be undertaken. An opportunity has, however, for the first time in the history of medicine, been presented for the physician to carry out his own methods, and these methods for the first tiuie to be judged on a fair basis. In this way only can each clinical observer, when lacking in success, be sure that it is the fault of the food he is giving, and not because the food has varied from what he supposed he had ordered. In quite a number of cases rather gross changes in the percentages of the different elements of the milk may be sufficient for the range of the individual digestion and for the nutrition of the especial case, but it has been my experience with a very large number of infants whose vitality was low and whose malnutrition was excessive, to find that the lives of these infants could only be preserved by gradual and minute changes in the percentages and combinations of the milk-elements. We therefore cannot be too particular in assuring ourselves that we are using a milk- modification which is as precise as any knowledge up to the present time has made it possible to be. Even slight changes- therefore, in the percent- ages of the three important elements of milk of which we have most accu- 186 PEDIATRICS. rate knowledge — namely, the fat, the sugar, and the proteids — are of real value in the management of the digestion and nutrition of the infant, and these changes are often necessary day by day as well as month by month. With this fact impressed upon us, we can well see that no one mixture will in all cases prove successful, but that a great variety in the percentages of the different elements of the milk will be needed in substitute feeding just, as they already exist in maternal feeding. This explains the diversity of results obtained in the past with the same food by different practitioners. Regarding the subject from this point of view, it is evident that there is no especial combination of percentages for the especial age of the infant, for the proper nutritive value of the food given to an individual infant must be adapted to that infant's special stage of development and to its special powers of digesting certain percentages and combinations of percentages. It has been frequently observed that an improper modification for the in- dividual may do much harm and may lead to something more than indi- gestion, — namely, to such diseases of nutrition as infantile atrophy, scor- butus, and rhachitis, — so that it is exceedingly important that the physician should understand the exact modification called for in each case as thor- oughly as he would the treatment of any disease in the individual. The means for prescribing a diversity in the elements of milk, accord- ing to the idiosyncrasy of the digestion we are dealing with, is supplied by a milk-laboratory equipped with special machinery and controlled by educated milk-modifiers. Purity of the original material is the first object to be attained. This material, milk, should be obtained from cows bred, fed, and cared for in the manner just described, and, in order to insure absolute uniformity in the methods, untiring vigilance must be used in the supervision of the farm, cows, and milk-house, and in the transportation of the milk from the farm to the laboratory. It is also necessary that the cows should be under the medical supervision of a skilled veterinary sur- geon. These are all questions which to my mind have been definitely decided, but which now need time and attention devoted to them to insure their being systematically carried out. As in all other advances which are made in practical medicine, so also in this one it is well to adopt at once a high standard of work and to demand everything that can in any way . tend to perfection. We may not always be successful in carrying out all the details, but, until we are, perfection will not be reached. It must, then, be borne in mind and understood that each link of that chain is of vital importance, because, if broken, the value of the whole chain may be lost. One end of this chain is at the milk-farm. Starting in the stall of the cow it passes on to the milk-house, from the milk-house to the milk-labora- torv, and from the laboratory it should be carried unbroken and intact to the infant consumer. Apparatus for Feeding. — Human ingenuity has not yet been able to devise anything which approaches the perfection of nature's apparatus for feeding, and the best that we can do to offset this complex mechanism is FEEDING. 187 to adopt that which is exactly the reverse, — namely, an apparatus of abso- lute simplicity. — and thus combat the tendency to fermentation by pre- venting, through perfect cleanliness, the apparatus from becoming a source of fermentation. To accomplish this object the receptacle from which the infant is to be fed should be made of glass, in the form which will enable it to be most easily cleansed, and, as in the future the question of trans- portation will undoubtedly be a grave one, the receptacle should be such that it can be adapted to transit and not easily broken. For this purpose what are practically test-tubes fulfil these indications best. These tubes have open mouths larger than those usually provided in the ordinary nursing-bottle, and. having no angles, are readily cleansed. The artificial receptacle is not self-regulating, and hence we must determine the amount of food in bulk which nature provides for the average infant at different ages, and from these average figures deduce the proper amount for the Fig 46 Stomach from infant 5 days old ; capacity 25 c.c. (Natural size.) Glass cylinder, capacity 25 c.c. (Natural size.) especial infant. The feeding-tubes are graduated for the more important periods of growth, for the purpose of continually impressing upon the mother and nurse what the physician often has the opportunity of telling them only at the beginning of the nursing period, — namely, that the error is in giving too much food rather than too little, an error, also, which nat- urally results when, as is commonly the case, the usual eight-ounce nursing-bottle is provided as the receptacle at the very beginning of infan- tile life. I have found that I can easily convince most mothers of the mistaken zeal of nurses who advocate giving the young infant large amounts of i'ood. by showing them the size of the infant's stomach at birth and comparing 188 PEDIATRICS. this small tube which corresponds to the stomach's capacity with an eight- ounce nursing-bottle. Nipples. — A nipple made of fine soft rubber adapted to the especial infant as to its size and the holes for the milk is substituted for the mater- nal nipple. These rubber nipples should be large enough to be turned inside out and carefully cleansed after each feeding. They should be boiled after being used, and kept in cold distilled water with a little soda in it. They should be renewed frequently, the oftener the better : pref- erably a new one should replace the old one three times a week. It will be found that the rubber nipple has to be adapted to the taste of the espe- cial infant, and that it often has to be changed as to its size, texture, and holes before the infant is satisfied with it and sucks satisfactorily from it. Intervals of Feeding. — The intervals between the feedings given below should also be adopted in substitute feeding, but the amount of food to be given now becomes a prominent feature in the division of the total amount of food which it is proper to give in the twenty-four hours, according to the age and development of the individual infant. Amount at Each Feeding. — The infant's weight and its gastric capacity quite frequently do not correspond. Yet there seems to be no doubt that the weight is a condition to which marked consideration should be given when we are attempting to determine so difficult a question as the proper amount of food to be given at each meal in the early months of life. The amount to be given at each feeding must be carefully regulated accord- ing to the gastric capacity. TABLE 41. General Rules for Feeding during the First Year. The day feedings are supposed to begin at 6 A.M. and to end at 10 P.M. Age. Intervals, hours. Number of Feedings in 24 hours. Number of Night Feedings. Amount at each Feeding. Total Amount in 24 hours. Cubic Cubic Centimetres. Ounces. Centim etres. Ounces. 1 week. . . . 2 10 30 1 300 10 2 weeks . . . 2 10 45 1* ' 450 15 4 weeks . . . 2 9 75 2| 675 22£ 6 weeks . . . 2* 8 90 3 720 24 8 weeks . . . 2* 8 100 H 800 26 3 months. . 2J 7 120 4 840 28 4 months. . 2£ 7 135 4J 945 31} 5 months. . 3 6 165 61 990 33 6 months. . 3 6 175 5| 1050 34} 7 months. . 3 6 190 6i 1140 37} 8 mon ths . . 3 6 210 7 1260 42 9 months. . 3 6 210 7 1260 42 10 months. . 3 5 255 *H 1275 42} 11 months. . 3 5 265 8f 1325 43f 12 months . . 3 5 270 9 1350 45" The above table shows how the intervals of feeding and the amount of food to be given should correspond to the gastric capacity at different FEEDING. 189 periods of the first year. It is so important to avoid stretching so easily distensible an organ as the stomach that it is wiser to give too little rather than too much food in the early days of life, and then gradually increase the amount if the infant cries from hunger. The first month being the most critical period for the infant's nutrition, as it is the time when the equilibrium of its metabolism is being estab- lished and its chance for life is least, especial interest should be attached to the series of careful investigations made at the Children's Hospital in St. Petersburg by Ssnitkin to determine the amount of food which should be given in the first thirty days of life. As the result of these investiga- tions he deduces the rule, t; the greater the weight the greater the gastric capacity." Ssnitkin's general results show that one-one-hundredth of the initial weight should be taken as the figure with which to begin the computa- tion, and to this should be added one gramme for each day of life. Illustration of Ssnitkin's rule to aid in adjusting the food to especially difficult cases in the first thirty days. Amount at each Feeding. Initial Weight. Early Days. At 15 Days. At 30 days. 3000 grammes 30 grammes. 30 -f- 15 = 45 grammes. 30 -f- 30 = 60 grammes. (About 1 ounce. ) (About 1J ounces.) (About 2 ounces. ) 4500 grammes 45 grammes. 45 -\- 15 = 60 grammes. 45 -f 30= 75 grammes. (About 1 J ounces. ) (About 2 ounces. ) (About 1\ ounces. ) 6000 grammes ...... 60 grammes. 60 -j- 15 = 75 grammes. 60 -j- 30 = 90 grammes. (x\.bout 2 ounces.) (About 2£ ounces.) (About 3 ounces.) It is wiser always to accomplish first the proper digestion of the food, even if there is no gain in weight, and then, when once the infant is digesting well, to increase the amount of the percentages of the different elements. At times when the infant is digesting well, and even gaining, it will suddenly cry so hard and with such evident hunger, that an imme- diate increase in the amount of its food is not only indicated but de- manded, no matter what its age or weight. In these cases the stomach has probably grown rapidly and out of its normal proportion to the age and size of the child, and a larger supply of food is what is needed. THE MILK-LABORATORY. — As milk-laboratories are now so well known, and have for some years been established all over the United States and in Canada and London, they need not be described in great detail. A milk-laboratory should be a place to which the. milk should be de- livered from such farms and under such precautions as have already been described ; it should be in a central locality, accessible to as many people as possible, and used exclusively to prepare ,from the prescriptions of physicians alone, any modification of milk which may be called for. As milk is one of the best means for the cultivation of bacteria, the laboratory should be situated in a healthy locality. It should be as free as possible from contaminating influences, should be kept absolutely clean, and every aseptic precaution against the harboring or development of 190 PEDIATRICS. pathogenic organisms should be taken. To insure perfect work the great- est vigilance is needed in every department of such a laboratory. From the moment that the milk is delivered from the farm at a tem- perature of about 4.4° C. (40° F.) it should be watched over and cared for with scientific accuracy during the whole process of the modification which it undergoes in the laboratory. The milk-rooms should be cool and free from dust, and isolated, so far as possible, from other parts of the laboratory. There should also be an entirely separate room where the returned packages and all articles received from the homes of the consumer should be directly brought from the street or wagons, and where these articles can be immediately sterilized in apparatus reserved for this purpose. The modifying materials used in the laboratory should be carefully kept for use in glass vessels, and at a temperature of about 4.4° C. (40° F.), to prevent the growth of bacteria. The reason for this is that milk modified from materials free from bacteria is not only better for the infant than milk in which the bacteria have been destroyed by heat, but that there are certain toxins which cannot be destroyed by heat, and by their virulence may cause serious disturbance even after the most thorough sterilization has been carried out. In a carefully guarded milk-supply also it is seldom necessary to ever pasteurize a milk which is sent out from a well-equipped laboratory. On the other hand, modification has been found to fail entirely when applied to old milk, dirty milk, and to milk bacteriologically impure. A special room should be provided for the milk-modifiers who are to put up the mixtures required by each prescription. There should either be a room in the laboratory where the milk is separated by means of ma- chinery and where it can be tested and steamed, or this can be done in the milk-room at the farm. The office at the laboratory should be entirely separate from these work-rooms, so that customers coming to leave their orders should not go near the materials used for modification and thus possibly contaminate them. All odors should be excluded from the work- rooms, as they are absorbed by milk very quickly. It is hardly necessary to say that the employees of a laboratory, whether they be in the office or in the work-rooms, should be intelligent and interested in their work, and that the modifying clerks should be especially instructed in the neces- sity of absolute cleanliness, should be made to understand the dangers of sepsis and the importance of asepsis, together with a practical knowledge of how to guard against and exclude pathogenic organisms. Milk-Room. — The milk should be aerated and cooled to about 6.66° C. (44° F.) at the farm, then packed in ice in such a way as to maintain its temperature during transportation below 7.22° C. (45° F.), and deliv- ered to the milk-room within a few hours of the time of milking. This milk, as a result of the especial manner in which the cows have been fed and cared for and the selection of them according to the proper FEEDING. 191 breed, may be said to have an almost uniform percentage of its elements. Even at those times of the year when the percentages of the different ele- ments of milk commonly vary from changes in the pasturage and in the habits and surroundings of the animals, the milk of these cows, which have their food supplied to them in stated rations at one time of the year as well as another, is not subject to the elemental variations which occur in the milk of ordinary cows. Separating-Room. — The milk can be separated either at the farm or in the laboratory in a room arranged and cared for in very much the same way as the milk-house at the farm. The walls are of white tile, and the ceilings are of material which can be washed and scrubbed. The floor is of asphalt, impenetrable to water, and is kept thoroughly moist- ened and free from every kind of dirt and dust. Ventilator. — In addition to the other precautions against pathogenic germs, the air of the separating-room is kept fresh and pure by means of a ventilator. This consists of a large steel fan, which revolves at the rate of two thousand times a minute, and by the force of its current carries away any flies or particles of dust Fig. 47. which may come within its reach. The air which comes into the separating-room, as well as into the milk-room and modifying-room, should be washed with sterile water. Separator. — The centrifugal separator revolves six thousand eight hundred times in a minute, and works with such searching effect on the milk that only a small percentage (0.13) of fat remains in the separated milk. The utility of the separator, however, does not consist wholly in its absolute withdrawal of the fat from the milk and in providing cream as fresh as to time as is the separated whole milk : it accomplishes two other very important results. First, by its great centrifugal force it separates from the cream and the centrifugal separator. separated milk any dirt or foreign matter of any kind which necessarily gets into every milk, and thus provides at once a practically clean milk, a most important result from a bacteriological point of view. Still. — A still for freshly preparing each day distilled water is part of the laboratory equipment. Modifying-Room. — In the modifying-room the milk is tested and the modification of the milk is completed. Babcock Pat-Tester. — To be doubly sure that the chemistry of the milk is what we suppose it to be from the uniform nature of the primal milk-supply, we take advantage of the knowledge which we have concern- ing the changes most likely to take place in certain elements of the milk. 192 PEDIATRICS. The percentage of the proteids, of the sugar, and of the mineral mat- ter in the milk of a herd of this kind, where uniformity in the feeding is the rule, is not apt to be appreciably affected. But the percentage of the fat in individual cows differs from day to day. and thus slightly affects the percentage of the fat in the milk of the herd. The fat, then, being the element by which we know whether each milking gives a uniform product, we test this element by means of what is called the " Babcock Fat-Tester." Fig. 48 shows the Babcock machine. Pig. 48. Babcock fat-tester. To determine the percentage of fat, test-bottles containing the acidified milk are placed in a centrifugal machine, by the rapid revolution of which the fat is made to separate quickly and completely. The milk is acidified in order that the proteids, casein and fibrin, may be changed to soluble acid albumins, which offer less resistance to the rising and aggre- gation of the fat-globules. Approximately equal volumes of milk and commercial sulphuric acid of 1.82 specific gravity are mixed in a test-bottle with a long graduated neck. A pipette, delivering about 17.5 c.c. of milk, and a measuring cylinder for the acid, are used. The bottles are whirled for several min- utes at a temperature of 93° C. (200° F.) in a horizontal wheel making from seven to eight hundred revolutions per minute. This wheel is sur- rounded by a copper jacket, which may be filled with hot water for heating during the test. The separation of fat by gravity alone is not complete even when the bottles are left standing for several hours. By the centrifuge, however, a perfect separation is accomplished in a few minutes. If whirled at once, no heat need be applied, as that caused by the strong acid and milk is sufficient. After whirling, the bottles are filled to the neck with hot water, returned to the machine, and whirled for one or two minutes longer, after which they are filled with hot water FEEDING. 193 to about the seven per cent, mark, and the machine is again turned for a short time, the temperature being kept up by means of a lamp or by filling the jacket with hot water. The fat separates and its percentage is noted while still liquid, preferably at about 65° C. (150° F.), the reading giving the percentage of fat directly without calculation and being easily taken to 0.1 per cent. This daily testing of the fat enables the modifier to preserve the accu- racy of his material, and to correct any variation in the percentage of the cream as it comes from the separator. Knowing the exact percentages contained in the cream and milk, the office clerk can, by a simple mathematical formula, give the required directions on the modifying clerk's formula for obtaining whatever per- centages of the other elements the physician may call for. Apparatus for the Transportation of Modified Milk. — Fig. 49 repre- sents the various forms of apparatus which are provided for feeding the infant in its home. Fig. 40. In the left of the picture is a basket holding eight tubes of a capacity of six ounces each. In front of this basket is a four-ounce tube in a wire stand. In the middle of the picture is a tin apparatus for warming the milk at the time of feeding. An alcohol lamp is shown beneath the warmer, and a tube of milk and a thermometer for testing the temperature of the milk are in the tin warmer. Next to and to the right of the tin warmer is a tube with a capacity of eight ounces. It is enclosed in a white worsted cozy, has the rubber nipple in place, and is supported in a wire stand. In the right of the picture is a basket containing six tubes with a capacity of eight ounces each. In front of this basket are an eight- ounce tube and a four-ounce tube. This apparatus is very simple and practical for transportation. A wicker basket, divided into a number of compartments corresponding to the number of feedings which are to be sent to the infant, has been found to be the most practical. These baskets with their tubes can be placed directly in the sterilizer, and are not harmed by the heat to which it is necessary to expose the food. This tin receptacle can be placed above an alcohol lamp ; the water in it is to be on a level with the height of the milk which is contained in the tube, and the tube is submerged in the water. It has been found neces- sary to take the temperature of the food by means of a thermometer 13 194 PEDIATRICS. placed directly in the tube. No rule can be laid down by which the tem- perature of the water-bath determines that of the milk, unless the tubes are of uniform thickness and the milk uniform in quantity and tempera- ture when placed in the bath. The thermometer must be washed in sterilized water with the greatest care, both before and after it is used. The food when given to the infant should have a temperature of from 36.6° to 37.7° C. (98° to 100° F.). As in direct feeding from the breast the food which the infant receives has the same temperature at the end of the feeding as at the beginning, we should copy this provision of nature and not allow the temperature of the food to vary during the time it is being taken. To accomplish this end, a white worsted cozy can be used. The cozy is warmed at the same time that the milk is being heated, and the tube when placed in it is pre- vented from cooling. Thus the infant receives a food of unvarying tem- perature throughout the whole of the feeding. Fig. 50 represents an ice-box which can be used in hot weather, and has proved to be of great practical utility. It admirably serves the pur- Fig. 50. Ice-box, holding twelve tubes. Receptacle for ice in centre of box. Laboratory prescription-blank in front of box, and packing paper under end of open lid. poses of an express box and of a home refrigerator. The ice is packed in a metal compartment in the middle of the box, and the tubes are placed, each in its own compartment, around the sides of the ice-receptacle. Materials for the Modification of Milk. — The cream as well as the fat-free milk contains its own definite percentages of sugar, proteids, and mineral matter. The following analysis shows the percentages of the fat, sugar, and proteids in a laboratory sample of sixteen per cent, cream as compared with the fat-free milk : FEEDING. Fat. Sugar. Proteids. Cream 16.00 0.13 4.00 4.40 3.60 Fat-free milk 4.00 195 To provide the means for adjusting the percentages of the sugar which are called for, a carefully prepared twenty per cent, solution of milk-sugar and distilled water is used. The reaction of the food is adjusted by means of lime-water. In addition to the materials used for purely milk mixtures, other arti- cles of food, such as freshly prepared oats, barley, and wheat, can be obtained at the laboratory, and these can be prescribed by the physician in any combination or according to any stated percentage of fat, sugar, proteids, or starch which he may wish. By calculation also a whole milk can be used in place of the separated milk, and a gravity cream in place of a separated cream, if a few hours' notice is given by the physician who is prescribing the mixture. It is well that this latter statement should be noted, as physicians are so apt to think that only separated milk and cream are used at the laboratories, and that the food is always sterilized or is always made alkaline with lime-water. This is not so, and it should be thoroughly understood that the laboratories, are ready to provide whatever the physician orders, and in whatever way he orders, and that they are not allowed to do anything else, either to prescribe, to change the prescription, or to sell a modified milk preparation without a physi- cian's prescription, — that is, the laboratory is merely an instrument in the hands of the physician, and is in no way responsible for the results obtained from the feeding, except so far as freshness of material and exactness of combination is concerned. The physician, on the contrary, can order his preparations to be delivered unheated or at any temperature, whether it be 65.5° C. (150° F.), 75° C. (167° F.), or 100° C. (212° F.) ; alkaline or not, as he pleases, and if alkaline, made so in any way he prefers to order, such as by lime-water or soda ; his fat percentages can be given him with gravity cream if he prefers it to separated cream, and his proteids with whole milk instead of separated milk ; also his sugar can be cane-sugar if he prefers it to milk-sugar. ^ The physician, however, should appreciate that separated milk con- tains far less dirt and much fewer bacteria than whole milk, and that using gravity cream means a six or eight hours' older cream, and necessa- rily more bacteria than a quickly separated cream, which gives us as fresh a material for modification as the milk. I personally have never been able to satisfy myself that the emulsion of the fat was in any way dis- turbed by the separator, and my clinical experience, which has been large with both separated and unseparated milk and cream, has never shown that any harm came from using the former. With these modifying materials the modifying clerks combine each infant's food according to the prescription before them, and pour it into the glass tubes from which the infant is to nurse. These tubes, which 196 PEDIATRICS. have been especially devised as the most practical for general use, are adapted both for transportation and for use as nursing-bottles, and are easily cleansed. There are two sets of clerks. One set is engaged in modifying the milk according to the prescriptions. As soon as the tubes are filled by the modifying clerks they are passed on to the stoppling clerks, who im- mediately seal them with aseptic non-absorbent cotton especially prepared for this purpose, and place them in baskets, the compartments of which are adapted to the number of feedings ordered for the special infant. The tubes are kept on tube-racks within easy reach of the modifying clerks. Each basket has its own label attached to it, with the address of the person to whom it is to be sent. The rule of absolute cleanliness is carried out in every possible detail, from the table on which the materials are combined to the dress and hands of the clerks. The milk is thus separated and recombined according to the prescrip- tions, stoppled, and placed in their respective baskets for transportation. Sterilization of the Milk. — The sterilizer is so arranged that the steam which passes through it can be regulated so as to produce any degree of heat required up to 100° C. (212° F.). This is accomplished by a regulator attached to the steam-pipe. The man in charge of the heating of the food, by keeping his hand on the regulator and his eye on the thermometer which is fitted to the sterilizer, can subject the baskets and the tubes in them to whatever degree of heat is ordered, and of course for the length of time required. The question whether milk should be boiled or steamed is one which is not of much significance, and can be settled according to the fancy of the individual practitioner, a greater or less destruction of the bacteria contained in the milk taking place according to the degree of heat to which it is submitted. My own experiments in comparing steamed with boiled milk show that the odor and taste of boiled milk are present when milk is steamed, but to a much less degree than in boiled milk ; also that while a thick scum is formed on milk boiled for twenty minutes, which is tenacious and does not disappear on shaking, only a very thin scum forms on milk steamed for twenty minutes, and that this is not tenacious and almost entirely disappears on shaking. After the food has been heated, the baskets are taken out of the sterilizer and placed in the cooling-tank, where the temperature of the food is reduced to 13.3° C. (38° F.). The baskets are then placed in the delivery-wagon, which conveys them to their various destinations. When the baskets are delivered at the homes of the consumers, the baskets and tubes of the previous day are returned to the laboratory. When they reach the laboratory they are taken directly from the street to the wash-room, which is entirely shut off from the rest of the laboratory. Wash-Room. — In the wash-room, in order to carry out absolutely the FEEDING. 197 aseptic precautions, the baskets and everything which has been returned to the laboratory are placed in a special sterilizer connected with the wash- room. The bottles, after being sterilized, are thoroughly washed in tubs, which are especially adapted for this purpose, in a solution of soda and water. All the tags and stoppers are destroyed after sterilization. The baskets are of woven willow, and are easily kept sterile. In this way, always guarding against possible infection of all kinds, the laboratory enables us to make use of the chemical and bacteriological knowledge which we have acquired in connection with the feeding of infants, and fulfils the requirements of that system of substitute feeding which up to the present time has proved to be the best. Principles of Prescription Writing in Percentage Feeding. — Let it be supposed that a modified milk is to be prescribed for an infant four months old with a normal digestion and of normal weight and general development. The regular prescription blank issued by the laboratory can be used, but, of course, a milk prescription can be written as one would write for a drug. The following is a sample prescription, in which the physician writes for a total proteid without reference to the relative proportions of casein- ogen and lactalbumin : g. Per Cent. Fat 4;00 Milk-sugar 7;00 Total proteid 1J50 (a) Caseinogen (b) Lactalbumin (whey proteid) .. . Ordered for Date Number of feedings 7 Amount of each feeding. . 135 c.c. (f^4^). Infant's age 4 months. Infant's weight 14 pounds. Alkalinity 5 per cent. Heat at 155° F. Signature. In regard to the question of the reaction, it can be left to the milk- modifier, as we leave to him the carrying out of other directions con- tained in the prescription. If the milk brought to the laboratory on the special day when we are sending our prescription has been produced from cows fed, as has been previously described, on sugar-beets, the milk may be already sufficiently alkaline for an infant's digestion when normal. If, on the contrary, the milk has its usual acid or amphoteric reaction, the milk-modifier will, make it slightly alkaline, in accordance with the physi- cian's prescription and according as the milk of the special day has a greater or less acid reaction ; or, if so ordered, he will make the alkalinity corre- spond to five per cent., ten per cent., twenty per cent., or to any percentage desired. For this purpose lime-water should be used, as being the best material and as least likely to do harm. If, however, the infant's diges- tion is not normal and we wish to prescribe a precise amount of lime- water, we can do so by writing for whatever percentage we choose, as we 198 PEDIATRICS. do for the other elements of the milk. In modifying the milk which comes from the farm connected with the laboratory, as a rule, one-twentieth part of lime-water (five per cent.) is sufficient to make the reaction corre- spond to that of normal human milk. Table 39, page 175, shows what the percentage of lime-water should be in order to obtain a greater or less degree of alkalinity. The hydrate of lime is said to be soluble to the extent of 1 part in 778 parts of water at a temperature of 15.5° C. (60° F.). This would make one ounce of lime-water to contain rather more than 0.03 gramme (J grain) of Ca0 2 H 2 , hydrate of lime. The milk from the farms connected with the laboratory has proved to be comparatively free from bacteria, and in most instances it is un- necessary to destroy the few bacteria which exist in it ; and as it is not harmful to the infant, it need not be exposed to heat. When, however, the milk has to be transported a long distance, or when the infant has a delicate digestion or is sick, it is often better to heat the milk to 68.3° C. (155° F.). This temperature is sufficient to kill those developed bac- teria which would be of any harm to the digestion of the infant, and at the same time is below 72° C. (161.6° F.), the point at which coagulation of the proteids is supposed to take place. We thus obtain a practically pure fresh milk, uncooked and sterile. We therefore write in our pre- scription 68.3° C. (155° F.). If the milk is to be sent an unusually long distance, if the weather is hot, or if the milk-supply has to last more than twenty-four hours, a higher degree of heating can be used, according to the wish of the prescriber. Thus, 100° C. (212° F.) is a temperature used for these purposes at the laboratory. When, again, we wish the milk to be absolutely sterilized, as may be the case when we are preparing it for an ocean voyage or for a trip across the continent, not only a high degree of heat, 100° C. (212° F.), but two or three heatings, with intervals of twenty-four hours, are necessary for this complete sterilization, and this can be called for in our prescription. The length of time during which the milk should be heated, as a rule, can be left to the judgment of the superintendent. Ten minutes is often sufficient to kill the developed bac- teria and to make this especially protected milk practically sterile. Expe- rience, however, has proved that during transportation the milk is often exposed to temperatures conducive to the further development of bac- teria, and that practically the bacteriological results which we obtain in the laboratory do not entirely hold when the milk is exposed to these varied conditions of transit. As a rule, therefore, from twenty to thirty minutes is the proper time to heat mixtures of modified milk sent from the laboratory. When the prescription is sent to the office the clerk copies it into a book, which records each day's feeding of each individual infant, and then translates the physician's prescription into such form as can be readily understood by the modifying clerks. Of course this form may vary in different parts of the world, according as the metric or the FEEDING. 199 apothecary system is in use. In the work of the American laboratories, although the prescriptions are written by the physicians in the metric system, it has been found more convenient, when delivered to the patrons of the laboratory, to have the amounts expressed in ounces and drachms. The office clerk, after translating the metric percentages into ounces and drachms, copies it on to a blank called the modifying clerk's prescription. The prescription is then placed in the hands of the modifying clerk, who combines the different elements of the prescription by means of the elemental materials which have been brought into the modifying-room from a different part of the laboratory. Practical Limits of Laboratory Modification. — I have requested physicians to write their prescriptions within certain limits as to the per- centages of the fat, sugar, and proteids, and to allow the mineral matter for the present to regulate itself. The limits which up to the present time the laboratory has found it necessary to place on the prescriptions for the milk-modifiers, and within which the modifying clerk is supposed to put up the prescriptions, are as shown in the following table : TABLE 42. Fat '. from 0.03 to 36.00 Sugar from 0.87 to 20.00 Proteids from 0.22 to 4.00 There is not much doubt that in the future more and more exact re- sults will be obtained, representing definite percentages of still wider limits. The results obtained from combining the modifying materials used by the modifying clerks have so often been proved to be practically cor- rect, that we can assume that when we write a prescription we shall obtain in return a product which in its various elements comes within a fraction of one per cent. The following figures show the various combinations of different per- centages, which when written for can be supplied by the laboratories : TABLE 43. Low Fats. Eat 0.03 0.04 0.08 0.12-16 Sugar 2.00 3.00 4-5.00 6.00-7.00 Proteids 0. 75 1.00 2.00 3.00-4.00 Low Sugars. Sugar 0.87 1.40 2.12 3.50-4.80 Eat 2.00 3.00 3.50 4.00 Proteids 0.75 1.00 2.00 3.00-4.00 Low Proteids. Proteids 0.22 0.34 0.45 0.53 Eat 2.00 -3.00 4.00 4.50 Sugar... 2.00 3.00 4.00-5.00 6.00-7.00 200 PEDIATRICS. The low fats show the lowest percentage of fat which can practically be used at the laboratory, and have been combined with various possible percentages of sugar and of proteids. The low sugars show, in like manner, the lowest percentages of the sugar which can be combined with these various percentages of fat and proteids. Finally, the low proteids show the various combinations which can be obtained with the fats and sugars. The Use of Whet in Percentage Feeding. — Although at present our knowledge of the comparative elemental percentages of the total proteids in both human and cow's milk is inexact, yet we can at least arrive at approximate results, with much benefit to an infant with weak digestion, in our endeavor to make the relative proportion of the lactalbumin in cow's milk correspond to what is probably provided by nature for purposes of nutrition in the proteid of human milk. It is evident, on examining the analysis of the proteids of human milk, that for some good reason the caseinogen is small in amount in comparison with the lactalbumin. In cow's milk, on the contrary, the lactalbumin is small in amount in com- parison with the caseinogen. Thus, while in human milk the lactalbumin is about two-thirds (f ) and the caseinogen about one-third (J) of the total proteids, in cow's milk the lactalbumin is only one-sixth (^) to five-sixths (f) caseinogen. (Konig.) We should, therefore, first determine the total proteid percentage and then calculate the amount of whey needed to obtain two-thirds (f ) lactalbumin and one-third (^-) caseinogen. As with our present knowledge this is not practicable except in comparatively low proteid percentages, we should calculate to come as near these proportions as possible. If. therefore, we are writing a prescription which calls for a total pro- teid of 1 per cent., we should calculate to have 0.75 per cent, of lactal- bumin and 0.25 per cent, of caseinogen. A prescription calling for fat 3 per cent., sugar 6 per cent., proteid 1 per cent., alkalinity 5 per cent,, would be written as follows : R Per Cent. X umber of feedings 9. Fat b;00 Amount at each feeding. . 75 c.c. ( ^2J). Sugar 6:00 Infant's age 3 weeks. Proteids (total) 1:00 Infant's -weight 9 pounds. (a) Lactalbumin (whey proteid). . 0:75 Alkalinity 5 per cent. (b) Caseinogen 0'25 Heat at 155° F. It is to be noted that although the total proteid percentage in the milk for an infant may be considerably increased, it is these higher percentages which are the most irrational in their nutritive values in the early months of infancy, if we hold to the rule that the caseinogen should be only one- third of the total proteids. This ratio of lactalbumin to caseinogen can be obtained if we are writing for a low proteid, as in the above prescrip- FEEDING. 201 tion. or in a prescription calling for a total proteid percentage of 0.75, of which 0.25 per cent, shall be caseinogen and 0.50 per cent, lactalbumin. If, on the other hand, we write for a high total proteid, such as 3 per cent., the highest percentage of lactalbumin that can be obtained is 0.85, and the remaining 2.15 per cent, is caseinogen, which practically reverse our ratio, making the caseinogen over two-thirds (f ) and the lactalbumin less than one-third (J). It can be said, however, that as the infant grows older its power to digest casein becomes proportionately greater, so that in the later months of infancy, the tenth, eleventh, and twelfth, its proteolytic function has become adapted to this change in the ratio of the caseinogen and lactal- bumin. so that the higher total proteids, such as 2.50, 3, 3.50, and finally -1 per cent., with the relatively high caseinogen and low lactalbumin become the proper nutritive proportion for the infant. The point especially to be emphasized is that in the early months of life, which demand a low proteid percentage, we can by the use of whey obtain, in a modified milk, the same proportions of lactalbumin and caseinogen which we find in human breast-milk at a corresponding period of infancy. A further consideration of the use of whey will be found on page 233. The prescriptions calling for definite proportions of casein and lactal- bumin which can now be filled at the laboratory are as follows : Fat. 1.00 1.00 1.00 1.00 1.00 1.00 1.50 1.50 1.50 1.50 1.50 1.50 2.00 2.00 2.00 2.00 2.00 2.25 2.25 2.25 2.25 2.25 2.25 2.25 2.50 TABLE 44. Casein- ogen. .25 Lactalbu- min. .25 Sugar. 4 to 7 Fat. 2.50 Casein- ogen. .25 Lactalbu- min. .50 Sugar. 4 to 7 .25 .50 4 to 7 2.50 .25 .75 4 to 7 .25 .75 4 to 7 2.50 .50 .50 4 to 7 .50 .25 4 to 7 2.50 .50 .75 4 to 7 .50 .50 4 to 7 2.75 .25 .25 4 to 7 .50 .75 4 to 7 2.75 .25 .50 4 to 7 .25 .25 4 to 7 2.75 .25 .75 4 to 7 .25 .50 4 to 7 2.75 .50 .50 4 to 7 .25 .75 4 to 7 2.75 .50 .75 4 to 7 .50 .25 4 to 7 3.00 .25 .25 4 to 7 .50 .50 4 to 7 3.00 .25 .50 4 to 7 .50 .75 4 to 7 3.00 .25 .75 4 to 7 .25 .25 4 to 7 " 3.00 .50 .25 4 to 7 .25 .50 4 to 7 3.00 .50 .50 4 to 7 .25 .75 4 to 7 3.00 .50 .75 4 to 7 .50 .50 4 to 7 3.50 .25 .50 4 to 7 .50 .75 4 to 7 3.50 .25 .75 4 to 7 .25 .25 4 to 7 .3.50 .50 .50 4 to 7 .25 .50 4 to 7 3.50 .50 .75 4 to 7 .25 .75 4 to 7 4.00 .25 .25 4 to 7 .50 .50 4 to 7 4.00 .25 .50 4 to 7 .50 .75 4 to 7 4.00 .25 .75 4 u> 7 .75 .50 4 to 7 4.00 .50 .25 4 to 7 .75 .75 4 to 7 4.00 .50 .50 4 to 7 .25 .25 4 to 7 4.00 .50 .75 4 to 7 202 PEDIATRICS. Peptonization of Milk. — Peptonized milk is cow's milk with its pro- teids partially or entirely predigested by means of the extract of pancreas and soda. There is no doubt that the proteids of cow's milk are at times a source of trouble to the infant's digestion, and that under certain cir- cumstances they can with great benefit be treated by predigesting them for a time, and allowing a stomach which otherwise digests well to rest and recover its entire digestive power. It is of use also where a decided idiosyncrasy of the individual precludes the digestion of these constituents of the milk. In many cases the indigestion is attributed to a lack of power to digest proteids at all, while in fact the stomach is simply rebel- ling against an amount of proteids above the standard percentage, or against some other constituent. It would seem that, for the average in- fant, this predigestion of the proteids is contrary to nature's teaching. There are certain natural functions which should be allowed to act as they do on human milk, and it seems irrational and contrary to the laws of physiology not to encourage all the functions to act naturally, instead of forestalling their action and allowing them to fall into disuse and thus to be weakened. The infant's stomach is intended to digest proteids, and not to have the proteids digested for it. Clinically, also, the use of pep- tonized milk supports this view, for, so far as I know, no very brilliant results have been obtained from its use. except when the infant's digestion has been in an abnormal condition and one which has called for some decided relief from the proteid elements of milk. Peptonized whole milk, therefore, as a food for young infants is one which consists of too large an amount of digested proteids, too little sugar, and a very large over- proportion of mineral matter, while peptonization of modified milk should only be given in cases in which it has been found that various combi- nations of the fat and sugar with very low percentages of the proteids have proved inefficient. When a peptonization of the proteids is prescribed, the clerk at the laboratory calculates the amount of peptonizing powder required for each feeding, and sends a number of powders corresponding to the number of feedings. The technique for the peptonization of milk is as follows : In a clean glass jar containing 4 ounces of cold distilled or boiled water dissolve 1 gramme (15 grains) of bicarbonate of soda and 0.25 gramme (5 grains) of pancreatine (extractum pancreatis), to which add 12 ounces of the milk. Set the jar in a vessel of water at a temperature of 41.6° C. (107° F.) for from seven to ten minutes. Cool immediately, and keep on ice until used. To peptonize modified milk an amount of the powders should be used corresponding to the percentage of the proteids in the mixture, taking the standard of whole milk to be represented by four per cent, of the proteids. The Use of Cereals in Laboratory P^eeding. — When a physician orders FEEDING. 203 cereals to be prepared at the laboratory, he is enabled to obtain prepara- tions containing exact percentages of the constituents of any cereal food. In substitute feeding, the addition to modified cow's milk of starch in various forms is frequently recommended. This brings us to the consideration whether starch should be made a part of an infant's food. Physiologically, we know that during the first ten or twelve months of life the function of converting starch into sugar is in the process of development. It is true that a partial conversion of the starch can be performed at quite an early age, and, in exceptional cases, to a much greater extent than by the average infant. It is rational to suppose that when a function is being developed it should not be taxed with a trial of the use which will later be demanded of it. That is, a function develops more perfectly if its power is not exerted too early. With these facts before us, and simply recognizing that the best known food for infants, woman's milk, does not, under any circumstances, contain starch. I believe that starch should not form a part of the infant's food in the early months of its life. When, in the latter part of the first year, it is deemed best to give cereals, it is desirable not to give immediately a high percentage of starch in the mixture. We should not ignore the fact that the various cereals contain fat and proteids as well as starch, and that the percentage of sugar in the mixture will be raised by the converted starch. A gradual change should be made in the infant's food until its digestive capabilities have become adapted to the food values indicated for digestion and nutrition in the second year, such as are represented by a higher rate of fat, sugar, and proteids. It is well at this period to use an undiluted milk, preferably from Holstein cows, and to obtain the increased sugar ratio from the starch given plus the 4.50 per cent, of sugar in the milk. Any additional sugar that may be needed at this time may be given with the food in the form of cane-sugar, rather than milk-sugar. The starch can best be obtained from the preparations of oats, barley, and wheat, as described on page 239. The Emulsion in Modified Milk. — As the question has arisen in the minds of some physicians as to whether it is wise to use a centrifugal cream in making a modification, the objection being that the centrifuge destroys the emulsion, the following photomicrograph (Fig. 51) of a drop of unmodified cow's milk is interesting to study. The analysis of this especial milk was as follows : Cow's Milk. Fat 4.04 Sugar 4. 55 Proteids 4.15 Mineral matter 0. 71 Total solids 13.45 Water : 86. oo 100.00 204 PEDIATRICS. Fig. 51. Unmodified cow's milk. Fig. 52. Cow's milk separated and recomposed. FEEDING. 205 Fig. 53. Human milk. Fig. 54. Modified cow's milk. 206 PEDIATRICS. Fig. 52 represents a drop of cow's milk modified to correspond to the same analysis as in Fig. 51 ; and in examining the two drops it will be seen that the emulsion in the modified drop is quite as fine as, if not finer than, that in the unmodified. Fig. 53 represents a drop of human milk, and Fig. 54 a drop of cow's milk, modified so as to correspond to the percentages of the human milk, which were as follows : Human Milk. Fat 2.67 Sugar 6.37 Proteids 2.69 Mineral matter 0. 15 Total solids 11.88 Water 88.12 100.00 The emulsion in these two drops of milk seems to correspond very closely, and certainly does not warrant the assumption that the emulsion has been seriously interfered with by separation and recomposition. It has been noticed that in certain instances when a cream mixture is subjected to the jar dependent upon transportation and delivery for any considerable distance, a portion of the fat has a tendency to collect on the surface of the milk in globules. Experiments made by White and Ladd under my direction have shown that transportation alone was not suffi- cient to produce this disturbance in the emulsion, and that it did not depend alone upon the use of centrifugal cream. Centrifugal and gravity cream mixtures, after eight to eleven hours of transportation on several successive days at a temperature such as prevails in average October weather, showed essentially the same macroscopic and microscopic ap- pearances, and their emulsions were hardly to be distinguished from that of whole milk. Moreover, it was found possible to produce these globules in a modified milk by placing the bottles in a box, the interior of which was kept warm during transportation by means of a vessel containing hot water, which was renewed at intervals. My opinion, based on the result of these experiments, is that the globules are produced by a combination of motion of transit with heat, such as prevails in summer ; and I have not found the nutritive value of the milk to be at all interfered with in the exceptional cases in which the change occurs. ILLUSTRATIVE CASES OP PERCENTAGE FEEDING. — The following cases were fed under my direction at the milk-laboratory during the first year of their lives, and merely illustrate the changes that would naturally be made in the food during this period in the life of a healthy infant. The first case was a male, born November 18, 1892. The table shows the record of its weight and food during its first year : FEEDING. 207 TABLE 45. Showing Management of the Food and Increase in Weight of a Healthy Infant during the First Fifty-Two Weeks of its Life. Date. Weeks of Weight. Amount Percentages of Food. Life. Feeding. Fat. Sugar. Proteids. Lime-Water. November 18 1 2 3 4 Grams. 3752 Lbs. 8 Oz. 6 C.c. 30 "*45 75 90 Oz. 1 3 2.00 3.00 4.00 6.00 6.00 7.00 1.00 1.00 1.00 5.00 10.00 5.00 12.50 10.00 5.00 10.00 12.50 10.00 5.00 oat-jelly. 5 December 23 6 8 4284 9 9 January 13 February 17 March 17 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 6944 *6048" 6748 7308 7504 7840 15 ' 13 15 16 16 17 8 7 1 5 12 8 105 120 135 150 165 180 210 4 4* 5 6 7 4.00 4.00 4.00 4.00 3.50 4.00 4.00 4.00 Wh 7.00 7.00 7.00 7.00 6.50 7.00 ' 6.66' 5.00 ole mi ole mi 2.00 2.50 3.00 2.50 1.50 2.00 ' 2.50 ' 3.00 Ik. Ik and 1—1 April 21 Q lO «3 (-< $ May 18 June 22 o rd CJ3 O o August 17 8820' ' 19 11 180 225 ' 6 ' 7* November 9 9870 22 The grammes in the third column have been reduced to pounds and ounces on the basis of twenty-eight grammes to the ounce, and the fractions of the ounce have been disregarded. 208 PEDIATRICS. The next case was a female, born November 1, 1892. The chart shows the line of growth in its weight from birth to the fifty-second week of its life : CHART 2 Weight at Bi rth 3,i ?0< ra mm es If Date of Birth Nov.lst. 03 o '£= CJI c o 1 c m d o en o en s c 8 c en c c r 7 c~. to o s -J in C 8 c 8 c | c 00 c s to C en 8 c «0 en © I ■ §1 Actual Weight 3 i • Gram's fci o 1 3,180 7 1 Nov 1 2 3,180 7 1 " 8 3 3.180 7 1 " 15 4 3,430 7 13 " 22 1 5 3,520 7 14 " 29 6 3,730 8 5 Dec.J 6 7 3,980 8 14 - |13 8 4,160 9 4 " [20 Ni 9 4,340 9 10 " |27 V 1 10 4,590 10 4 Jan.) 3 "Nv 11 4,870 10 14 10 1 12 5.060 11 4 " 17 I 13 5,270 11 12 1 ■ 24 ! | 14 5,560 12 6 " 31 1 15 5,870 13 1 fFec | 7 1 16 6,070 13 8 - |14 | \l 17 6,300 14 1 " |21 1 18 6,370 14 4 » ^8 I 19 6,510 14 8 Mar 7 \l 20 6,650 14 13 14 21 6,920 15 7 •• 21 1 22 6.980 15 9 2S 2? 7.150 15 15 Apr. 4 24 7,240 16 2 » 11 25 7,560 16 14 - 13 j\ 25 7,6*30 16 15 " 25 >l 27 7,300 17 6 Hay 2 29 7,730 17 4 » 9 29 7,840 17 8 » 16 30 8,070 18 - 23 31 8,160 18 3 " 30 32 8,190 13 4 June 6 M 33 8,490 IS 15 •> 13 34 8,470 13 14 » 20 35 8,700 19 6 " 27 ^36~ 8.762 19 8 July 4 \ 37 8,824 19 11 » 11 1 33 8,950 19 14 " 13 1 39 8,970 20 " 25 40 3,930 20 1 Aug. 1 \ 41 1 9,060 20 4 " 3 VI 42 9.140 23 6 ' 15 1 43 9,310 20 13 " 22 /T 44 9.170 20 8 » 29 V 45 9.290 20 12 Sep. 5 1 1 45 9,340 20 13 12 47 9.470 21 2 icr 43 9.640 21 9 " 26 49 9,630 21 8 Oct. 3 \l 50 9,740 21 10 10 ' 51 9,870 22 1" 1 52 9,899 22 1 24 -3, -O CO CO CO CD o o e E |tO CO CO 1 fr- ee s l-ll-. OJ CD -o -0 s CO (O CO c rs3 o £ to c? 1 o oo o 00 o 00 o 00 o o3|ui K CJI CO i o CO ss CJI £ ~o S CO CO p •** CO O _tl 13 Teeth til ! Mi nths 1 l_ Wkgl '?a/s rtlt.7 Pounds\l Oun i 1 I.J 1 ■ 1 FEEDING. 209 The following table records the quantity and quality of this infant's food during the first year : TABLE 46. Showing Management of the Food and Increase of Weight of a Healthy Infant during the First Fifty-Two Weeks of its Life. Date. Weeks of Weight. Life. ' November 1 . November 8 . November 15 November 22 November 29 December 6. . December 13. December 20. December 27. January 3 . . . January 10 . . January 17 . . January 24 . . January 31 . . February 7 . . February 14 . February 21 . February 28 . March 7 March 14. . . . March 21.... March 28 April 4. „ April 11 April 18 April 25 May 2 May 9 May 16 May 23 May 30 June 6 June 13 June 20 June 27 July 4 July 11 I July 18 July 25 August 1 August 8 August 15 August 22 August 29 September 5 September 12 ... . September 19 September 26 ' October 3 October 10 October 17 October 24 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Gratis . 3180 3180 3180 3430 3520 3730 3980 4160 4340 4590 4870 5060 5270 5560 5870 6070 6300 6370 6510 6650 6980 7150 7240 7560 7600 7800 7730 7840 8070 8160 8190 8490 8470 8700 8762 8824 8950 8970 8980 9060 9140 9340 9170 9290 9340 9470 9640 9630 9740 9870 9890 Lbs. 7 9 9 10 10 11 11 12 13 13 14 14 14 14 15 15 15 16 16 16 17 17 17 18 18 18 18 18 19 19 19 19 20 20 20 20 20 20 20 20 21 21 21 21 22 22 Amount at each Feeding. C.c. 60 60 90 75 90 105 120 135 150 180 195 Oz. 2 2 3 2* 6* Percentages of Food. Fat. ! Sugar, i Proteids. Lime- Water, 2.00 4.00 4.00 3.00 3.00 3.00 4.00 4.00 4.00 4.00 4.00 4.00 Wh Wh 5.00 7.00 7.00 7.00 6.00 7.00 7.00 7.00 7.00 7.00 7.00 6.00 ole mi ole mi 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.25 1.50 2.00 2.50 3.00 Ik. Ik and loat-jelly 5.00 10.00 5.00 12.50 10.00 5.00 O 2 o 9 The grammes in the third column have been reduced to pounds and ounces on the basis of twenty-eight grammes to the ounce, and the fractions of the ounce have been disregarded. 11 210 PEDIATRICS. The following cases have a practical bearing on the method of substi- tute feeding by means of milk laboratories. The first illustrates how important it is to be able to vary the percent- ages of the different elements of the milk, and to know that we are obtaining these variations exactly as they are ordered. An infant was being nursed by its mother, who was healthy, and who had an abundance of breast-milk. Their summer home was by the sea-side, in a healthy situation, and the infant was surrounded with everything that could be desired for perfect hygiene. The infant during the first two months of its life nursed well, thrived, and was perfectly quiescent in its daily life. When it was three months old, the mother was very much worried by some family matters and did not take much exercise. The infant now began to have colic, and, although it gained in weight, it was very restless and cried continuously. An analysis of the mother's milk at this time gave the follow- ing result : Fat 2.69 Sugar 6.15 Proteids 3. 71 Mineral matter 0. 17 Total solids 12. 72 Water 87.28 100.00 The indications for treatment were, of course, to lessen the amount of mental dis- turbance in the mother and to make her exercise more. The mother having followed these directions, the symptoms in the infant soon became less severe. After a few days, however, the unfavorable symptoms returned, and it was found that the mother had not been exercising and was again mentally disturbed. As it seemed impossible to regulate the function of the mammary gland under these circumstances, it was decided to feed the infant from the milk-laboratory. The following prescription was ordered : Prescription 3. R Pat 3.50 Sugar 6. 50 Proteids 1.00 Keaction Slightly alkaline. Heated to 75°^C. (167° P. ). Eight tubes, each holding 90 c.c. (3 ounces) . The infant digested this food perfectly, had no colic, and again became tranquil. As. however, it only made a slight gain in weight during the first two or three weeks of this substitute feeding I changed the prescription to the following one : Prescription 4. R Pat 4.00 Sugar 7.00 Proteids 1.50 On taking this food the infant began to make regular gains in weight, and con- tinued to thrive until it was four months old, when it was brought back to its city home, where it was subjected to many of the annoyances which are so frequently seen, and which, although somewhat disastrous to the infant, tend to advance our knowledge of substitute feeding. The infant was surrounded with too much excitement, and was FEEDING. 211 exposed to unnecessary changes of temperature in its home. During the process of removal from the sea-side to the city it caught a slight cold, and had intestinal symp- toms characterized by loose discharges from the bowels and undigested food. This condition was easily obviated in a few days by simply changing the prescription at the laboratory to the following one : Prescription 5. R Fat 2.50 Sugar 5. 50 Proteids 1.00 Lime-water 10.00 Under this treatment the food was again fairly well digested, the discharges lessened in frequency, and were of a better character. The infant, however, during this sickness had lost over 224 grammes (about J pound) in weight. At this juncture the grandmother of the infant so influenced the mother that she insisted upon having a wet-nurse procured at once. Although I did not approve of this change, the family were so urgent in their demands for a wet-nurse that I procured one for them. This wet-nurse was nursing her own infant and another infant at the Infants' Hospital. Both infants were thriving in every way. An analysis of this wet- nurse's milk gave the following results : Fat 2.92 Sugar 6.20 Proteids 4.62 Mineral matter 0. 16 Total solids 13.90 Water 86.10 100.00 The milk for this analysis was taken from the middle of the nursing. The per- centage of proteids was so high that I did not dare to allow the foster-infant to be put to the breast at once. I therefore endeavored to regulate the percentages of the elements of the wet-nurse's milk in the usual way. At the end of two days another analysis of her milk was made, with the following result : Fat 3.39 Sugar 5. 95 Proteids 4.78 Mineral matter 0.21 Total solids 14.33 "Water 85.67 100.00 The extraordinarily high percentage of proteids in this analysis made me abso- lutely refuse to allow the foster-infant to begin with its nursing from the wet-nurse. The family, however, were very impatient, and argued that, as the other two infants were gaining in weight, digesting well, and looking remarkably ruddy, it must be a good milk which they were receiving from the wet-nurse. Two days later, although the foster-infant was decidedly improving on the substitute food from the laboratory, it happened to lose 30 grammes (about 1 ounce) in weight, and the family then insisted that this wet-nurse should be tried. Another analysis of the wet-nurse's milk was then made, and showed that the percentage of the proteids had been reduced to between 3 and 4. 212 PEDIATRICS. I had already endeavored to find other wet-nurses whose milk would better corre- spond to what the infant needed, but was unsuccessful in obtaining any the analysis of whose milk showed the percentage of the proteids to be below 3. The analyses of the milk of two of these wet-nurses were as follows : Fat 3.88 Sugar 6. 55 Proteids 3.14 Mineral matter 0. 14 Total solids 13.71 Water 86.29 100.00 Pat 3.39 Sugar 4.50 Proteids 4. 70 Mineral matter 0.18 Total solids 12. 77 . Water 87.23 iooToo The first wet-nurse was then brought to the foster-infant's home, and the infant was put to the breast. It absolutely refused to take the breast for twelve hours, although it was crying with hunger. Finally it was induced to nurse, but immediately after the nursing had an attack of colic. These attacks of colic were moderately severe, and occurred after each nursing. The infant soon appeared to like the milk and took it eagerly at the regular nursing intervals. In twenty-four hours from the time when the infant began to nurse its bowels were again affected. The number of discharges became frequent, and the milk evidently was not being digested well. These conditions lasted for several days, when it was found that the infant had lost over 480 grammes (about 1 pound) in weight. As the severity of the colic was increasing, and as the infant had lost its color, the mother agreed to have the feeding by the wet-nurse discontinued. I then wrote the following prescription to be put up at the laboratory : Prescription 6. R Fat 2.00 Sugar 5.00 Proteids 1.00 Lime-water 10.00 To be heated to 75° C. (167° F.). This mixture was given to the infant. In twenty-four hours the number of dis- charges from the bowels grew less, and in a few days became almost normal. It began to gain in weight, and though seeming very hungry, looked better and ceased to have colic. The prescription was then changed to the following one : Prescription 7. R Fat 3.00 Sugar 6.00 Proteids 1.00 Lime-water 5.00 On taking this food the infant began to make regular gains in weight, but still seemed hungry, so that at the end of another week the prescription was changed to the following one : FEEDING. 213 Prescription 8. R Fat 4.00 Sugar 7.00 Proteids 1.50 The infant now improved steadily. It made the normal average daily gains in weight, and soon recovered its color and former strength. From this time it continued to thrive. This case is interesting in many ways. It was very evident that a per- centage of proteids over 3 was more than this especial infant could digest. It therefore had to be weaned from its mother. The wet-nurse's milk, which was agreeing perfectly with her own infant and with another infant which she was nursing at the hospital, had a percentage of proteids be- tween 3 and 4. As I knew from my experience with the mother's milk that this high percentage of proteids would not agree with the infant, I was not surprised to find that, instead of agreeing with it, it made it sick. This case substantiates the statement that, while there are many varieties of good milk, there are also many infants who cannot thrive on them all, but only upon such as suit their individual digestive powers. It is interesting also to record in this case that as the infant grew older, it was found that the percentage of the proteids could be increased in its food without harming its digestion, and that by the time it was eight months old it was having in its food percentages of proteids between 3 and 4, the very percentages which caused such serious digestive disturb- ance when it was younger. When it was ten months old it was able to digest 4 per cent, of proteids in its food. This case as a whole so well illustrates the use of the milk-laboratory that it is hardly worth while to multiply instances of its value. I believe that by the establishment of these laboratories a new era has been entered upon in the province of infant feeding, and one which will enable us to produce results which have never before been obtained. 1 The following prescriptions which I have sent to the laboratory at dif- ferent times will give you a very fair idea of the simplicity and precision of substitute feeding. Prescription 9. A girl 6 years old ; duodenal jaundice (functional). R Fat ■ 0.50 Milk-sugar 6.00 Proteids 3.00 Lime-water 10. 00 12 tubes, each 4 ounces. 1 The first laboratory for the exact modification of milk that has been established in the world was opened to the public in 1891 in Boston, under the name of the Walker-Gordon Laboratory. The development of the system of modification in percentages and the estab- lishment of this as well as of eighteen other laboratories in different parts of the country and in London, which now represent the Walker-Gordon Company, was accomplished by the joint efforts of Mr. G. E. G-ordon, Mr. G. H. Walker, and Mr. J. H. Waterhouse. 214 - PEDIATRICS. Prescription 10. .4 boy 6 weeks old; healthy. R Fat 3.00 Milk-sugar 7.00 Proteids 1.50 Reaction Slightly alkaline. Heated to 75° C. (167° F.). 12 tubes, each 2 ounces. Prescription 11. A boy 6 months old : healthy. R Fat * 4.00 Sugar 7.00 Proteids 2.00 Reaction Slightly alkaline. Heated to 75°" C. '(167° F. ). 8 tubes, each 6 ounces. Prescription 12. .4 girl 4 months old : proteid digestion weak. R Fat ^ 4.00 Sugar 7.00 Proteids „ . 0. 75 Linie- water 5. 00 Heated to 75° C. (167° F.). 8 tubes, each 4 ounces. Prescription 13. A boy 6 months old : sugar digestion weak. R Fat 3.00 Sugar 4.00 Proteids 2.00 Lime-water 5. 00 Heated to 75° C. (167° P.). 8 tubes, each 6 ounces. Prescription 14. A girl 4 months old : summer diarrhoea. Food has to be sent to a distant town by express. R Fat 2/50 Sugar 6.00 Proteids 1.00 At time of each feeding add lime-water ^ ounce. Heated to ~~ 100= C. (212° F. ). 20 tubes, each 3J ounces. In this case the diarrhoea had not been sufficiently studied to deter- mine whether it was putrefactive or fermentative, so that a safe general prescription was sent to begin with. The lime-water had to be introduced at each feeding on account of the 100° C. (212° F.) heating, necessitated by the hot weather and the distance to be sent. If the lime-water had been introduced at the laboratory and heated to 100° C. (212° F.) with the food, a reaction would have taken place between the lime and the sugar, and the mixture would have turned brown and have had a peculiar taste. Feeding of Average Ixfaxts borx at Term. — When an infant is born at term, is of normal development and weight, and is healthy. I am in the habit of regulating the quantity of its food according to the table on page FEEDING. 215 188. The quality of the food with which I usually begin is as shown in the following prescriptions. These percentages, however, are intended only to be provisional until the proper amount for the individual has been ascertained. When these prescriptions are used the infant is sup- posed to be digesting well and gaining in weight progressively. Prescription 15. For the -first twenty-four to thirty-six hours of life. R Milk sugar, iive-per-cent. solution, in sterilized distilled water. Prescription 16. First week. R Fat 2.00 Sugar 5.00 Proteids 0.75 (or .25 or .50). Eeaction Slightly alkaline. Heated to 75° C. (167° F. ). Prescription 17. Second iveek. R Fat 2.50 Sugar 6.00 Proteids 1.00 Eeaction Slightly alkaline. Heated to 75° C. (167° F.). Prescription 18. Third week. R Fat 3.00 Sugar 6.00 Proteids 1.00 Eeaction Slightly alkaline. Heated to 75° C. (167° F.). Prescription 19. Four to six weeks. R Fat 3.50 Sugar 6. 50 Proteids 1.00 Eeaction Slightly alkaline. Heated to 75° C. (167° F. ). Prescription 20. Six to eight weeks. R Fat ' 3.50 Sugar 6.50 Proteids 1.50 Eeaction Slightly alkaline. Heated to.. 75° C. (167° F.). Prescription 21. Two to four months. R Fat 4.00 Sugar 7.00 Proteids 1 . 50 Eeaction Slightly alkaline. Heated to 75°~C. (167° F.). 216 PEDIATRICS. Prescription 22. Four to eight months. R Fat 4.00 Sugar 7.00 Proteids 2.00 Reaction Slightly alkaline. Heated to 75° C. '(167° F.). Prescription 23. Eight to nine months. R Fat 4.00 Sugar ; 7.00 Proteids 2.50 Reaction Slightly alkaline. Heated to 75° C. (167° FA. Prescription 24. Nine to ten months. R Fat 4.00 Sugar 7.00 Proteids 3.00 Reaction Slightly alkaline. Heated to 75° C. (167° F.). Prescription 25. Ten to ten and one-half months. R Fat 4.00 Sugar 5.00 Proteids 3.25 Reaction Slightly alkaline. Heated to 75° C. (167° F.). Prescription 26. Ten and one-half to eleven months. R Fat... 4.00 Sugar 4. 50 Proteids 3. 50 Reaction , Slightly alkaline. Heated to 75° C. (167° F.). Prescription 27. Eleven to eleven and one-half months. R Unmodified cow's milk. At about the tenth or eleventh month I usually begin to give at first one and then two meals daily of equal parts of oat-jelly, with plain cow's milk heated to 68.3° C. (155° F.), and a little salt added according to the infant's taste at the time of the feeding. Freshly prepared barley or wheat can, if preferred, be given with milk at this age. In the twelfth month I usually accustom the infant to taking a little bread one day old with its milk, and to be fed from a spoon, so that by the time it is a year old it is taking bread and milk for its breakfast and supper, and oat-jelly and milk for the three middle meals. Influence of Fat on the Color of F^cal Dejections. — I have con- sidered it of some scientific and practical interest to record the color of FEEDING. 217 the faecal discharges which corresponds apparently to the percentage of fat in human milk and in the corresponding modified milk. Plate III., 3 and 4, facing p. 84, show the color of the normal yellow dejections of two infants who were being nursed by their healthy mothers and were them- selves digesting well and thriving. Plate III., 8 and 9, facing p. 84, represent the color of the normal yellow dejections of two infants who were fed on a modified milk which corresponded to average human milk. The percentages of the fats, sugar, and proteids in this modified milk were respectively 4, 7, and 1. The infants were digesting well and thriving. The resemblance in color and consistency between the faecal dis- charges resulting from human milk and from modified milk in which the percentage of fat was 4 is very striking. Plate III., 7, facing p. 84, shows the faecal discharges of a healthy in- fant fed on a modified milk having a percentage of 3 for its fat, 6 for its sugar, and 1 for its proteids. The color of the yellow is much lighter. This change of color is still more strikingly illustrated in Plate III., 6, facing p. 84, in which the infant was taking modified milk composed of fat 2 per cent., sugar 5 per cent, and proteids 1 per cent., and in which the resulting faecal discharge had a very much lighter color than in the other cases. HOME MODIFICATION. — In arranging an infant's food it is best to adopt the most simple, precise, and scientific means of expressing what we wish to prescribe. This is done by thinking, speaking, and writing our pre- scriptions in percentages and by having the food put up by trained clerks in a milk-laboratory. In this way we are more certain of obtaining what we prescribe than by any other method. When, however, a milk-labora- tory is not accessible, or if for any reason, such as that of expense, laboratory feeding is not available, the mother or nurse should be taught to modify the milk in the infant's home. This is what is called Home Modification, and under these circumstances much must be taken into consideration regarding the details of obtaining and using those mate- rials for the modification of milk which it is unnecessary to know when the same modification is ordered at a milk-laboratory. It is, in fact, these very details which the laboratory, as a saver of time and an instrument of precision, supplies for us, and thus makes the exact knowledge of them unnecessary. Difficulties and Dangers of Home Modification. — It must be impressed upon the minds of those w T ho are attempting to modify milk that what they are using for this purpose may be a source of great danger to the infant consumer. Milk is a dangerous food unless it is carefully pro- tected, so that it is first necessary to explain wherein the danger lies, and then to learn how to avoid it. Thus only can milk and cream be safely used for infant feeding in a household. One of the chief dangers from milk and cream lies in the fact that 218 PEDIATRICS. they are such good culture-grounds for pathogenic organisms. The germs of such diseases as diphtheria, scarlet fever, typhoid fever, and tuberculosis are well known to be transmitted by milk, and, in addition to this, with very little exposure, milk becomes filled with various forms of bacteria, many of them virulent, such as the toxin of cholera infantum, and all of them foreign to the original purity of the milk as it is elaborated in the mammary gland. In this way not only may the diseases just re- ferred to be produced, but also various forms of fermental diarrhoea and of ilep-colitis. The most simple way to avoid the dangers arising from pathogenic organisms and from using milks and creams of unknown percentages is to obtain these milks and creams of known percentages for modification from the milk-laboratories in sealed glass jars. When this is not possi- ble, certain primal precautions are to be taken. As the milk-ducts of the cow contain, especially in their lower parts, numerous bacteria which have gained entrance from without, the ducts should be freed from these bacteria by milking a few ounces from each teat, so as to get a milk as free from bacteria as possible. Other common sources of contamination, such as uncleanness of the cow herself and her udders should also be avoided. The cow should be milked in a clean place and by milkmen with fresh, clean clothes, and whose hair and hands have been thoroughly washed and dried with fresh, clean towels. Disease of a virulent nature has been proved to have been transmitted through the milk with disas- trous effect to the consumer by the diseased finger of a milker. Another and by no means trivial source of danger is the giving of im- proper percentages of the different food-stuffs to the infant in improper combinations. This may arise not only from the ignorance of the pre- scriber as to what combination of percentages ought to be given in the especial case, but also because he may be calculating his percentages on a basis which does not correspond to the percentages of the especial ma- terials which he is using, materials which must necessarily vary from day to day. Under these circumstances the infant may not only suffer from all grades of indigestion, leading to serious gastro-enteric disturbance, but also contract such diseases of nutrition as infantile atrophy, rhachitis, and scorbutus without the prescribing physician knowing on what food-combi- nations these diseases have been contracted, for the simple reason that, while he has prescribed on paper what he supposes to be the correct food for the especial case, an entirely different food may result from his not taking into account in his calculations the great variety of percentages with which he is dealing, and which may arise not only from his failure to appreciate that slight changes in the quantities of the materials he is using may result in great percentage differences in the food, but also from the fact that although he may calculate the quantity of each material correctly, his calculations are rendered worthless by the numerical variation in his factors from day to day. These differences in percentages have over and FEEDING. 219 over again in delicate infants proved to be of such serious consequence that they cannot be ignored, and every known means should be employed to avoid them ; that is, the physician should know definitely what combi- nation of percentages he is giving in the especial case, and then if this combination does not suit the case he will at least know that it is his own misconception of what was best to give, and not the fault of a combina- tion of percentages, which was really the correct one, but which through his mistake was never really given to the infant. The difficulty of obtaining a mixture of definite percentage in a home modification, in which a milk of unknown fat percentage is used may be emphasized in the following manner. Let us suppose that a home modi- fication calling for a 2 per cent, fat is made. If the milk in this case is from a Jersey cow with high percentage of fat, as, for example, five per cent., the resulting proteid will be 1.60 per cent. On the other hand, if the milk used to obtain this same 2 per cent, of fat in the modification is from a Holstein cow yielding a 3 per cent, fat in the milk, the resulting proteid would be (the same quantity of materials being used) 2.66 per cent. Therefore, unless the physician knows the fat percentage of the milk he is using, he may, by means of the same formula for modification, have a variation in his proteids of from 1.60 per cent, to 2.66 per cent. Another illustration of what different results in the percentage of the proteids may arise from using creams of various percentages is shown in the following table : TABLE 47. Cream used in the Fat obtained by calcula- Lowest possible modification. tion in the mixture. proteids. Per Cent. Per Cent. Ten per cent 2 0. 75 Ten per cent.. 3 1.13 Ten per cent 4 1. 50 Twenty-four per cent 2 0.31 Twenty-four per cent 3 0.47 Twenty -four per cent 4 0. 63 Here it is shown that in a given home modification unless the cream used is of known definite percentage the resulting mixture may show pro- teids varying from 0.31 per cent, to 1.50 per cent., a difference which in most cases of difficult digestion is of very serious import. There are other difficulties which arise in using creams in which the percentage is exactly known. For instance, when creams, of certain per- centages are used it is impossible to obtain in the modification certain per- centages of the proteids, so that it is necessary in changing from day to day the proteid percentage in a modified milk to have at command creams of different fat percentages, such 10, 12, 16, or 20 per cent. Thus, if a cream with a 10 per cent, of fat is used the following are the limitations as to the lowest possible percentages of the proteids which can be obtained from it when different mixtures of fat are desired. 220 PEDIATRICS. TABLE 48. Per Cent. In a mixture calling for 2 per cent, fat the lowest possible proteid is 0.75 In a mixture calling for 3 per cent, fat the lowest possible proteid is 1.13 In a mixture calling for 4 per cent, fat the lowest possible proteid is 1.50 In a mixture calling for 4.50 per cent, fat the lowest possible proteid is 1.82 Therefore, as is often the case when we wish to use a 3 per cent, or 4 per cent, fat combined with a fractional percentage of the proteids, or at least as low as 1 per cent., it will not be possible to make this modification with a 10 per cent, cream. In like manner, with a 12 per cent, cream, it is impossible to obtain as low a proteid percentage as 1 with as high a fat percentage as 2, as is shown in the following table : TABLE 49. Per Cent. In a mixture calling for 2 per cent, fat the lowest possible proteid is 0.63 In a mixture calling for 3 per cent, fat the lowest possible proteid is 0. 94 In a mixture calling for 4 per cent, fat the lowest possible proteid is 1.25 In a mixture calling for 4.50 per cent, fat the lowest possible proteid is 1.41 However difficult it may be to obtain a variety of percentage combi- nations when we know definitely the percentage of the creams which Ave have at our command, still greater difficulties arise when we have to use a gravity cream in a home modification, for gravity cream depends for its percentage of fat on the quality of the milk from which it is obtained, on the number of the hours of the setting, and on other conditions such as temperature and handling. When set for five or six hours it is rarely that a milk will give a higher than an 8 or 10 per cent, cream ; if allowed to set for a longer time so much greater is the danger of contamination. A gravity cream varies very readily from 8 to 12 per cent, so that in- accuracies cannot fail to occur and must be allowed for when a home modification of milk is made with a gravity cream. For instance, we may suppose that we wish to prescribe a milk modification demanding 3 per cent, fat, 6 per cent, sugar, and 2 per cent, proteids, and we make use of a cream with a supposed fat percentage of 10. If this cream should vary so that its fat was 8 we should have a mixture containing only 2.4 per cent, fat instead of 3. On the other hand, if the percentage of fat in the cream was 12, on using the same formula we should obtain a mixture con- taining 3.6 per cent, fat in place of 3 per cent. Again, if the cream had been tested and found to contain 8 per cent, fat instead of 10 per cent., and a sufficient quantity of this cream was used to produce 3 per cent, fat in the mixture, the proteids would be 2.50 per cent, instead of the 2 per cent, prescribed. On the other hand, if the cream was known to be 12 per cent, fat, and a less quantity was added, so that the fat in the mixture should be 3 per cent., the proteids would necessarily be reduced to 1.66 per cent. Not only do decided variations in the fat percentage of a gravity cream arise from the milk of one cow or herd, but there may also be a decided FEEDING. 221 variation in the creams obtained under the same conditions but from dif- ferent herds, and these variations occur whether the cream is siphoned, poured off, or skimmed. In order to obtain a definite idea of the variation in the fat percentage of milk such as one would be likely to purchase for the purpose of home modification, I had a series of observations made upon the milk obtained from five different dairies in Boston, and hence, presumably, from as many different herds. The milk was purchased for three suc- cessive days and subjected to the same conditions, and on each day each sample of milk yielded practically the same results. In each instance the milk was allowed to set for eight hours at a temperature of about 3.3° C. (38° F.), and the top quarter carefully poured off and the strength of the resulting cream tested with the following results : TABLE 50. Per Cent. Herd A gave a cream with a fat percentage of 6.2 Herd B gave a cream with a fat percentage of '. . 7 Herd C gave a cream with a fat percentage of 10 Herd D gave a cream with a fat percentage of 11 Herd E gave a cream with a fat percentage of „ . 12 These experiments seem to show conclusively that given a milk of unknown strength, the top quarter may vary in its fat percentage from 6 per cent, to 12 per cent., and one might obtain very wide differences in the percentages of a home modification, in which the fat percentage of the milk used is not estimated. Variations are especially liable to occur when the milk of one or two cows or of a small herd is used, for it is not unusual to find that cer- tain cows give widely different cream percentages in their milk, such as from 8 per cent, to 14 per cent., thus making a possible variation of 6 per cent., and it has also been shown by the records of the experiment station at Durham, New Hampshire, that out of one hundred herds the percentage of fat in the mixed milk of each herd varied from 3 per cent, to 6 per cent. It is therefore important for the correct home modification of milk that the physician should know the analysis of the milk of the special herd of cows which he is using, to see whether all his patients are being fed from that herd or from a number of herds, and to determine the percentage of fat in the cream from the same herd on different days. The variation in the fat percentage in different herds is apt to be con- siderable, as the owner often has a preference for one or another kind of stock, and frequently has a larger portion of that particular kind in his herd. It is also well known that the milk of the whole herd, for reasons of convenience, is not mixed together each day, and that, therefore, the testing of such milk on certain days is misleading, as it may contain little or much fat, according as it may have been produced by the poorer or richer milk producers of the herd. ^--222 PEDIATRICS. Owing to the different conditions of the cows and of the feeding during the year, and to the fact that the fresh cows which are giving the larger quantities of milk will at times happen to be cows giving a low per cent, of fat, while at other times the large milkers will be cows which yield a high per cent., the variation in the percentage of fat from the same herd may in the course of the year often vary as much as 2 per cent. It should, therefore, be appreciated that unless the cows are especially cared for, as are the herds connected with the milk-laboratories, the percentage of fat is constantly varying. If, therefore, it is necessary for the physician to use different herds in prescribing, it will be necessary for him to use a different formula for each herd ; or if he should use the same herd, he will be obliged, in order to get the same percentage, to use a different formula at different periods. These statements hold true when the milk can be obtained at once after milking and under the most favorable circumstances. If, on the contrary, an ordinary milk is set after it has passed through the hands of a city milkman, the same rules will not apply for obtaining, for instance, a 10 per cent, cream, as the cream will be likely to have partly risen when the milk is delivered, and if it is then set for eight hours, a twenty- or twenty-four-hour cream maybe the result, which is not only objectionable because the cream is old, but because it varies greatly in its fat percentage. In making a home modification it must also be noted how appreciably the total amounts of milk and cream used for a mixture in which speci- fied percentages of fat and proteids are desired must differ according to the cream used. For instance, in a 40-ounce mixture, in which 3 per cent, fat and 1.50 per cent, proteids are prescribed, 8.1 ounces of milk and 7.3 ounces of cream will be required if the cream used is 12 per cent. ; while if the cream is 16 per cent, the milk required would be 10.8 ounces and the cream 4.8 ounces, and yet the actual percentages of the fat and proteids in the two mixtures would be the same. The member of the household to whom the modification of the milk is intrusted, and to whom the technique of the modification is explained, should first be warned that she should always endeavor to prevent im- purities from getting into the milk, in preference to trying to eradicate them after they have begun to alter the normal composition/ of the milk. She should conscientiously carry out to the minutest detail the directions which are given to her. The milk of a herd of cows is preferable to that of one cow, for many of the reasons already spoken of, but especially because the elemental percentages are less likely to vary in the mixed milk of a herd than in that of the individual cow, and because the mixing lessens the deleterious effects on the milk arising from occasional disturb- ances of health in an individual member of the herd. The cows, if pos- sible, should be of a common breed and such as give a moderately rich milk. The milk should be received into absolutely clean receptacles, thor- FEEDING. 223 oughly strained, and rapidly transferred to a clean and cold place free from dust. It has been shown by Freeman that when milk is set the great mass of the bacteria rise with the cream, so that the separated milk is compara- tively free from bacteria, and thus becomes bacteriologically the best material for obtaining the required percentage of proteids in a prescribed mixture ; the necessity for pasteurization is thus also greatly diminished, so far as the milk is concerned. Materials for Home Modification. — Certain materials and apparatus are required to modify a milk in the home. To obtain the required per- centages of the fat resource is chiefly had to creams of various strengths ; the sugar is supplied by commercial milk-sugar ; the proteids are derived either from whole milk or separated milk, the caseinogen percentage being obtained from milk and the lactalbumin mostly from whey. The alka- linity can best be regulated by freshly prepared lime-water. The water should be freshly distilled or clear water filtered and boiled. Definition of Terms. — For the purpose of uniformity it is well that the meanings of the terms used in speaking of the materials required for a modification of milk should be clearly defined. Separated milk means a milk from which the fat has been partially or wholly removed, either by the centrifuge or by gravity. Fat-free milk means a separated milk which contains no fat, or at least only a fractional percentage. Cream means that which remains after separated milk has been re- moved from whole milk. It contains most of the fat of the whole milk and certain percentages of all the other elements of whole milk. Its proteid percentage is only slightly lower than that of whole milk, the higher fat percentage creams showing the greater variations, and none of the creams in ordinary use showing a proteid percentage as great as 1 per cent, below that of the whole milk from which they are derived. The sugar percent- age is slightly lower than in milk, and the salts are slightly diminished. Whole milk, therefore, can be considered a 4 per cent, cream. Whey means a milk which contains all its sugar and water while most of the fat and all the caseinogen have been removed. The fat per- centage is therefore very low, and the proteid percentage as a whole is low, the remaining proteids consisting almost entirely of lactalbumin. Caseinogen is the mother substance from which the casein is obtained by precipitation or coagulation. Lactalbumin is the proteid not coagulable by acids and rennet. Average Analysis of Whole Milk, 16 per cent. Cream, and Whey. Whole Mi*. 16 ~- Whey. Per Cent. Per Cent. Per Cent. Fat 4.00 16.00 0.32 Sugar 4.50 4.00 4.79 Proteids . 4.00 3. 60 0. 86 224 PEDIATRICS. Apparatus. — The apparatus used in the home modification of milk is as follows : Home-Sterilizer. — If great precautions are taken to guard the milk and cream, they (especially the separated milk) need not be pasteurized or sterilized. In many cases, however, the physician may deem it safer to heat the milk, especially when he is treating a case of gastro-enteric dis- turbance, or when in hot weather it is necessary to transport the food a long distance. If heating is ordered, a special apparatus will be required This apparatus, which is called a home-sterilizer, can be obtained at the laboratories, or it can be readily devised in the home from a tin pail. Fig. 55 represents the home-sterilizer. It is simply a tin can supported on its Fig Sterilizer and thermometer. Stand for tubes. Sterilizer covered with cozy after removal from heat. legs so that it can be heated by a lamp, or, if preferable, the legs can be removed and the can placed on a stove. Thermometer. — The sterilizer has a lid, to which is fitted a thermom- eter by which the degree of heat within the can is indicated. Tubes. — The tubes, varying in number according to the number of feedings which are required in twenty-four hours, are placed in this stand, which can be lowered into the sterilizer until the water therein is made to rise as high as the level of the milk in the tubes. Stoppers. — The tubes are stopped with cotton-wool. Cozy. — The sterilizer is covered with a thick cozy, through which the thermometer from the lid passes and indicates the degree of heat retained within the sterilizer after the flame has been removed. Graduate. — A 250 c.c. (8f ounces) glass graduate, divided into half- drachms, will be needed. FEEDING. 225 Cotton-Wool. — A roll of aseptic non-absorbent cotton-wool should be provided. Milk-Sugar. — Milk-sugar must be used. Sugar-Measure. — A sugar-measure, which holds 13.5 grammes (3f drachms), can be obtained at the laboratories. Pig. 56. Sugar-measure. This measure obviates the expense of having the milk-sugar put up in packages by the apothecary, and is sufficiently exact to regulate the sugar percentage in the mixtures which will presently be referred to. It is well to remember, however, that a pound of milk-sugar contains 464 grammes (7000 grains), and that if it is preferred to order the sugar in packages of 13.5 grammes (3f drachms) directly from the apothecary, in place of using the measure, one can simply tell him to make thirty-five packages from the pound, and the mother can then be directed to use a package of milk-sugar instead of a measureful. Siphon. — Finally, a glass siphon, 0.6 cm. (J inch) caliber, is needed. The siphon can be used in any quart glass jars which the family happen to have. The siphon should be a glass tube one-quarter to one-half inch in diameter. It can be bent in a gas-flame. The end out of which the milk is to flow should be at least six inches longer than that which is to be in- serted in the jar. To operate the siphon, fill it with boiled water, close the longer end with the finger, invert the siphon, and place the shorter end in the milk. Then withdraw the finger, and the water, followed by the milk, will run out of the long arm of the siphon. The mouth should never be used to start the siphon under any circumstances, as pathogenic organisms might in this way be introduced into the milk. Method of Obtaining Cream and Separated Milk. — In order to obtain the separated milk and the creams of different percentages the jars of milk are to be set in a vessel containing ice and water with some salt in the proportion of 5 grammes (1 teaspoonful) to 960 c.c. (1 quart) of water. Clean, freshly-boiled cotton cloths are then thrown over the uncovered jars. The mouths of the jars are kept open for about fifteen minutes to dispose of the animal heat. The jars are then to be sealed tightly, as. is done in preserving, and are left in the ice-water for a variable number of hours according to the fat percentage of cream desired. Care must be taken that the temperature of the water does not fall below 1.66° C. (35° F.). Fig. 57 represents one of the jars which has been set for six hours 15 226 PEDIATRICS. Fig with the siphon in position for siphoning out the lower 240 c.c. (8 ounces) of fat-free milk. The upper 240 c.c. (8 ounces) in the jar represent a cream of 10 per cent., and the intermediate 480 c.c. (16 ounces) contain a certain percent- age (about 2 per cent.) of fat which in six hours has not separated from the milk. The fat percentage of the cream and the number of ounces of cream to be obtained from the top of the jar depends upon the number of hours of the setting, under the sur- rounding conditions, and also upon the per- centage of fat in the milk which is set. Prescriptions for Home Modification. — With the required cream siphoned from the top of the jar and the fat-free separated milk si- phoned from the bottom can now be obtained the combination of approximate percentages prescribed for the especial case. These combinations must all be deduced from mathematical formulae, and the physi- cian can either do this himself in each case or can make use of the following tables, which I have had prepared for this purpose. The prescriptions have been calculated from a fat-free milk and a cream of 10 per cent, fat, obtained as shown in Fig. 57. The calculations are made for a mixture of 20 ounces. The required percentages of the fat, sugar, and proteids have first been tabulated and then the correspond- ing amounts of milk, cream, lime-water, water, and sugar placed opposite them. In all the following prescriptions the milk-sugar is to be thor- oughly dissolved in the water of the mixture before the other materials are added. Jar containing milk, cream, and siphon. C, cream ; M, milk ; S, si- phon. Fat Sugar Proteids 0.25 Lime-water 5.00 Prescription 28. ... 0.25 ... 4.00 Cream, 10 per cent J ounce. Pat-free milk 1 ounce. Lime-water . . . 1 ounce. Water 17| ounces. 20 ounces. Milk-sugar 2 measures. Pat 0.50 Sugar 4. 50 Proteids 0. 50 Lime-water 5.00 Prescription 29. Cream, 10 per cent 1 ounce. Pat-free milk f ounce. Lime-water 1 ounce. Water 174; ounces. 20 ounces. Milk-sugar If measures. FEEDING. 227 Prescription 30. Fat 1.00 Sugar 5.00 Proteids 0. 75 Lime-water „ 5.00 Cream 2 ounces. Fat-free milk 2 ounces. Lime-water 1 ounce. "Water 15 ounces. 20 ounces. Milk-Suirar 2 measures. Fat Sugar Proteids . . . Lime-water Prescription 31. . . 2.00 ! Cream 5.00 0.75 5.00 Fat-free milk Lime-water 1 Water 15 20~ Milk-sugar 2 Prescription 32. ounces. None. ounce ounces. ounces, measures. Fat 2.00 Sugar 5. 50 Proteids 1.00 Lime-water 5.00 Cream 4 ounces. Fat-free milk 1^ ounces. Lime-water 1 ounce. Water 13J ounces. 20 ounces. Milk-sugar 2\ measures. Prescription 33. Fat 2.50 Sugar ■ 6.00 Proteids 1.00 Lime-water 5.00 Cream 5 Fat-free milk Lime-water 1 Water 14 20~ ounces. None, ounce, ounces. Milk-sugar . Prescription 34. Fat Sugar Proteids . . . Lime-water 3.50 6.50 1.50 5.00 Cream 7 Fat-free milk 1 Lime-water 1 Water .. ... 11 ounces, measures. ounces. ounce, ounce, ounces. 20 Milk-sugar 2£ Prescription 35. Fat . . . 4.00 Sugar 7.00 Proteids 1.50 Lime-water 5.00 Cream 8 Fat-free milk Lime-water 1 Water 11 ounces, measures. ounces. None, ounce, ounces. Fat Sugar Proteids 2.00 Lime-water 5.00 20 Milk-sugar 2f Prescription 36. . . 4.00 . . 7.00 Cream ....... 8 Fat-free milk 2£ Lime-water 1 Water 8* ounces. measures. ounces, ounces, ounce, ounces. Milk-suerar , 20 91 ounces, measures. 228 PEDIATRICS. Pat 4.00 Sugar 7.00 Proteids 2. 50 Lime-water 5.00 Prescription 37. Cream 8 Fat-free milk 5 Lime-water 1 Water 6 ounces. ounces, ounce, ounces. 20 ounces. Milk-sugar Prescription 38 Pat 4.00 Sugar 7.00 Proteids 3.00 Lime-water 5.00 Cream 8 ounces. Pat-free milk . 7f ounces. Lime-water 1 ounce. Water 3£ ounces. Milk- 20 ounces. 2 measures Prescription 39. For weaning. Pat 4.00 Sugar 5.00 Proteids 3.00 Lime-water 5.00 Cream 8 Pat- free milk Lime-water. . Water Milk-sugar ounces. 1\ ounces. 1 ounce. 3J ounces. 20 ounces. 1 measure. Pat Sugar Proteids . . . Lime-water. Prescription 40. For weaning. .. 4.00 ... 5.00 3.25 5.00 Cream Pat-free milk, Li me- Water. » ounces. 8 ounces. 1 ounce. Water 3 ounces. 20 ounces. Milk-sugar f measure. Pat . . . Sugar . , Proteick Prescription 41. For weaning. . . 4. 00 I Cream 8 ounces. . . 4. 50 • Pat-free milk 12 ounces. . . 3.50 ! 20 ounces. After the various materials have been mixed, in the proportions shown in the formulae, the requisite amount of food for one feeding is poured into each of the tubes. If it is desired to pasteurize at 75° C. (167 c F.), the tubes are stoppled with cotton-wool, care being taken to have a reason- ably tight stopple in and a dry neck to the tubes. The tubes are then placed in the rack and lowered into the sterilizer, and the water in the sterilizer is adjusted to the level of the milk in the tubes. Heat, by means of a lamp or stove, is then applied to the sterilizer, which is watched, with the FEEDING. 229 cover off. until the thermometer shows that the water-bath has reached a point of 77.2° C. (171° F.). The lamp is removed as soon as this tem- perature is reached, the cover put in place, and the cozy over it. The thermometer should mark a temperature of between 75° C. (167° F.) and 77.6° C. (170° F.) for thirty minutes, at the expiration of which time the tubes are to be removed from the sterilizer, and are to be kept in a cool place, preferably the ice-chest, until needed. A temperature of 75° C. (167° F.) is sufficiently high to coagulate the lactalbumin. The percent- age of lactalbumin in cow's milk, however, is so small that there is no macroscopic change in the appearance of the milk when heated to this point. On the other hand, a temperature of 68.3° C. (155° F.) will kill most of the organisms in milk, and it is better to heat to this point so as to avoid coagulating the lactalbumin. When the milk is to be transported long distances, as in ocean voyages, it may be considered best to destroy the undeveloped spores of the organisms. To accomplish this the milk should be boiled three times for ten minutes at intervals of twelve hours. From what has already been said, it will be readily understood that these formulae, calculated with a 10 per cent, cream, are entirely insuffi- cient in their range for the treatment of a large number of cases which require a correspondingly large number of combinations of percentages before they can be made to digest and to thrive. It therefore becomes necessary for the physician to be prepared to write his prescriptions for a home modification with a number of different creams, as 10 per cent., 12 per cent., 16 per cent., 20 per cent., and many others ; that he should also know how to combine these creams with whole milk, with fat-free milk, with whey, and with cereals. In order to do this he must either, as by using the preceding tables, keep beside him for use the number of ounces required for certain percentage combinations, or he must bear in mind the complete analyses of all the materials used, as well as some mathematical equations by which he can calculate any number of percentage combi- nations. Table for the Calculation of a Home Modification. — In order to simplify, so far as possible, the calculation of various cream mixtures for home modification, the following table has been arranged by Dr. Maynard Ladd to show certain commonly used percentage combinations with creams of different strength. The figures are given for twenty-ounce mixtures ; if the total quantity used in twenty-four hours is thirty ounces, the quantity of each ingredient should be increased one-half; if forty ounces are required, the quantity of each ingredient should be doubled. It will be noted that the amount of fat-free milk used — that is, the lowest quarter of the milk from which the cream has been raised — varies according to the strength of the cream ; whereas the other ingredients are not similarly dependent. The table also shows certain percentage combinations which cannot be made either by a ten per cent, or a twelve per cent, cream. 230 PEDIATRIC; TABLE 51. Prescriptions calling for a mixture of nventv ounces. Cream in ounces. Fat-free Milk in ounces, used with Creams of a u - • ■A 2 53 ~ t- ^ - - X £ '3 ^y X 0.50 5.00 2.00 0.75 6.00 1.00 1.00 5.00 0.75 1.50 4.00 0.50 2.00 5.00 0.75 2.00 5.50 1.00 2.50 6.00 1.00 3.00 6.00 0.50 3.00 6.00 0.75 3.00 6.00 1.00 3.50 6.50 1.00 3.50 6.50 1.50 3.00 7.00 1.00 3.00 7.00 1.50 3.00 7.00 2.00 4.00 7.00 1.00 4.00 7.00 1.50 4.00 7.00 2.00 4.00 7.00 2.50 4.00 7.00 3.00 4.00 6.00 3.00 4.00 5.00 3.00 4.00 5.00 3.50 * Impossible combination with the percentage of cream indicated. In using this table, accurate results can be obtained if the percentage of cream is known and a guaranteed cream can be purchased from the laboratory. If this is impracticable, the physician must use his inge- nuity in estimating the fat percentage of cream, and such estimation can, of course, only be approximate, as is clearly shown by the widely divergent results obtained from setting different specimens of milk, as described on page 221. However, as a basis on which to form an ap- proadmate estimation we may assume that a milk of average strength — that is. one with fat 4 per cent., sugar 4.50 per cent., proteid 4 per cent.. — will yield, if it has not been previously setting, and if placed in a tem- perature of about 3.3° C. (38° F.). a top quarter (eight ounces in each quart of milk) of cream containing 10 per cent, fat at the end of six hours, or 12 per cent, fat at the end of eight hours. A gravity cream containing 16 per cent, fat can be obtained under very favorable condi- tions by setting the milk twelve hours, but it is safer not to count on so high a percentage. Milk which has been setting eight hours will yield a more uniform percentage of cream than one which has been setting six hours. If the milk which is used is known to be exceptionally low in fat. as in certain herds, it would be safer to let it set eight hours and calculate on a 10 per cent, instead of a 12 per cent, cream in the upper- most eight ounces. If the milk is known to be exceptionally rich in fat. it is more likely at the end of six hours to yield a 12 per cent, cream than a 10 per cent, cream. Each measure of sugar may be approximately FEEDING. 231 estimated to be equivalent to a level tablespoonful. It is better, how- ever, to buy a measure such as is described on page 225. THE THEORY OF PERCENTAGE MODIFICATION.— Dilution of Creams with Whole Milk. — Although a number of combinations of various percentages of fat and sugar can be obtained by diluting creams with whole milk, yet, the proteid percentage in any instance does not bear the same ratio to the fat percentage as holds in the cream from which the dilution is made. The finer variations in the relative proportions of fat and proteids which are easily obtained by systematized modification in the laboratories are impossible by the simple dilution of cream. The following table shows the fat percentages of cream which can be obtained by diluting a 20 per cent, cream with whole milk. TABLE 52. 1 part 20 per cent, cream -f 3 parts whole milk = 8 per cent, cream. 1 part 20 per cent, cream -(- 1 part whole milk = 12 per cent, cream. 3 parts 20 per cent, cream -\- 1 part whole milk = 16 per cent, cream. Dilutions of Cream with Water. — If cream of definite percentages of fat, sugar, and proteids are diluted with equal or multiple quantities of water, various mixtures are obtained in which the percentages of these three elements bear a fixed ratio to those of the cream used. (Westcott.) The percentages of the dilution can easily be calculated by multiplying the percentages of the cream by a fraction of which the numerator is the integer representing the quantity of cream, and the denominator the in- teger representing the sum of the quantity of the cream and of the diluent. Thus, for an 8 per cent, cream with percentages of 8 per cent, fat, 4.40 per cent, sugar, and 3.90 per cent, proteids, a mixture of equal parts cream and water would give 4 per cent, fat and 1.95 per cent, proteids. The resulting sugar percentage would also bear the same fixed ratio to that of the sugar percentage in the cream. Dilutions of Cream with Solutions of Sugar. — If it is desired to obtain various combinations of fat, sugar, and proteids by diluting creams with solutions of sugar, the various percentages of sugar solution can be obtained by dissolving one ounce of milk-sugar in twenty ounces, sixteen and one-half ounces, fourteen and one-quarter ounces, twelve and one- half ounces, or ten ounces of boiled or distilled water, which results re- spectively in sugar solutions of 5, 6, 7, 8, or 10 per cent. (Westcott.) When these sugar solutions are used as the diluent the calculation of the resulting sugar percentage can be made by the following formula, which expresses the fact that the sugar percentage of the dilution is the sum of the percentages contributed by the sugar solution and the cream. "W + C In this equation S represents the resultant sugar percentage : W represents the quantity of water ; s' represents the percentage of the sugar solution : 232 PEDIATRICS. c represents the percentage of sugar in the cream ; and C represents the quantity of cream. For example, for a dilution of 1 part of 12 per cent, cream to 3 parts of an 8 per cent, sugar solution the resulting percentages would be 3 per cent, fat and 0.95 per cent, proteids, while the sugar percentage would be s= 3 X8+ (1X^-20) = 28,20 = ? Q5 3 + 1 4 The following tables have been prepared by Dr. T. S. Westcott to show the different resulting fat, sugar, and proteid percentages obtained by mix- ing in various proportions different sugar percentage solutions with 4 per cent, fat cream (i.e., whole milk) 8 per cent, fat cream, 12 per cent, fat cream, and 16 per cent, fat cream. TABLE 53. 3 parts of milk to 1 part 5 to 10 per cent, sugar solution .= fat, 3.00; sugar, 4:60 to 5.85 ; proteids, 3.00 TABLE 54. Four per cent. Cream [whole milk) . Fat, 4.00; Sugar. 4. 40 ; Proteids, 4. 00. 1 part of milk to 11 parts 5 to 7 per cent, sugar solution — fat, 0.33 ; sugar, 4.95 to 6.78 ; proteids, 0.33 7 parts 5 to 7 per cent, sugar solution = fat, 0.50 ; sugar, 4.92 to 6.67 ; proteids, 0.50 3 parts 5 to 8 per cent, sugar solution = fat, 1.00; sugar, 4.85 to 7.10 ; proteids, 1.00 1 part 5 to 10 per cent, sugar solution = fat, 2.00 ; sugar, 4.70 to 7.20 ; proteids, 2.00 TABLE 55. Fight per cent. Cream. Fat, 8.00; Sugar, 4.30; Proteids, 3.90. 1 part of cream to 7 parts 5 to 7 per cent, sugar solution = fat, 1.00 ; sugar, 4.91 to 6.66 ; proteids, 0.49 3 parts 5 to 8 per cent, sugar solution = fat, 2.00 ; sugar, 4.82 to 7.07 ; proteids, 0.97 16 parts 5 to 8 per cent, sugar solution = fat, 3.07 ; sugar, 4.73 to 6.58 ; proteids, 1.41 1 part 5 to 10 per cent, sugar solution = fat, 4.00 ; sugar, 4.65 to 7.15 ; proteids, 1.95 TABLE 56. Twelve jier cent. Cream. Fat, 12.00; Sugar, 4.20; Proteids, 3.80. 1 part of cream to 11 parts 5 per cent, sugar solution = fat, 1.00 ; sugar, 4.93 ; proteids, 0.32 11 parts 6 per cent, sugar solution = fat, 1.00 ; sugar, 5.85; proteids, 0.32 parts 7 per cent, sugar solution = fat, 1.00 ; sugar, 6.76 ; proteids, 0.32 parts 5 to 7 per cent, "sugar solution = fat, 1.50 ; sugar, 4.90 to 6.65 ; proteids, 0.48 parts 5 to 7 per cent, sugar solution = fat, 2.00 ; sugar, 4.87 to 6.53 ; proteids, 0.63 parts 5 to 8 per cent, sugar solution = fat, 2.50 ; sugar, 4.83 to 7.20 ; proteids, 0.79 parts 5 to 8 per cent, sugar solution = fat, 3.00 ; sugar, 4.80 to 7.05 ; proteids, 0.95 parts 5 to 8 per cent, sugar solution = fat, 3.53 ; sugar, 4.76 to 6.88 ; proteids, 1.12 2.4 parts 5 to 8 per cent, sugar solution = fat, 3.53 ; sugar, 4.76 to 6.88 ; proteids, 1.12 2 parts 5 to 8 per cent, sugar solution = fat, 4.00 ; sugar, 4.73 to 6.73 ; proteids, 1.27 FEEDING. 233 TABLE 57. Sixteen per cent. Cream. Fat. 16.00; Sugar, 4.00 ; Proteids, 3.60. 1 part of cream to 15 parts 5 per cent, sugar solution = fat, 1.00 15 parts 6 per cent, sugar solution = fat, 1.00 15 parts 7 per cent, sugar solution — fat, 1.00 9 parts 5 per cent, sugar solution = fat, 1.60 9 parts 6 per cent, sugar solution = fat, 1.60 9 parts 7 per cent, sugar solution = fat, 1.60 7 parts 5 per cent, sugar solution = fat, 2.00 7 parts 6 per cent, sugar solution = fat, 2.00 7 parts 7 per cent, sugar solution = fat, 2.00 5.4 parts 5 per cent, sugar solution = fat, 2.50 5.4 parts 6 per cent, sugar solution = fat, 2.50 5.4 parts 7 per cent, sugar solution = fat, 2.50 4.3 parts 5 per cent, sugar solution = fat, 3.02 4.3 parts 6 per cent, sugar solution = fat, 3.02 4.3 parts 7 per cent, sugar solution = fat, 3.02 3.6 parts 5 per cent, sugar solution = fat, 3.48 3.6 parts 6 per cent, sugar solution = fat, 3.48 3.6 parts 7 per cent, sugar solution = fat, 3.48 3 parts 5 per cent, sugar solution = fat, 4.00 sugar, 4.94 sugar, 5.87 sugar, 6.81 sugar, 4.90 sugar, 5.80 sugar, 6.70 sugar, 4.87 sugar, 5.75 sugar, 6.62 sugar, 4.84 sugar, 5.70 sugar, 6.53 sugar, 4.81 sugar, 5.62 sugar, 6.43 sugar, 4.78 sugar, 5.56 sugar, 6.35 sugar, 4.75 sugar, 5.50 sugar, 6.25 sugar 7.00 proteids, 0.23 proteids, 0.23 proteids, 0.23 proteids, 0.36 proteids, 0.36 proteids, 0.36 proteids, 0.45 proteids, 0.45 proteids, 0.45 proteids, 0.56 proteids, 0.56 proteids, 0.56 proteids, 0.68 proteids, 0.68 proteids, 0.68 proteids, 0.78 proteids, 0.78 proteids, 0.78 proteids, 0.90 proteids, 0.90 proteids, 0.90 proteids, 0.90 3 parts 6 per cent, sugar solution = fat, 4.00 3 parts 7 per cent, sugar solution = fat, 4.00 3 parts 8 per cent, sugar solution = fat, 4.00 Dilutions of Creams with Whey. — When it is desired to increase in a mixture the relative proportion of the lactalbumin to the caseinogen, whey can be used for this purpose. There are, however, in doing this, certain precautions which must be taken, since the excess of pepsin re- sulting from the preparation of the whey is apt to precipitate the case- inogen of the proteids in the cream, and to leave coagula in the mixture. To obviate this the whey should be raised to a temperature of 65.5° C. (150° F.) for five minutes in order to destroy the rennin, and then allowed to cool before mixing it with the cream, especially when the total quantity of food for twenty-four hours is prepared at one time. This procedure, however, seems to be unnecessary when the whey is added to cream and milk mixtures which have been partially pepto- nized. In this case the amount of whey to be added should first be decided upon and then this quantity should be deducted from the quan- tity of diluent used, so that when the whey is added the total quantity shall not be altered. If this be done, the increase in proteids (0.86) contributed by the whey can be calculated by multiplying 0.86 by the number of ounces of whey and dividing the product by the total num- ber of ounces in the prescribed mixture. Since the proteid (lactal- bumin) percentage of whey is less than 1 per cent., a very nutritious mix- ture may be obtained by using undiluted whey and bringing up the fat percentage by the addition of cream. In this case, since there is no diluent, the fat percentage cannot be varied altogether at will, but must depend upon the desired proteid per- centage and vice versa. 234 PEDIATRICS. The proteid percentage, however, for any definite fat percentage can be varied by making use of different grades of cream. Thus, with a 3 per cent, fat (F), proteids ranging from 1.18 (from a 20 per cent, cream) up to 1.92 (from an 8 per cent, cream) can be obtained, and with a 4 per cent, fat (F) a variation of proteids between 1.30 per cent, and 2.32 per cent, can be similarly obtained. The formula by which the amount of cream (C) to be used in a total mixture (Q) in which the diluent is whey is as follows : p Q[F (fat p . c. in cream used) — 0.32 (fat p. c. in whey)] 7.68 or 11.68 or 15.68 or 19.68 according as a cream of fat 8 per cent., 12 per cent., 16 per cent., or 20 per cent, is used. The following table gives the varying combinations of fat and proteids that can be obtained by mixtures of whey and creams of various fat percentages. For the sake of comparison the quantities of cream re- quired for a mixture of twenty ounces have been given in the final column : TABLE 58. Combinations of fat and proteid percentages which can he made by creams of 4 per cent., 8 per cent., 12 per cent., 16 per cent., and 20 percent, diluted with whey, containing a fat percentage of 0.32. Cream in Twenty-ounce Mixture, the Balance With 20 per cent. Cream. Whey. For 1.00 F. P. = 0.94 0.70 ounce. For 2.00 F. P. = 1.06 1.71 ounces. For 3.00 F. P. = 1.18 2. 72 ounces. For 4.00 F. P. = 1.30 3.74 ounces. With 16 per cent. Cream. ! For 1.00 F. P. = 0.98 0.87 ounce. For 2. OOF. P. = 1.15 2.14 ounces. For 3. OOF. P. == 1.32 3.42 ounces. For 4.00 F. P. = 1.50 4.69 ounces. With 12 per cent. Cream. For 1.00 F. P. = 1.03 1.16 ounces. For 2. OOF. P. = 1.28 2.88 ounces. For 3. OOF. P. = 1.53 4.59 ounces. For 4.00 F. P. = 1.79 6.30 ounces. With 8 per cent. Cream. For 1.00 F. P. = 1.13 1.77 ounces. For 2. OOF. P. = 1.53 4.38 ounces. For 3. OOF. P. = i;92 6.98 ounces. For 4.00 F. P. = 2.32 9.58 ounces. With 4 per cent. Cream ( Milk). For 1.00 F. P. = 1.44 3.69 ounces. For 2.00 F. P. = 2.29 9.13 ounces. For 3.00 F. P. = 3.15 14.56 ounces. For 4. OOF. P. = 4.00 20.00 ounces. FEEDING. 235 Preparation of Sweet Whey. — Sweet whey is best made by the fol- lowing method : For each pint of whey needed, take one quart of whole fresh milk or fat-free milk, heated to 37.7° C. (100° F.), and add 8 c.c. (2 drachms) of the essence of pepsin or some of the preparations of liquid rennet. This will precipitate the casein in the form of a curd, which is then broken up with a fork, and the fluid which remains is the whey. This is strained through two thicknesses of boiled cheese-cloth and one thickness of absorbent cotton and slowly cooled to a tempera- ture of 10° C. (50° F.), and kept on ice until needed. If the whey is to be mixed with cream, it must first be heated to 65.5° C. (150° F.), in order to kill the rennet enzyme. Whey mixtures should not be heated above 68.3° C. (155° F.) if one wishes to keep safely under the coagula- tion point of the lactalbumin. General Formulae for Calculation of all Percentage Combinations. — The following formulae and equations, calculated by Westcott, can be used for obtaining any combinations of the percentages of the fat, sugar, and proteids of milk prescribed, provided that creams of varied fat per- centages are used, as has been already explained. The mixtures with cream may be made with whole milk, with fat-free milk, and with whey. The following symbols will be used : F = prescribed percentage of fat. S = prescribed percentage of sugar. P = prescribed percentage of proteids. C = total quantity of cream in ounces. M = total quantity of milk in ounces. W = total quantity of water in ounces. L = total quantity of dry milk-sugar in ounces. Q = total quantity of mixture. a and a' = known percentage of fat in cream and milk respectively. b and b' = known percentage of proteids in cream and milk re- spectively. c and c' = known percentage of sugar in cream and milk respectively. Since the actual quantity of proteids in a percentage mixture is the sum of the quantities of proteids contributed by the milk and the cream, and, again, since the actual quantity of fat is the sum of the quantities of fat contributed by the milk and the cream, the following fundamental formulae represent, these facts. Since P, F, etc., are represented by integers instead of hundredths, the following equations (1) and (2) should for greater accuracy be expressed as divided by 100, as already expressed in the formula for sugar on page 237 ; but since both sides of the equation are divided by 100, the equality of the numerators is also true. (1) QXP = VM + bC. (2) QXF = a'M + aC. 236 PEDIATRICS. And since the same reasoning applies to the actual quantity of sugar in the mixture with the addition of the dry sugar needed to bring the per- centage up to the percentage of sugar prescribed, we have (3) Q X A = ^^_ L . v ' ^^100 100 100 Transposing (1), so as to get a. value for M, we obtain (4) M= QP-1>C If this value of M is substituted in equation (2) we have, by transposi- tion and collecting, (5) c= Q(VF-a^P) By finding a value for M, from (2) instead of (1) we have (6) M = QF-aC From equation (3), by transposition, we obtain L = QS-(c'M-cC) V ; 100 These formulae are of universal application for any strengths of the cream and milk percentages. Formulse for Cream and Whole Milk (4 per cent. Cream).— Thus, for a combination of 16 per cent, cream (a = 16, b = 3.6, S = 4), and 4 per cent, milk (a' = 4. b' = 4. S = 4.40), as a' and b' are equal, this value can be taken out of the numerator and the denominator of (5), leaving ( 8) c = Q fF - p ) . a — b Substituting values for a and b. the formula becomes (9) C _Q (F-P)__ Q (F-P) V ' ' 16 — 3.6 — 12.4 and formula (6) becomes (10) M== QF-16C = QF_ 4C- ; 4 4 In the same way. for a 12 per cent, cream (a= 12, b = 3.8, S = 4.20) and a 4 per cent, milk, formula (8) becomes (11) C = Q(F-P) _ Q(F-P) v ' 12 — 3.8 8.2 FEEDING. 237 and (6) becomes ( 12) M _QF-12C = Q_F_ 3G K } 4 4 Similarly, for 10 per cent, cream (a = 10, b = 3.85, S = 4.25) formula (8) becomes (13) C = 3igz-_P1 = Q(F--P) | V J 10 — 3.85 6.15 (14) M = 41-100. v y 4 4 Formulae for Cream and Pat-free Milk. — When in place of mixing the cream with whole milk a fat-free milk is used, we take formula (5) and substituting for the fat value (a') of the milk we get c = Q(b/F-Q X P) = QVF ^QF aV-OXb ab' a' and from (4) we get (16) M= QF-bC Thus, for 16 per cent, cream and fat-free milk (15) becomes (17) C = ^>criptiox 43. R Fat 1.50 Sugar 4. 00 Proteids : lactalbumin. 0.25 ; caseinogen. 0.25 0.50 24 meals, each 8 c.c. (2 drachm- . If the infant is over thirty-two weeks, the prescription should be changed in a few days, under the same conditions as in Prescription 42, to PREMATURE INFANTS. 275 Prescription 44. R Fat 1.50 Sugar 5.00 Proteids : lactalbumin, 0. 50 ; caseinogen, 0.25 0.75 24 meals, each 12 e.e. (3 drachms). If the infant is over thirty-six weeks, the milk should, after forty-eight hours, be changed to Prescription 45. R Fat 2.00 Sugar 5. 50 Proteids : lactalbumin. 0. 75 ; caseinogen, 0.25 1.00 24 meals, each 16 c.c. (4 drachms"). The infant, however, under all circumstances, must be watched criti- cally, and any or all of the percentages of the elements or amounts of the. food increased or decreased according to the individual indications. When the infant is born at the thirty-eighth or thirty-ninth week its development is usually so near that of the infant at term that the incubator will not be needed, and the food can be given in about the proportions which would be adapted to the early clays of the infant at term (Prescrip- tion 16. page 215). Prognosis. — The prognosis in a premature infant during the early weeks of its life and until it is steadily gaining in weight must be guarded, as the mortality rate is very high, and these infants are apt to die suddenly simply from a lack of vitality. The younger the infant the greater is the danger of its dying. The most frequent causes of death among prema- ture infants are a lack of development of the thorax or lungs, atelectasis, an insufficient supply of fresh air, improperly cleansed incubators, leading to various forms of infection, undue exposure, careless handling, and im- proper feeding. Hutinel, from his experience with premature infants at the Hospice des Enfants-Assistes, attributes the high mortality to the fol- lowing causes : (1) Some infants are not viable ; their organs being incompletely formed, cannot perform the functions necessary for the maintenance of life. (2) Others present malformations inconsistent with life, or are affected with an hereditary taint, such as syphilis, which has already done irrep- arable damage at the time of birth. In these two cases the incubator is useless ; if it protects against cold, which is all it can do, it cannot perfect undeveloped organs or cure hereditary blemishes. (3) Some babies which seem well at birth fall ill soon after they are put into an incubator, and die there. In these cases the incubator is not to blame. (4) This class includes premature infants who are apparently well developed and comparatively healthy when placed in the incubator. It seems as if they ought to develop, but they die after a few days. The 276 PEDIATRICS. author considers that they die from various infections. These are not simple surface infections, for the actual presence of the pus-producing organisms in the blood have been frequently demonstrated. The infec- tions are due to the lack of resisting power on the part of the infantile mucous membrane which cannot oppose the entrance of germs if the surrounding atmosphere is contaminated. That the air comes from out- side is not sufficient to eliminate contagion, as the incubator must be opened from time to time, and the patients are attended by those who may readily infect them. The author insists most strongly upon a well- ventilated and sunny room for incubators, and holds that in hospitals there should be at least three apartments devoted to the rearing of pre- mature infants : one for the healthy, one for the ailing, and one for the ill ones. Germs undoubtedly flourish in an incubator with its constantly elevated temperature, so that an infant should be removed just as soon as it is able to maintain its temperature at 98.4° F. for thirty-six or forty- eight hours. It should then be enveloped in cotton and surrounded with hot bottles. Plenty of fresh air and sunshine are required. If one of these babies falls ill it must be separated at once from the others. In regard to putting it back into the incubator, infection when it occurs is more likely to begin outside. Incubators should be so constructed that they can be readily cleansed. The temperature changes involved in doing this are of little importance provided they are not too prolonged. By following these principles the author has lost only three out of twenty-one cases, aver- aging less than four and a half pounds. The following record and chart are those of a premature infant who was kept in a room with a temperature of 23.8° C. (75° F.) and in a basket heated to 29.4° C. (85° F.). TABLE 59. Weight for Sixty-one Days of Infant Premature at Thirty-two Weeks. Day of Life. Grammes. (Pounds. Oz.) Remarks. Birth-weight 2964 (6 8) Cow's milk, with spoon. Third 2724 ( 6 0) Mother's milk, with spoon. Sixth 2814 (6 3 ) Mother's milk, with spoon. Ninth 2964 (6 8) Mother's milk direct from breast. Thirteenth 3178 (7 0) Mother's milk direct from breast. Sixteenth 3388 (7 7) Modified milk. Twentieth 3598 ( 7 14) Modified milk. Twenty-third 3812 (8 6) Modified milk. Twenty-seventh 4116 (9 1) Modified milk. Thirtieth 4236 (9 5) Modified milk. Thirty-third 4476 (9 13) Modified milk. Thirty-seventh 4600 (10 2) Modified milk. Forty-first 4840 ( 10 10) Modified milk. Forty-fourth 4900 (10 12) Modified milk. Forty-eighth 4994 (11 0) Modified milk. Fifty-first 5084 (11 3) Modified milk. Fifty-fifth 5234 (11 8) Modified milk. Fifty-eighth 5324 (11 11) Modified milk. Sixty-first 5384 (11 13) Modified milk. PREMATURE INFANTS. 277 CHART Days of Life F 107° 106° 105° 104° 103° 102° 101° I00 3 99 ° 98 G 97° 96° 95° 160 150 140 130 120 MO 100 90 80 7Q i 2 3 4 5 6 7 9 9 10 ii 12 13 14 15 16 17 18 19 20 21 6' 416° 41 (° 40.5° 40.0° 39.4° 38.8° 38.3° B7.7° 37.2° 37.0° 36 6° 56.1° 35.5' 35 0." M £ M « >i B tt, M K M i S K H E M K if E M I ■ E H Y M E M K _/ I ^ V" - 1 L, \ / y / / \ J [/ / s ■> r i • \/ 1/ 7, v.. V. ^ 1/ ^W_ A ■ ~\ V V \ A ^ A A \ / V I \ \ / V V 1 \ ^ 1/ V 1/ \/ s — The question is often asked whether premature infants, even if their lives are saved, can eventually be as well developed physically and men- tally as are those born at term. In my experience there seems to be no question that when once we have succeeded in making the infant gain steadily in weight and assume the appearance of an infant at term its subsequent condition differs in no respect from that of infants born at term. Fig. 69 illustrates the wisdom of doing all in our power to save the lives of these infants, as it represents at nine months what was one of the worst cases of lowered vitality and extreme emaciation in a premature infant that I have ever seen. This picture was taken when the infant was nine months old and weighed 8400 grammes (17| pounds). As its birth-weight was 2040 grammes (about 4^ pounds), it will be seen that its weight has quadrupled. He was fed entirely on modified milk from the laboratory during the first year, and was a fine large boy, walking and talk- ing at two years of age. He was perfectly healthy and well developed both physi- cally and mentally. His sister, who was premature at the twenty-eighth week, was eight years old. She was well developed and strong, and was unusually bright and intelligent for her age. She was, in fact, decidedly in advance mentally of the other children of her age at school. The following is the record of an infant prematurely born at about the thirtieth week, and weighing 2850 grammes (about 5 pounds 15 ounces), which was the first premature infant that happened to be treated in the incubator represented in Fig. 66, page 268. It illustrates the value of careful and exact incubation and feeding. 278 PEDIATRICS. The infant was born at ten minutes past three in the morning of February 16. It was placed in the incubator at 9 p.m. of the same day, the temperature of the incu- bator being 34.4° C. (94° F.). Infant premature at 30 weeks. Birth- weight, 2040 grammes {4 X 4 pounds.) Treated in incubator 64 days. Age, 9 months ; weight, 8400 grammes (17% pounds.) On the following day, February 17, the infant was given by the nurse 4 c.c. (1 drachm) of diluted cow's milk every hour for three feedings, which he vomited almost immediately after taking. The intervals of feeding were then increased to two hours, but the milk was not retained. The nurse then gave him 2 c.c. (J drachm) every three hours during the night, which he retained for a number of feedings, but then vomited bile and mucus, together with the undigested food which had been given him. February 18 the infant was found to have lost 420 grammes (14 ounces) in weight, to be very weak, and to be unable to retain the milk diluted with water. The me- conium came away on this day, and there was a uric acid stain on the napkins. The infant was very restless. Its respirations were irregular, and its feet and hands were cold. The temperature of the incubator, which up to this time had been kept at 84.4° C. (94° F.), was lowered to 33.8° C. (93° F.), as the infant had begun to perspire. A substitute food was ordered from the milk-laboratory on this day, the prescription for which was as follows : Prescription 46. R Fat 1.00 Sugar 3.00 Proteids . 0. 50 To be heated for thirty minutes at 75° C. (167° F. ). Lime-water 5.00 24 tubes, each containing 4 c.c (1 drachm). PREMATURE INFANTS. 279 This food was given to the infant every hour. On the following day. the 19th, the record was that the food had been retained, that the infant had seemed so hungry that the amount had to be increased to 10 c.c. (2£ drachms), and that it was found advisable to feed it every two hours rather than every hour. There was no vomiting. There were two movements of the bowels, which still showed evidences of undigested milk and some meconium. The infant's weight on this day was found to be the same as on the previous day, 2300 grammes (5 pounds 1 ounce). On the following day. February 20, the infant was found to have gained 30 grammes (1 ounce). It was taking its food regularly every two hours, alternating with the mother's milk, which had come in considerable quantity. There were still evi- dences of uric acid in the urine. The temperature of the incubator was kept at 31.6° C. (89° F.). On the following day, February 21, the weight was as on the previous day, 2230 grammes (5 pounds 2 ounces). The color of the faecal discharges was yellowish brown. There was only one discharge in the twenty-four hours, obtained by the use of a suppository. The temperature of the incubator was kept at 30° C. (86° F.). On the following day, February 22, it was found that the infant had lost 60 grammes (2 ounces). The substitute food was then given every two hours, alternating with the breast-milk. On that day there were three yellow well-digested movements. The temperature of the incubator was kept at 29.4° C. (85° F.). The infant seemed stronger, was very quiet, and slept except when it awoke to receive its. food. On the following day, February 23, there is no record of the infant's weight, but it was evidently in a very precarious condition and seemed exhausted. It did not take its nourishment readily. It had five small faecal discharges in the twenty-four hours, which, however, were yellow and fairly digested. On the following day, February 24, the breast-milk was omitted, and 4 c.c. (1 drachm) of modified milk were given every two hours, the percentage of the sugar being raised from 3 to 3.5. There were four small faecal movements during the day ; the first one was green, the last three were yellow and decidedly better digested. The temperature of the incubator was kept at 29.4° C. (85° F.). During the day the infant gained 60 grammes (2 ounces) in weight. It was so weak on these two days that it would have been dangerous to take it out of the incubator to weigh it, so that the continual record of the weight which could be obtained by the scale-bed of the incubator was of the utmost value in regulating the changes in the food necessary to save the infant's life. On the following day, February 25, the infant's weight was found to be 2260 grammes (5 pounds 3 ounces), an increase of 30 grammes (1 ounce). The percentages in the modified milk were then changed to the following : Prescription 47. R Fat 1. 50 Sugar 4.00 Proteids 0. 75 One drop of brandy was given with each feeding. There was one faecal discharge, which was yellow and well digested. On this day 4 c.c. (1 drachm) of food were given to the infant every two hours until its feeding at 10.30 p.m. After this it seemed so hungry that at midnight 36 c.c. (9 drachms) were given, at 3 a.m. 40 c.c. (10 drachms) were given, and at 5.30 a.m. 30 grammes (1 ounce) were given. The weight was now found to be 2420 grammes (5 pounds 5 ounces), an increase of 60 grammes (2 ounces) in the twenty-four hours. The amount of food which the infant had taken in the previous twenty-four hours was found to have been 375 grammes (12$ ounces). The faecal discharges were yellow and well digested. Brandy was continued. 280 PEDIATRICS. The temperature of the incubator was kept at 29.4° C. (85° F.). At times a little breast-milk was given to the infant, in order to satisfy the mother, but it evidently did not agree with it. On February 27 the weight was found to be 2450 grammes (5 pounds 6 ounces). The prescription for the modified milk was then changed as follows : Prescription 48. R Fat 2.00 Sugar 5.00 Proteids 0. 75 Thirty grammes (1 ounce) of this were given to the infant every two hours during the day, and every two and one-half hours during the night. One yellow well-digested faecal discharge was obtained by means of a suppository. The temperature of the in- cubator was then reduced to 27.7° C. (82° F.). The following day, February 28, the weight was found to be 2480 grammes (5 pounds 7 ounces). The brandy was still continued, and there was one yellow well- digested faecal discharge. The breast-milk had been entirely omitted, and 450 grammes (15 ounces) of modified milk had been taken in the twenty-four hours. On the following day, March 1, it weighed 2510 grammes (5 pounds 8 ounces). The amount of modified milk given was 495 grammes (16J ounces) in the twenty-four hours, and one drop of brandy was given with each feeding. There was great im- provement in the infant's appearance, and it was much stronger. On the following day, March 2. there had been no increase or loss in weight. The temperature of the incubator was kept at 27.2° C. (81° F.). 510 grammes (17 ounces) of the modified milk were taken in the twenty-four hours. There was one faecal movement, well digested and yellow. On the following day. March 3. the weight was found to have increased to 2600 grammes (5 pounds 11 ounces). The percentages of the modified milk were then changed to the following : Prescription 49. R Fat 2.50 Sugar 5. 00 Proteids 1.00 There were two well-digested faecal discharges on this day. The temperature of the incubator was reduced to 25° C. (77° F.). 615 grammes (20J ounces) of the modi- fied milk were given in the twenty-four hours. The following day, March 4, the infant was found to have lost 60 grammes (2 ounces), and the temperature of the incubator was therefore raised to 26.6° C. (80° F.). 630 grammes (21 ounces) of modified milk were taken in the twenty-four hours, and there was no especial change in the infant's condition. On the following day, March 5, 30 grammes (1 ounce) in weight were found to have been gained, and the infant was looking better and decidedly gaining in strength. It was evident that the proper temperature for this especial infant at this age and at this period of its development was 26.6° C. (80° F.). After this time the infant continued to develop normally, and on being taken out of the incubator in April was thriving in every way. When five months old it weighed 7110 grammes (14 pounds and 13 ounces). The next case was that of an infant which was four weeks premature, and which was, for a premature infant, tolerably vigorous at birth. It was under the care of Dr. Samuel Breck, with whom I saw it in consultation. It was not placed in an incubator. Unfortunately, its nurse had no idea of the importance of protecting it from external influences. It was fed on a carefully prepared food from the milk-laboratory, and began to gain in weight, and in every way showed no evidence of its vitality being interfered Showing Detail Percentages of Food. F.ECAL Days Intervals BETWEEN Amount AT EACH of Life. Meals. Meal. Fat. Sugar. Proteids. Lime- Water. No. Chai C.c. Dr'ms. 1 3 per ct. meconal. Lungs normal. Emaciated. sol. in aq. dis. 3.00 2 1 hour. 4 1 1.00 1.00 5.00 2 brown C (167° F.). 3 1 hour. 4 1 1.00 3.00 1.00 5.00 2 4 1 hour. 4 1 1.00 3.00 1.00 5.00 2 5 1 hour. 4 1 1.00 3.00 1.00 5.00 2 only rspired freely. Temperature of diges^iccough relieved by brandy. 6 1 hour. 4 1 1.00 3.00 1.00 5.00 2 en. imperceptible for 10 seconds. 7 1 hour. 4 1 1.00 3.00 1.00 5.00 2 1 little, temperature of incubator 8 1 hour. 4 1 1.00 3.00 1.00 5.00 2 , neonatorum. Black cloth over 9 1 hour. 4 1 1.00 4.00 1.00 5.00 2 yellow 10 1 hour. 4 1 1.00 4.00 1.00 5.00 2 well d 11 1 hour. 8 2 1.00 4.00 1.00 5.00 2 12 1 hour. 8 2 1.00 4.00 1.00 5.00 2 13 1 hour. 8 2 1.00 4.00 1.00 5.00 2 fesh-air box for 10 minutes three 14 1 hour. 8-10 2-2X 1.00 4.00 1.00 5.00 2 Oxygen as on 13th. * 15 1 hour. 8-10 2-2)/ 2 1.00 4.00 1.00 5.00 2 16 1 hour. 12 3 1.50 5.00 1.00 5.00 2 a. when incubator below 29.4° C. 17 1 hour. 12 3 1.50 5.00 1.00 5.00 2 18 1 hour. 12 3 1.50 5.00 1.00 5.00 2 19 1 hour. 12 3 1.50 5.00 1.00 5.00 2 20 1 hour. 12-14 3-3)4 1.50 5.00 1.00 5.00 2 21 1 hour. 16 4 1.50 5.00 1.00 5.00 9 22 1 hour. 16 4 1.50 5.00 1.00 5.00 2 23 1 hour. 16-18 4r4V 2 1.50 5.00 1.00 5.00 2 24 1 hour. 16-18 1.50 5.00 1.00 5.00 2 25 1 hour. 18-20 4%-5 2.00 5.00 1.00 5.00 1 26 1 hour. 18-20 13^-5 2.00 5.00 1.00 5.00 2 27 1 hour. 18-20 4)^-5 2.00 5.00 1.00 5.00 1 28 1 hour. 18-20 4K-5 2.00 5.00 1.00 5.00 2 29 1 hour. 20 5 2.00 5.00 1.00 5.00 2 30 1 hour. 22 o l A 2.00 5.00 1.00 5.00 3 slightl 31 1 hour. 22 &A 2.00 5.00 1.00 5.00 4 32 1 hour. 22 2.00 5.00 1.00 5.00 4 33 1 hour. 24-26 6-6% 2.00 5.00 1.00 5.00 5 temperature of incubator as low 34 1 hour. 28 7 2.00 6.00 1.00 10.00 8 lily. 35 1)4 hrs. 32 8 2.00 6.00 1.00 10.00 5 yellow well d fen. Began to feed with nipple. 36 1% hrs. 32 8 2.00 6.00 1.00 5.00 5 Slight cyanosis. Oxygen. 37 134 hr s. 1)4 hrs. 1% hrs. 32 8 2.00 6.00 1.00 5.00 3 38 48 12 2.00 6.00 1.00 5.00 3 39 48 12 2.00 6.00 1.00 5.00 3 40 1)4 hrs. 48 12 2.00 6.00 1.00 5.00 5 eding. 41 1J4 hrs. 48 12 2.00 6.00 1.00 5.00 2 42 l)f hrs. 1)1 hrs. 48 12 2.00 6.00 1.00 5.00 2 43 48 12 2.00 6.00 1.00 5.00 1 tor. Omit oxygen. 44 VA nr s. 48 12 2.00 6.00 1.00 5.00 2 45 1)4 hrs. 1)4 hrs. 1)| hrs. 1% hrs. 48 12 2.00 6.00 1.00 5.00 5 46 48 12 2.00 6.00 1.00 5.00 6 47 48 12 2.00 6.00 1.00 5.00 6 48 48 12 2.00 6.00 1.00 5.00 4 49 lj^hrs. 48 12 2.00 6.00 1.00 5.00 4 50 1)4 hrs. V-A hrs. 1% hrs. 56 14 2.00 6.00 1.00 5.00 6 51 56 14 2.00 6.00 1.00 5.00 5 52 64 16 2.00 6.00 1.00 5.00 6 53 154 hrs. 154 his. 64 16 2.00 6.00 1.00 5.00 5 54 64 16 2.00 6.00 1.00 5.00 2 55 1% hrs. 64 16 3.00 7.00 1.00 5.00 1 56 1% hrs. 64 16 3.00 7.00 1.00 5.00 1 ?er and brighter, and is tranquil. 57 1% hrs. 154 hrs. 154 hrs. l^l hrs. 154 hrs. 154 hrs. 64 16 3.00 7.00 1.00 5.00 3 58 64 16 3.00 7.00 1.00 5.00 1 59 64 16 3.00 7.00 1.00 5.00 3 60 64 16 3.00 7.00 1.00 5.00 1 61 64 16 3.00 7-00 1.00 5.00 3 limited. Put back into incubator. 62 64 16 3.00 7.00 1.00 5.00 5 63 154-2 hrs. l%-2 hrs. 154-2 hrs. 154-2 hre. 64 16 3.00 7.00 1.00 5.00 2 64 64 16 3.00 7.00 1.00 5.00 2 frater at 35° C. (95° F.). 65 64 16 3.00 7.00 1.00 5.00 2 ! stronger. 68 64 16 4.00 7.00 1.00 5.00 2 I At six m onths wei£ 'hed 7080 g ramrues (14 pounds >us. PREMATURE INFANTS. 281 with : but the nurse was possessed with the idea that it needed plenty of cold fresh air. The window in the infant's room was left open one night when the weather was quite cool. The following day it did not take its food well, was somewhat cyanotic, and was found to have lost almost 240 grammes (h pound). It was then placed, as it should have been in the beginning, in a warm room, treated with the utmost care, and not handled much. None of these measures, however, were sufficient to prevent a still further les- sening of its vitality. It never rallied from the first blow which was struck at its vitality, and lost its life practically through the ignorance of the nurse who was in charge of it. A post-mortem examination showed nothing abnormal, except that the mesenteric glands were somewhat enlarged. The next case was that of an infant born at about the twenty -fifth week of intra- uterine life. Its weight was 1080 grammes (about 2\ pounds). There were a number of interesting points to be recorded in this case. It was not strong enough to suck, and had to be fed with a spoon. Its mother's milk, the analysis of which is given below, at once caused such disturbance that modi- fied milk from the laboratory had to be substituted. {Mother's Milk.) Fat 1.29 Sugar 4. 10 Proteids 6. 83 Mineral matter 0.26 Total solids 12.28 Water 87.72 100.00 The prescription for the modified milk which it digested well was Prescription 50. Modified Milk. R Fat 1.00 Sugar 3.00 Proteids , 0. 75 The infant's temperature in the rectum was 36.7° C. (98° F.). It seemed to be doing fairly well, but did not gain. in weight, and on the fifth day of its life was unable to swallow. It was then fed by gavage. It was treated with great care so far as keeping it warm was concerned, but an in- cubator could not be obtained for it, and it died when it was seven days old. It is interesting in this case to notice that the meconium came as is usual in the infant at term, and began to change its color on the third day, and that by the fifth day the faecal movements were yellow and well digested. Table 60 records the details of an infant's life in an incubator during a period of sixty-four days. This record will be of great use to any one who has charge of a premature infant in an incubator, as it illus- trates exactly what emergencies are likely to arise and how they can be met. The infant, as is seen by referring to the column of remarks, came very near dying a number of times, and unquestionably would have died had it not been carefully managed, as, for example, by the administration of oxygen, by prompt changes in its food, by the regulation of the tempera- ture of the incubator, and by the constant attention of a day nurse and a night nurse. TABLE 60. Shaming Details of Sixty-four Days of Life in the Incubator of , ■ Infant Premature at Thirty Weeks. iiiiiii I'LltCKNTAUES OF FOOD. 18^20 v'U, 20 22 Vi 22 'JI-'V, 28 32 8 .■a 8 32 8 48 48 12 48 48 !•> 48 12 48 12 56 14 64 64 16 10 16 No. Character. W'ght. ~Fs.cKh Discharges. ; months weighed 7UM) grammes (11 pounds 12 c - (.'> ounces; at each meul. Looked brig hi. |, :i ,j . j formed. No lanugo. Heart r Uric acid on napkin. Food heated to 75° C. (167° F.) Temperature went Fed with dropper. ■li-li! -pi lid ..fii ncubator. Somnolent. Ijess icterus. Handy and feet warmer. Oxj times daily. Seems himprrv. Kverv other feeding takes 'i 1 .. ■ ' txv-ni as on 13th. Icterus neonatorum, iihirkv fresh-air box for io minutes three Oxygen as on l;iUi. : daily. Feet cold when iucubatorbetow 29.4° e. Oxygen. Very hungry. Oxygen. Oxygen. i K.'ea-iiinal i-yunosis. Brandy 5 drops every Feet and hands not 6 as2f>.l.:il,„ '■nii.l washed in water at :i.j° ('. ('.'3°F.) .-sleeps well, lines not n't. Is vnmine stronger. Thriving. Bmnuy omitted. I developed and \ ienlnus. PREMATURE INFANTS. 281 with : but the nurse was possessed with the idea that it needed plenty of cold fresh air. The window in the infant's room was left open one night when the weather was quite cool. The following day it did not take its food well, was somewhat cyanotic, and was found to have lost almost 240 grammes (£ pound). It was then placed, as it should have been in the beginning, in a warm room, treated with the utmost care, and not handled much. None of these measures, however, were sufficient to prevent a still further les- sening of its vitality. It never rallied from the first blow which was struck at its vitality, and lost its life practically through the ignorance of the nurse who was in charge of it. A post-mortem examination showed nothing abnormal, except that the mesenteric glands were somewhat enlarged. The next case was that of an infant born at about the twenty-fifth week of intra- uterine life. Its weight w r as 1080 grammes (about 2\ pounds). There were a number of interesting points to be recorded in this case. It was not strong enough to suck, and had to be fed with a spoon. Its mother's milk, the analysis of which is given below, at once caused such disturbance that modi- fied milk from the laboratory had to be substituted. {Mother- s Milk.) Fat 1.29 Sugar 4. 10 Proteids 6.83 Mineral matter 0. 26 Total solids 12.28 Water 87.72 100.00 The prescription for the modified milk which it digested well was Prescription 50. Modified Milk. R Fat 1.00 Sugar 3.00 Proteids 0. 75 The infant's temperature in the rectum was 36.7° C. (98° F.). It seemed to be doing fairly well, but did not gain in weight, and on the fifth day of its life was unable to swallow. It was then fed by gavage. It was treated with great care so far as keeping it warm was concerned, but an in- cubator could not be obtained for it, and it died when it was seven days old. It is interesting in this case to notice that the meconium came as is usual in the infant at term, and began to change its color on the third day, and that by the fifth day the fsecal movements were yellow and well digested. Table 60 records the details of an infant's life in an incubator during a period of sixty-four days. This record will be of great use to any one who has charge of a premature infant in an incubator, as it illus- trates exactly what emergencies are likely to arise and how they can be met. The infant, as is seen by referring to the column of remarks, came very near dying a number of times, and unquestionably would have died had it not been carefully managed, as, for example, by the administration of oxygen, by prompt changes in its food, by the regulation of the tempera- ture of the incubator, and by the constant attention of a day nurse and a night nurse. DIVISION V. DISEASES OF THE NEW-BORN Before entering into a description of the individual diseases of the new-born, it will be profitable first to consider some of the general aspects of disease as it occurs in early life. Disease in General. — The peculiarities which characterize disease in children are mostly limited to the period of infancy and the early and middle periods of childhood. In later childhood, that is, after the eighth or ninth year, disease, both in its etiology, pathology, symptoms, and prog- nosis, resembles closely that which is met with in adult life. In the earlier periods of life, on the contrary, we meet with distinct differences, depending partly on the great role which congenital diseases play in the various stages of development and partly on the greater vul- nerability of the growing tissues and their lessened power of resistance not only to the known specific infections but to numberless as yet undif- ferentiated varieties of pathogenic micro-organisms, which are as yet but little understood. Inheritance. — A very important element to be taken into considera- tion as influencing the tendency to disease is inheritance. The occurrence in the parents of such diseases as tuberculosis, rheumatism, and the various neuroses seems to render the tissues of the children not only more recep- tive to these conditions but to so vitiate them that they are readily affected by many other diseases. The direct inheritance of such diseases as syph- ilis and the great mortality arising from them are distinctly characteristic of disease in infancy. Malformation. — The greater number of diseases and the greater ten- dency to disease in early life, as compared with a later period, is caused in large measure by a lack of normal intra-uterine development, resulting in malformations, each representing a disease in itself and each having such influence on the tissues in general that they become abnormally re- ceptive to many diseases. These malformations, such as of the mouth, nose, bladder, and rectum, are of especial significance from a surgical point of view, while those which are of especial interest to us medically are malformations of the heart and brain and such conditions of arrested de- velopment as are represented by atelectasis. Traumatism. — A class of diseases distinctly infantile is represented by traumatic causes, such as certain forms of meningeal hemorrhages, 282 DISEASES OF THE NEW-BORN. 283 abrasions occurring during delivery, which afford, as in the case of an un- healed umbilicus, a ready entrance for the micro-organisms of tetanus and of erysipelas. The various forms of ophthalmia neonatorum must be in- cluded in this class of affections. General Etiology. — In addition to the congenital causes of infantile disease just enumerated the etiology of the acquired diseases of early life is of great interest and importance, for there is no doubt that most of the diseases of early life are the direct result of the ignorance or neglect of those who have the charge and direction of infants during this period. The chief etiological factors of disease in infancy are improper food and unhygienic surroundings. These conditions may cause such specific dis- eases of nutrition as rhachitis, scorbutus, and infantile atrophy, or may result in such a marked degree of malnutrition that there is a decided predisposition to various acute diseases such as those of the gastro-enteric tract and of the lung, and, later, to such neuroses as chorea and many functional disturbances. General Pathology. — The pathological processes which occur in early life, as distinctive from a later period, are essentially acute, the chronic morbid processes, except those which result from acute disease, being rare. Hyperplasia of the lymph-nodes and their susceptibility to infection of all kinds, together with their great activity in carrying infection, are a charac- teristic feature of infantile pathology. A series of 726 consecutive autopsies made at the New York Infant Asylum and tabulated by Holt, shows the relative pathology of the differ- ent organs. None of these autopsies were under one month, 72 per cent, were under one year, and only 3 per cent, were over two years. According to these figures the lungs first and the intestine second were found affected in the greatest number of cases, and it was noted that it was rare to find the lungs normal after any acute infectious disease had lasted a week. Out of the above-mentioned 726 cases, pathological conditions were found in the lung in 399 cases ; of these, 322 w T ere cases of pneumonia, of which 139 were primary and 56 were tuberculous. There were 6 cases of congenital atelectasis, 1 case of serous pleurisy, 5 cases of empyema, and although there was dry pleurisy in nearly all the severe cases of pneumonia, there was no case of pleurisy uncomplicated by disease of the lung. The gastro-enteric tract was affected in 189 cases ; of these, 116 cases were acute ileo-co litis with or without gastritis. There were no cases of gastritis without intestinal lesions. There were 72 cases of acute diarrhoea without gross lesions. There was one case of intussus- ception. The brain and meninges were affected in 35 cases, of which 11 were tubercular meningitis. There were 26 cases of malnutrition without gross lesions. The kidneys were affected in 26 cases, 7 of which were mal- formations, and only 5 cases were primary. The heart was affected in 6 cases ; of- these, 3 were congenital malformations, 3 were pericarditis, all occurring in cases of pneumonia, and there were no cases of acute or 284 PEDIATRICS. chronic endocarditis. The peritoneum was affected in four cases. The mouth was affected in one case (noma). It thus appears that pathological conditions of the liver and spleen are rare in early life, as are primary disease of the kidneys and organic disease of the brain itself. New growths are rare, and, when present, are usually of the kidney or bones. Diseases of the bones and joints are very com- mon, and are usually tubercular or syphilitic, more commonly the former. Diseases of nutrition are extremely common. General Symptoms. — The clinical picture of disease in older children does not present many features different from what is seen in the adult. In infancy and early childhood, however, there are many differences. The infant cannot express its thoughts and sensations in words, and in place of this indicates its discomfort by cries and various movements. In addition to this, the nervous system is in so sensitive a condition and in such unstable equilibrium that its manifestations in disease are very misleading. In disease of the lung, for instance, the young child is very apt to locate its discomfort in the abdomen, while gastric distention may be symptomatically represented by marked pulmonary symptoms. Cere- bral symptoms which would at a later period point towards organic lesions of the brain or its meninges, often in early life simply indicate a disturbance of the meningeal circulation which may arise in almost any disease with a heightened temperature or with interference with the circu- lation, as in pertussis, in cardiac disturbance, and in acute gastro-enteric disease. The reverse of this picture is at times seen in cases of consider- able pleuritic effusion with displacement of the heart, in which very slight rational signs, in comparison with the same condition in adults, are shown, the child appearing fairly well and inclined to run about its nursery. Again, with very slight lesions in the lungs, most violent pulmonary symptoms may arise. An insignificant disturbance of digestion may pre- sent most alarming symptoms of pallor and collapse. Infants and young children may, from purely nervous causes, vomit so continuously that the symptoms, when the vomiting has ceased, closely simulate a typhoid con- dition, and, still more frequently, tubercular meningitis. The prodromal symptoms of many diseases, both benign and malig- nant, simulate each other so closely in early life that the diagnosis must often be left in abeyance for many days longer than would be necessary at a later period. Pulmonary, gastro-enteric, and cerebral diseases fre- quently show this correspondence of symptoms. Affections of the ear, where the aural symptoms are marked, as they often are, produce a great variety of symptoms pointing towards other organs, such as cough and vomiting, and owing to the late closure of the petrosquamosal suture, the most pronounced cerebral symptoms. The rational indications of a dis- ease, therefore, in early life are a symptom-complex, and we have to rely almost entirely on our physical examination. It must be remembered, however, that seemingly grave and alarming symptoms do not neces- DISEASES OF THE NEW-BORN. 285 sarily indicate a serious disease, while mild and unobtrusive symptoms may be the beginning of a fatal disease. Of especial importance in infantile symptomatology are the cry. the facial expression, the posture, and the movements of the body ; these will be described when the various diseases are spoken of. General Diagnosis. — It has already been stated that the diagnosis in children is most satisfactorily made by the physical signs, but the examina- tion is often so difficult to obtain that we necessarily also depend greatly on the history given by the parents and on inspection. There are, how- ever, certain methods of examination which are preferable to others and which diifer in their system from those which we employ in adults. The employment of these methods, though involving more time, render it possible to obtain a satisfactory examination in almost every case. General Prognosis. — The mortality in early life is greater in inverse proportion to the age, so that the prognosis in diseases which in older children would be regarded as benign should in the early weeks and months of life be considered as serious, and the prognosis should be cor- respondingly grave. On the other hand, certain organic diseases, such as those of the kidney and heart, which would be attended with a very bad prognosis in later life, in childhood are much more likely to recover, on account of the wonderful recuperative powers of children due to their rapid reconstructive metabolism. Young children may die after a few hours' illness apparently from their lack of power to resist the onset of various infections, such as scarlet fever and pneumonia, before these diseases have declared themselves by their characteristic symptoms. Sudden death from various and obscure causes is also not very uncommon in weak infants who are suffering from mal- nutrition. Internal hemorrhages, as in Buhl's disease, asphyxia from many causes, sudden collapse in the course of pertussis, laryngospasm, or cardiac disease, may also be the cause of sudden death. Maternal Impressions. —A few words should be said concerning the subject of maternal impressions. For many years there has been accumu- lating a considerable amount of evidence showing that a violent mental impression made upon a woman who is at the time carrying a child may be followed by a physical or mental defect in the child which bears a striking relation in character to the impression made upon the mother. Thus, Sir Walter Scott narrates that King James the First could not endure the sight of a drawn sword. This feeling had been attributed by those who believe in maternal impressions to the terror which his mother ex- perienced at witnessing the murder of Rizzio. Still more numerous are the facts adduced to prove that bodily defects, such as harelip, club-foot, and hairy mole, may be caused by strong impressions of pain or terror experienced by the mother at the time when the foetus is in a certain stage of intra-uterine development. Interesting as these instances are. it is the general belief that nothing more has been proved than that they 286 PEDIATRICS. depend on a coincidence. The final decision on this obscure subject must rest on future investigation, and until something more definite is known Ave should guard a woman during her pregnancy from all unpleas- ant impressions with far more care than we do at present. The diseases which we speak of as diseases of the new-born are distinct from those which are acquired later in life, in that they represent in almost every case an arrest of the normal development which should occur during intra-uterine life. A stage of development which is normal at a certain period of intra-uterine life becomes abnormal if it persists to a later period, and this persistence of an early stage of development constitutes in the great majority of cases what is known as congenital malformation, Such a failure of development may be the result of intra-uterine inflam- mation, which, either by crippling the various functions or by arresting the normal intra-uterine growth, produces a condition of disease at birth. In many cases, however, the causes are so obscure as to elude our usual methods of examination. Diseases of the new-born may also be made to include certain abnormal conditions which arise immediately after birth or in the early days of life. Although many of these affections must pass into the hands of the surgeon for treatment, yet it is very important for the medical practitioner to be able to recognize at once their true nature and their significance. For purposes of simplicity, these diseases can be classified into diseases of the head, diseases of the neck, diseases of the trunk, diseases of the extremities, and general diseases. DISEASES OF THE HEAD. Caput Succedaneum. — The normal average head at birth may be misshapen from various causes. Of the conditions which may cause unusual appearances, the most common is Fig. 70. called caput succedaneum, a case of which is represented in Fig. 70. This infant, a male, two hours old, presented a swelling over the right parietal bone extending back to the occiput, causing an irregular tumor and a great increase in the anteroposterior diam- eter of the head. The tumor did not fluctuate. The presentation was occiput left anterior, and no instruments were used. The swelling corre- sponded to the place where there was the least pressure, — that is, the presenting part. It is needless to say that this caput suc- cedaneum requires no treatment, as it gradually disappears of itself by absorp- tion in a few days. It is simply a swelling of the scalp caused by a passive congestion with extravasation of blood and lymph into the connective tissue external to the pericranium. Caput succedaneum. Male, 2 hours old. DISEASES OF THE XEW-BORN. 28? Caput succedaneum must be carefully distinguished from another swelling of the scalp, cephalhematoma, which may occur in connection with it. and which appears as the caput succedaneum disappears. Cephalhematoma. — During labor a hemorrhage may take place from the blood-vessels of the head which gives rise to a tumor in one of three situations: (1) between the occipito-frontalis aponeurosis and the perios- teum ; (2) between the periosteum and the skull ; or (3) between the skull and the dura mater. The first two are known as external cephal- hematoma, the last as internal cephalhematoma. The cause cannot be en- tirely from pressure over the presenting part, as the lesions have been found in breech presentations. Cephalhematoma is distinguished from caput succedaneum by its sharp limitation to one of the parietal bones, by its fluctuation, and, if seen late, by its surrounding bony wall It can be diagnosticated posi- tively by the withdrawal of some of the fluid by a hypodermic syringe. Another condition which may simulate it somewhat is a depressed fracture. The differential diagnosis from this latter condition can best be made by remembering the fact that the resistant rim of the cephalhematoma is raised above the level of the surrounding bone, and is somewhat compressible, while on the inside it can be felt to slope evenly towards a fluctuating centre. In fracture no such arrangement occurs. (a) External Cephalhematoma. — By far the most common form is that in which the tumor has formed between the skull and the periosteum. It shows itself as an irregular circular swelling over a parietal bone, and gives on palpation a distinct feeling of fluctuation. The skin over it is not discolored or reddened. In the cases that have existed for a few clays a bony wall can be felt surrounding the tumor, the edges of which give a crackling sensa- tion under the finger. In this stage it may strongly suggest a fluid tumor coming through a circular hole in the skull. Fig. 71. A ' 1 W*'* Iks Double cephalhematoma. Infant, 4 days old. Fig. 71 represents a case of double cephalhematoma of the external variety ; that is, it is an extravasation of blood under the pericranium. Its base corresponded to the denuded bone, and was oval or circular. There were bulging tumors on each side of the sagittal suture with a deep sulcus between them. On palpation there was fluctuation, and on feeling the circumference of the tumor there was noticed an elevation and a crackling sensation as though one were touching fine crystals of ice on the edge of water which is beginning to freeze. 288 PEDIATRICS. Fig. 72. Double external cephalhematoma. Both parietal bones. Warren Museum, Harvard University. Pig. 73. External cephalhematoma. Parietal bone dissected. Warren Museum, Harvard University. DISEASES OF THE NEW-BORN. 289 Fig. 72 represents the dried preparation of a double cephalhema- toma which is in the Warren Museum. On the left side of the skull (the right side of the picture) the integu- ment has been nearly removed, showing a raised bony rim. " On the right side of the skull (the left side of the picture) the integu- ment has been cut off and partially deflected, showing the cavity which contained the diffused blood. Fig. 73 is a parietal bone dissected so as to show the condition of the bone in a case of external cephalhematoma. The specimen shows well the raised rim and the porous condition of the bone underlying the tumor. In two or three places the bone sub- stance has entirely disappeared. (b) Internal Cephalhcematoma. — Internal cephalhematoma is situated between the inner surface of the skull and the dura mater, and is rare. It is at times found in connection with the external variety. The prognosis in these cases is bad. They are usually fatal, and there is no known treatment which can save them. Meningocele. — By the term meningocele is understood a protrusion of some part of the membranes of the brain through a hole left in the cranial wall by defective ossification. In some instances this is caused by an intra-uterine hydrocephalus. These tumors generally contain some of the cerebro-spinal fluid in the bag of membrane. Such fluid can often be reduced into the skull by gentle pressure, but at the risk of bringing on symptoms of cerebral disturbance. Fig. 74 represents a small meningocele above the left ear about 2.5 cm. (1 inch) in diameter. Some fluid was withdrawn from it by an aspirating needle, and the con- tents of the sac proved to be serous without cells. The sac refilled after tapping. No more extensive operation on it has so far been undertaken. The child was rhachitic. It had a fall some time previous and struck its head. Nothing abnormal was noticed about the child previous to the fall, but after the ac- cident a swelling appeared above and behind the ear. Fig. 74. The swelling increased in size when the child cried, was soft, fluctuating, and not tender. The knee-jerks and sensation were normal. The ophthalmoscopic examination disclosed nothing abnormal. ^^M A much more serious condition is shown in the meningocele in the following case. The infant was two weeks old when operated upon. Behind its left ear was an irregular tumor about 7.5 cm. (3 inches) long. The ear was pushed Meningocele. Fen forward, and appeared to be growing from the tumor. old. The labor was normal, and the infant at birth was perfectly healthy and well formed, except for the tumor, which was congenital. On examination the tumor was found to be fluctuating and translucent. There were large veins on its surface. No impulse could be felt on crying, nor did pressure cause any cerebral symptoms. On aspirating it, 45 c.c. (1£ ounces) of a clear reddish fluid were 19 290 PEDIATRICS. withdrawn. This fluid contained red blood-corpuscles and a few endothelial cells. No unfavorable symptoms followed the aspiration. After the withdrawal of the fluid two openings could be felt, the anterior probably connecting with the external auditory meatus and the posterior with the anterior fontanelle. The tumor was increasing in size so rapidly that an operation was decided upon. On removing it an opening in the skull large enough to admit two fingers was found. The child made a rapid re- covery from the operation, and was left with only a scar behind the ear. There were no cerebral symptoms. During convalescence the child seemed to be mentally bright. Encephalocele. — Still more common than the pure meningocele is that condition in which the hernia contains some of the cerebral sub- stance as well as the membranes. This condition is called encephalocele ; or if, as is often the case, it contains a portion of a dilated ventricle, so that the tumor is filled with cerebro-spinal fluid, it is known as hydro-encepha- locele or as hydro-encephalo-meningocele. Fig. 75 represents a remarkable case of hydro-encephalocele which was treated by Dr. Lovett in the hospital. The infant from the time of its birth had tonic and clonic convulsions, occurring usually as often as once in three hours. It was brought to the hospital when it was two months old. It was well formed in every way, except that it had a tumor on the back of its head which was at least one-third as large as its skull. The tumor was only partly covered with skin, the upper part of it being a thin translucent membrane. It communicated with the brain through a large square hole in the back of the skull. The tumor fluctuated slightly and appeared to be a multilocular cyst, for when it was aspirated only a part of the contained fluid could be withdrawn. The tumor was removed by Dr. Lovett and the wound sewed up tightly. The cyst was found to con- tain a viscous fluid with slight flakes in it which proved to be particles of cerebral substance. The convulsions immediately became less frequent, and ultimately on treatment with bromide of potash disappeared almost entirely. The infant in other respects was very little affected by the operation, and recov- ered rapidly. After remaining in the hospital two weeks it was taken to its home, where it died some months later of some intercurrent affection. Regarding these tumors in general, it is enough to say that we should view with suspicion any fluctuating swelling that seems to have a deep attachment in the neighborhood of one of the cranial sutures. The most frequent seat of these tumors is in the occipital region and at the root of the nose. Their treatment has not proved very successful. Some few may steadily decrease of themselves and ossification may block up the abnormal opening. Pressure and the injection of Morton's fluid have both been tried, and in some cases have been attended with success. At present the operative plan of treatment is considered the best. With- out interference the tendency is usually towards rupture of the hernia, convulsions, and death. Anencephalia. — The cerebro-spinal system is formed from the medul- lary tube, which is made by the infolding of epiblast along the medullary groove : if the formation of the medullary tube is for any reason incom- plete, or if the dorsal wall of the tube is destroyed, the cerebrum or part DISEASES OF THE NEW-BORN. 291 of the cerebral axis will remain rudimentary. According to the amount of interference with the development we may find more or less of the brain remaining in a rudimentary condition, and thus producing greater or less degrees of what is called anencephalia. Total anencephalia is rare. Partial anencephalia is much more common. These cases are not of especial interest, as it is exceptional for them to live beyond a few days. Congenital Hydrocephalus. — One of the more common malforma- tions of the head is a hydrocephalic condition at birth, called congenital hydrocephalus. It is described on page 970. Fig. 75. Fema onths old. Hydro-enct Harelip. — If the maxillary process on one or both sides of the face fails to unite with the intermaxillary process, a cleft will remain open in the contour of the upper lip on one or both sides of the intermaxillary bone, and hence we shall have single or double harelip as the case may be. If the cleft extends the whole distance from mouth to nostril it is called complete, but if the nostril is not reached by the opening it. is called partial harelip. If there is a failure of the palatine processes to join, one or both nostiils will open into the roof of the mouth as well as into the 292 PEDIATRICS. pharynx, and we shall have the malformation known as cleft palate. This may be a large chasm running the whole length of the roof of the mouth, or may be only a small opening, or nothing but a bifurcation of the tip of the uvula may be left to show that the normal process of development has not gone on to completion. Besides their unsightly appearance, which always causes the mother great concern, these malformations may so interfere with the infant's taking the breast as to render sucking impossible and make it necessary to feed the in- fant with a spoon. Fig. 76 represents a typical case of dou- ble harelip uncomplicated by cleft palate. The intermaxillary bone was of a large size, protruded considerably beyond the mar- gin of the lips, and was somewhat twisted Double harelip. ° r ' upon itself. This alteration of the position of the intermaxillary bone may cause the teeth that grow from it to appear in very unusual places, so as to protrude, for instance, from the nostril. The operation should be performed during the early weeks of life, as the growth of the facial muscles is not then sufficient to interfere with the healing of the wound. There is considerable difference of opinion as to when cases of con- genital harelip should be operated on. In general, it can be said that cases of single harelip unassociated with cleft palate can be operated on from three to six weeks after birth, while the severer forms are best left for as many months. When the infant is wasted and is in a poor general condition, the indication is to postpone the operation, as it is seldom that this defect is the cause of the general lack of proper development. Cleft Palate. — In speaking of harelip most of the conditions occur- ring in cleft palate have been described. The difficulty of feeding, if the cleft involves the hard as well as the soft palate, is very great, and can best be accomplished with a spoon. The difficulty in articulation and the unpleasant sound of the voice are reasons which lead the parents to demand early treatment. We should wait a longer time before operating than in cases of harelip, as it is seldom wise to operate upon this deformity before the child is three years old. The operation for cleft of the soft palate is called staphylorrhaphy, and that for the closure of a cleft in the hard palate is termed uranoplasty. The larger the opening in the palate the more successful will be the treatment by apparatus in comparison with that by the knife, and many prefer to close the cleft by fitting artifi- cial plates. Tongne-Tie. — In quite a number of cases the fraenum of the tongue is abnormally short at birth. In extreme cases the tip of the tongue is so DISEASES OF THE NEW-BORN. 293 closely bound to the lower jaw that it cannot be protruded beyond the line of the gum or touched to the roof of the mouth. The mother usually notices that the infant does not nurse readily, and brings it to the physi- cian to discover the cause. In most cases on passing the finger into its mouth the infant is found to suck fairly well ; but there can be no doubt that this condition, which is called tongue-tie, interferes somewhat with the process of sucking. Children who have not learned to talk at the usual time in the second and third years are frequently brought to me with the statement that they are tongue-tied, and the parents wish the condition to be treated. Large numbers of children are taken to the physician under this supposition but in very few instances are they tongue-tied. These children belong to the class of retarded speech. The condition is a central one of the brain, and not a local one in the mouth, and if children hear well and are bright and mentally well developed, even though they do not speak at the third, fourth, or even fifth year, as a rule they learn to speak later. Treatment. — The treatment is to cut the fraenum. This operation should be followed by no hemorrhage and requires no dressing. Having the child's head held in a fairly good light by an assistant, and guarding the lower part of the tongue with the perforated flange of a director, a small cut is made in the tense fraenum with a pair of blunt-pointed scissors. By making the cut close to the gum there is no danger of wounding the ranine artery. The cut is prolonged as far as is necessary by tearing with the finger-nail. Ranula. — Beneath the tongue we sometimes find the mucous mem- brane bulging out as a bluish, translucent tumor which is soft, painless, and semi-fluctuating. This condition is called ranula, and is a retention cyst caused by the blocking of a mucous duct. When opened, a small amount of glairy fluid escapes, but the collapse of the walls of the cyst brings the edges of the cut together and they quickly adhere. The fluid will soon re-collect ; therefore the only sure way of dealing with these cysts is to pinch up their anterior wall with fine forceps, and with the scissors remove so much of it as to leave no opportunity for the edges to adhere. A gentle application of nitrate of silver to the edges and interior of the sac after the cut has been made with the scissors materially helps to promote the cure. It is not common in new-born children, but it occurs often enough to deserve mention. Protrusion of the Ears. — A deformity which is quite frequent at birth, and which increases as the infant approaches childhood, is the pro- trusion of the ears. The ear, besides at times being placed in an irregular position on the head, has in these cases a tendency to stand out from the head farther than is considered normal. This position of the ear usually annoys a mother very much, and the physician will frequently be con- sulted as to the means by which the deformity may be rectified. 294 PEDIATRICS. Treatment. — In a large number of cases the persistent application of pressure by means of various devices, one of which is a fenestrated cap, will cause the ears to be flattened against the side of the head. In intract- able cases an operation will have to be performed, but it is very simple and does not leave an unsightly scar. Ophthalmia Neonatorum. — Ophthalmia neonatorum has been divided into two forms, the catarrhal and the purulent. (a) Catarrhal Ophthalmia. — The catarrhal form may be caused by any slight irritation of the eyes of the infant. It runs a very mild course, the inflammation attacking chiefly the palpebral conjunctiva. Often the only symptoms noticed are a slight photophobia and a collection of the secre- tion in the angles of the lids and upon their borders. Its whole course is mild, and often it is all over in a few days. (b) Purulent Ophthalmia. — Although a considerable number of causes for purulent ophthalmia in the new-born have been given, such as trauma, exposure to light and cold, and others, certainly ninety-five per cent, of all cases are caused by infectious material from the genito-urinary tract of the mother, and in most instances by gonorrhoeal pus. The early signs of the disease may appear at any time from the third hour of life, and the earlier the pus appears the more virulent will be the course of the disease and the more unfavorable the prognosis. If infection takes place during the birth of the child, the symptoms usually begin on the third day ; but, as contaminated linen and fingers may carry the infectious material to the infant's eyes at a later period, the symptoms may be delayed indefinitely. Symptoms. — The disease begins as a redness of the conjunctiva, with a slight discharge from the corner of the eye. This is succeeded with startling rapidity by intense inflammation of the lids. In twenty-four hours the upper lid may become so much swollen as to overhang the cheek and render opening the eye impossible. On separating the lids, a little greenish pus, which may even be tinged with blood, wells up between them. At first the cornea is unaffected, but if the pus accumulates under the oedematous lids it soon shows signs of ulceration. In the second twenty-four hours the ulceration may perforate the cornea and evacuate the aqueous humor, thus bringing the iris into contact with the posterior surface of the cornea. The inflammation may extend around the eye and well over the forehead and malar prominence, but it does not persist in the latter region very long. All the symptoms disappear slowly, and recovery takes place, except in those cases in which the cornea has been permanently injured by ulceration. Treatment. — In treating this disease we must be very prompt and energetic. It often may be averted by what is known as Crede's method. This consists in dropping one or two minims of a two per cent, solution of nitrate of silver into each eye of the new-born infant. Although this has been known to cause even a considerable amount of irritation, yet it DISEASES OF THE NEW-BORN. 295 undoubtedly exerts a powerful influence in warding off this dangerous disease. Alter the disease has once begun, two indications must be kept in mind: (1) to reduce the inflammation, and (2) to prevent the pus from accumulating behind the tightly closed lids. By far the best way of apply- ing cold to the eye is by compresses of thin, soft pieces of linen cut into small squares. Not more than two thicknesses are to be used at once. These compresses are to be cooled by laying them on a piece of ice or floating them in ice-water. They must be constantly changed. To re- move the pus. a gentle irrigation, such as can be easily obtained by using a medicine dropper, is sufficient. The secretion is highly contagious, not only for the infant's other eye, but for those who are taking care of it. Therefore one must avoid all spattering, and should cover the infant's well eye before beginning the irrigation. In the irrigation of the eye one should first turn the child's head a little to the diseased side, and with the fingers of the left hand gently separate the lids as far as possible. Then, holding the dropper with the right hand, irrigate between the lids, directing the stream from the nose. After each irrigation vaseline should be applied to the edge of the lids. This should be done at least every half-hour, day and night, until the swelling has so far subsided as to preclude the danger of any secretion being retained. For irrigation many solutions have been advocated. The most simple, and perhaps the best, is a saturated solution of boracic acid, or one of bichloride of mercury in the strength of 0.05 gramme (1 gram) to 480 c.c. (1 pint) of distilled water. In the later stages of the disease, where all the tissues are relaxed, a solution of nitrate of silver, 0.5 gramme (10 grains) to 30 c.c. (1 ounce) of distilled water, may cau- tiously be used once a day. This same solution painted on the conjunc- tiva with a camel's-hair brush once daily early in the disease is very effective in shortening the course of the disease. DISEASES OF THE NECK. Hsematoma of the Sterno-cleido-mastoid Muscle. — During the birth of the child, either from the violence of the expulsive efforts of the uterus, or, as more frequently happens, from the pressure of the forceps in head presentations, or from too vigorous traction upon the feet in breech presentations, or for no assignable reason, the sterno-mastoid muscle may be partially ruptured in its sheath and a haematoma form be- tween the torn ends. This tumor may be either in the sternal or in the clavicular portion of the muscle, or may be just above the junction of the two. For a short time it is soft and tender, but gradually it loses its sensitiveness and becomes converted into fibrous tissue, which then tends to contract. It may appear as a small tumor, but in infants with fat necks it may not be noticeable at first. As turning the head towards the 296 PEDIATRICS. affected side lessens the tension upon the swelling, the infant will rigidly hold its head in that position. It is in this way that cases of infantile torticollis are thought by most writers to arise. Treatment. — After the painful stage has passed, the treatment is by gentle massage and manipulations addressed to stretching the shortened muscle. If these methods fail, the child must be placed in the hands of an orthopaedic surgeon for more extended treatment, either by appa- ratus or by division of the tendinous attachments of the sterno-mastoid muscle. Branchial Fistulae. — At an early period of development the neck of the foetus has along its sides a series of four branchial clefts, which com- municate freely with the oesophagus and represent the gills of aquatic animals. The upper one of these forms the tympanum and the eustachian tube, the rest are normally obliterated. Sometimes we find traces of these branchial clefts in the form of small fistulous tracts which admit a probe a short distance and end blindly. Their most frequent seat is just above the sterno-clavicular articulation, but they may be found any- where along the anterior border of the sterno-mastoid muscle. Some- times the entrance of these fistulae becomes stopped, so that they dilate and form large cysts containing mucus, blood, and atheromatous detritus. These form at times large and unsightly bunches, which require surgical treatment. Often the operation of obliterating them is not an easy one, for they are apt to have deep and complicated attachments. Treatment. — If they do not cause any inconvenience it is better to let them alone, as they often prove very intractable to treatment. If they are annoying because of a slight mucous discharge, we can try to eradi- cate them with the galvano-cautery, or by passing a probe into the wound and dissecting from around it the lining of the sinus. DISEASES OF THE TRUNK. Mastitis. — In certain infants during the early days of life we find a swelling and hardness of one of the mammae. This condition appears to be an inflammatory one, and is abnormal. In connection with the swollen condition of the mamma, a secretion is found to come from the nipple which corresponds closely to milk, and which has been called " witches' milk."' A number of analyses have been made of this fluid, and the follow- ing are some of them : ( SeMossberger. ) Fat 0. 82 Casein, sugar, and extractives . 2.83 Mineral matter 0.05 Total solids 3.70 Water 96.30 100.00 DISEASES OF THE NEW-BORN. 297 ^ Von Gesner. ) Fat 1.45 Casein 0. 55 Proteids 0.49 Sugar 0.95 Mineral matter 0.82 Total solid? 4.26 Water 95. 74 100.00 This condition occurs in boys as well as in girls, and, as far as I know, has no special significance. With ordinary antiseptic precautions the inflammation usually subsides in a few days, leaving the affected breast the same size as the other. The following case represents this condition of the mamma in a female one week old : The swelling of the mamma was noticed on the fourth day of her life. A little fluid looking like diluted milk could be expressed from the mamma. The treatment of the case was simply to keep it thoroughly clean by washing it with sterilized water, carefully drying it, and applying a compress with a little simple ointment on it. Depressed Sternum. — There are a great many congenital malforma- tions which may occur in different parts of the thorax. Fig. 77 repre- Fig. 77 Congenital depression of sternum. Male, 6 years old. sents one of these. It occurred in a boy who was born with a depression of the lower part of the sternum. He was six years old when first seen, and had a rounded depression, about 4 cm. (1J inches) in diameter, beginning at the third costal cartilage and extending to the ensiform cartilage. He was perfectly healthy. The cardiac dulness extended to 2.5 cm. (1 inch) to the left of the mammary line, and its impulse was in the fourth left interspace. The spinal column was straight. The epiphyses of the wrists were slightly enlarged, but there was no other evidence of rhachitis. When he was 298 PEDIATRICS. two months old he had a severe attack of pertussis, which lasted for over two months. At five years of age he had a very severe attack of bronchitis. Although this depression of the sternum was present at birth, and later increased in depth and in circumference, it eventually ceased to enlarge. The circumference of his head and that of his chest was 50.5 cm. (20 inches). The heart was somewhat displaced upward and to the left, but was apparently unaffected by its abnormal position. Light gymnastic exercises to broaden the chest and to strengthen the thoracic muscles were advised for treatment. Such a malformation as this sometimes results as one of the changes subsequent to Pott's disease. More often the sternum protrudes, but occasionally recession takes place, closely resembling the condition in this case. Prominent Sternum. — A prominence of the sternum, called pigeon- breast, occurs more often than the depression. It may happen without an assignable cause, or it may be due to rhachitis, and may also result from some spinal distortion, such as that of Pott's disease, or lateral curvature. In the latter case the sternum is often tilted to one side. Spina Bifida. — Spina bifida consists of a lack of closure of the laminae of the vertebrae. This condition is normal at a certain period of intra-uterine life, but when persisting to a later period, and when oc- curring at birth, becomes abnormal from a developmental point of view and represents a distinct malformation. As the fusion of the laminae at the base of the spinous process takes place in sequence from above downward, the most frequent seat for spina bifida is in the lumbar and lumbo-sacral regions. There it appears as a tumor situated exactly in the middle line, covered sometimes Avith healthy skin, but as frequently roofed over by nothing but a thin adherent transparent membrane. Rarely the tumor is solid, containing nothing but an empty sac that has been walled off from its connections with the spinal canal. It is then called spina bifida occulta. In true spina bifida the tumor is filled with cerebro-spinal fluid, which can be seen to increase in amount as the child cries, and can, by pressure upon the sac, be forced back, in this case often giving rise to cerebral symptoms. According to the contents of the tumor, spina bifida has been divided into several varieties. (a) Spinal Meningocele. — When there is a protrusion of the mem- branes filled with fluid the tumor is called a spinal meningocele. (6) Meningo-myelocele. — The most common form is where the spinal cord, as well as the membranes, is found in the tumor. It then becomes a meningo-myelocele. The position of the cord in these tumors is a very variable one. It may run directly through the tumor and even be sus- pended by a kind of mesentery ; or, as is usually the case, it may be spread out like a fan over the surface ; in any instance it is rudimentary in character. (c) Syringo-myelocele. — Syringo-myelocele is a rare form, in which the sac is formed of meninges and cord, the central canal of the cord being dilated to make the cavity of the tumor. Spina bifida occurs usually in poorly developed infants, and in a large DISEASES OF THE NEW-BORN. 299 majority of cases it is associated with other malformations, such as con- genital hydrocephalus, harelip, club-foot, paralysis of the lower ex- tremities, and in severe cases there may be incontinence of urine and of feces. Sometimes the infant is well formed and healthy in every other respect. If left to itself, the course of spina bifida is in one of two directions : (1) spontaneous closure and obliteration of the sac ; (2) ulceration of the sac, usually followed by convulsions and death. In the first case, which is very rare, the sac shrivels up and thus effects a spontaneous cure. The following case was one of spontaneous closure : Fig. 78. Spina bifida. Spontaneous cure. Male, 4% years old. A boy, four and one-half years old, showed an elevated cicatrix in the lumbar region, which suggested the former existence of a spina bifida. The case was seen by Dr. Lovett when it was eighteen months old, and so far as could be learned there had been a large tumor present at birth. The sac burst in this case, and. contrary to the general result, the child did not die, but was left with paralysis of the legs, which made it stand in the curious and abnormal position shown in Fig. 78, He 300 PEDIATRICS. also suffered from incontinence of urine and of feces. The child had never walked, and it seemed probable that his disability was caused by the fact that the nerves were spread on the walls of the sac, as is usual in many cases, and that they were incorporated in the cicatrix. A result such as is described in the above case is, however, very ex- ceptional. The rule is, either that there is an ulceration of the sac, fol- lowed by a large loss of cerebro-spinal fluid, convulsions, and death, or that the opening in the spine being very small the loss of fluid is constant, and the result is the same. In some instances there is an infection of pyogenic organisms through the walls of the sac, which causes a septic meningitis in the cord, and finally in the brain. Such a case has been reported and beautifully illustrated by Holt, showing the presence of the bacteria and a resulting purulent hydrocephalus. Fig. 79 represents another case of spina bifida which will illustrate the ordinary course of the affection. Pig. 79. Spina bifida of dorsal lumbar region. Infant 48 hours old. Died when 10 days old. It shows a large spina bifida in the dorso-lumbar region. The membrane cover- ing the tumor was so translucent that the spinal cord could be plainly seen through it. At birth there was a small tumor. It filled with fluid at the end of twelve hours, and at the end of forty-eight hours it looked as it does in this picture. The top of the tumor suppurated, the fluid began to leak away, and the child died within ten days. This is the course pursued by the disease in the majority of cases which are not operated upon. Fig. 80 represents the case of a boy five years old, who had had this large tumor since birth. It was situated over the lumbar region of the spinal cord, and in the median line. The fluid was withdrawn several times for purposes of examination, and when the sac was lax an opening 5 cm. (2 inches) long could be felt in the spinal canal. It was elliptical in shape. From the fact that the child suffered from incon- tinence of urine and had a certain degree of paralysis of the legs, it was fair to infer that the nerve-supply of the legs and pelvis was incorporated in the tumor. This case was tapped and treated with an injection of Morton's fluid, but the DISEASES OF THE NEW-BORN. 301 treatment was entirely unsuccessful, and although the sac was aspirated several times the fluid always returned. Treatment. — The only rational treatment of spina bifida is by opera- tion, and the operation now commonly done is excision of the sac and closure of its neck. Fig. 80. Spina bifida of lumbar region. Male, 5 years old. Rhachischisis. — Rhachischisis is one of the principal forms of con- genital defects of the spine. It is characterized by a deficiency of the vertebral arches either complete or partial. The cord is rudimentary and is split open so that the endothelial lining of the central canal is exposed. This may occur in the whole of the cord or in a part of it, constituting total or partial rhachischisis. This disease is of pathological rather than clini- cal interest, as the infants die in a short time. Phlebitis and Arteritis Umbilicalis. — The cause of both of these con- ditions is a septic infection of the umbilical stump. It is considered by most pathologists to begin as an inflammation of the perivascular cellular tissue, and only secondarily to invade the walls of the vessels. The region around the umbilicus is red and hot, and we may be able by gentle press- ure to squeeze a few drops of pus from the stump of the cord. It is a very dangerous affection, as septic emboli readily pass from the infected vessels into the general circulation and set up metastatic inflammation in the thoracic as well as in the abdominal organs. Treatment. — The treatment is to sustain the infant's vitality by stimu- lation and thoroughly to disinfect the umbilicus with solutions of bichloride of mercury or carbolic acid, followed by the application of boracic acid or iodoform powder. A flaxseed poultice is often of service, and some 302 PEDIATRICS. authors recommend placing the infant upon its abdomen in order that gravity may aid in draining away the pus. Congenital Umbilical Hernia into the Cord. — Dr. Howard Marsh, in the Report of St. Bartholomew's Hospital for 1874, calls attention to the " familiar anatomical fact that from about the sixth to the twelfth week of intra-uterine life the caecum and neighboring portions of the ileum are contained in the part of the umbilical cord which is next to the body of the embryo, and that they should subsequently withdraw into the cavity of the abdomen. In some cases, however, this recession fails to take place, and the intestine remains, even up to the time of birth, still lodged in the beginning of the cord, which is dilated in the form of a membra- nous sac." Not only may portions of the intestine be thus left outside of the abdominal wall, but, as in a case recently operated upon by Warren, the liver may be found lying in a hernial sac made from the dilated base of the umbilical cord. The infant was sent to Dr. Warren at the Massachusetts General Hospital a few- hours after its birth. At the umbilicus was seen the cord, which was greatly distended at its point of insertion into the abdomen, forming a tumor 6.5 cm. (2| inches) in diameter. The coverings of the cord were inserted into a raised rim of skin, and were opaque, so that the contents of the hernia could not be determined. When the infant was one day old, Dr. Warren enlarged the umbilical ring some- what, separated the liver from the myxomatous tissue of the cord, which was in some places firmly adherent to it, and returned the mass within the abdomen. The wound was tightly closed with strong silk sutures. There was considerable shock following the operation, but there were no symptoms of peritonitis. In two weeks the wound had healed, and the infant recovered. Fung-us of the Umbilicus. — The umbilical cord, after being ligatured at birth, falls off by the seventh or eighth day, leaving a clean, dry cica- trix. After the separation of the cord we sometimes find a red protru- sion, with a moist surface, that may even have a short central canal. This is generally due to an imperfect disintegration of the cord. It may bleed very readily if touched, and give rise to a discharge so irritating that the skin for some distance around the umbilicus becomes eczematous. This condition is called fungus or polypus of the umbilicus. Treatment. — The treatment is very simple. The larger ones are best removed by ligation ; the smaller ones can be destroyed by the applica- tion of nitrate of silver or the actual cautery. Meckel's Diverticulum. — A condition which may at first simulate umbilical polypus, and of which umbilical polypus may be a symptom, is the persistence of a Meckel's diverticulum. This consists of the persist- ence of a piece of intestine, usually patent, connecting the small intestine with the umbilicus. It represents a vitelline duct that failed to atrophy when the placental circulation became established, and betrays its presence by an escape of faeces from the umbilicus. It is a rare malformation. Umbilical Hernia. — The ordinary umbilical hernia, which is simply a DISEASES OF THE NEW-BORN. 303 protrusion of a knuckle of the intestines through the unclosed abdominal opening left by the separation of the cord, is of very common occurrence. Treatment. — The lighter grades tend to recover spontaneously, and it is not advisable to operate upon them, or in fact on any umbilical hernia, until it has proved to be absolutely intractable, for it is an operation accompanied by considerable danger to the life of the infant. The lighter grades of umbilical hernia are usually easily reduced, but there is often great trouble in keeping them so. Various devices are employed for this purpose, but most of them are very unsatisfactory. At the Children's Hospital we are in the habit of proceeding in the following manner : Having gently reduced the hernia, the skin of the abdomen is so pushed up between the fingers that it makes a vertical fold, at the bottom of which lies the umbilicus. The hole should be deep enough to lay one's finger in it. The tension is kept up by applying a wide strip of ad- hesive plaster transversely across the abdomen. This makes a pad of flesh, which closes the umbilical opening and retains the intestine in place. The cure is a slow one, and the treatment must be continued for many months in severe cases, without once allowing the hernia to come out. The milder cases are also aided by exercises which tend to develop the abdominal muscles. This can be very simply effected by having the child lie on the floor, and, while the feet are held down, making him rise to a sitting position with the back held straight. This is accomplished by the rectus muscles of the abdomen, and if the opening is a transverse one it tends to close it. Fig. 81 represents an extreme case of umbilical hernia in an infant five months old. The hernia caused an eversion of the whole umbilical region. Fig. 81. ^^^^*4^B 9 ^J • *' ; ', Large umbilical hernia. Infant 5 months old. Cases of incarcerated and even strangulated umbilical hernia have been reported, but are very rare. A few have been operated upon successfully. The danger from all such procedures is usually considered great, but there has been such an advance made in the modern methods of abdominal 304 PEDIATRICS. surgery that the operation is looked upon with increasing favor. Cases of hernia, whether umbilical or inguinal, are especially difficult to manage if the infant has pertussis or some similar disease. Inguinal Hernia. — The most common forms of inguinal hernia that occur in young children are (1) the congenital, (2) the funicular, and (3) the infantile or encysted. An ordinary acquired form such as is the rule in the adult may be met with, but it is not so common. Strangulated and incarcerated hernise occur at times, as in the adult, although they are rare. There seems to be some evidence that the tendency to hernia is hereditary. Felizet reports eighty-five cases of hernia occurring in his practice, in which, omitting all cases in which the father pursued some laborious trade, such as that of a blacksmith, he found that in 24.7 per cent, the parents had had similar hernise. Malgaigne reports a percent- age of 29 due to heredity in a series of three hundred and sixteen cases of hernia. Infants are at times brought to our hospitals with a history of colic who, on examination, are found to have more or less incarceration of these herniae ; which emphasizes the importance of making a systematic physical examination in every case for abdominal hernia, and of not taking it for granted that the symptoms are caused by indigestion. (1) Congenital Form. — The congenital form is that variety in which the knot of intestine has made .its way along a still patent funicular pro- cess. If it reaches into the scrotum it will be found completely to en- velop the testicle. (2) Funicular Form. — In the funicular form, the tunica vaginalis having become shut off from the funicular process just above the testicle, the hernia comes down the patent process, but does not envelop the testicle as in the preceding variety. (3) Infantile Form. — Compared with the two forms just mentioned, the infantile or encysted 1 form of hernia is quite rare, nor can it be diag- nosticated with certainty without an operation. In it the funicular pro- cess has closed above but not below, and the intestine encased in a pouch of peritoneum forces its way into the process and descends. Diagnosis. — The diagnosis between direct and indirect hernia has little importance in childhood, as the inguinal canal is so short that the rings are practically at the same level. The condition which will be most readily confounded with hernia is hydrocele. Both give rise to an elastic tumor in the inguinal region and in the scrotum, and in fact resemble each other in many ways. Hydrocele is translucent by transmitted light ; hernia is opaque. Hydrocele is always dull on percussion ; hernia is usually resonant. If you can reduce them, hydrocele will go back slowly and noiselessly, hernia at the last quickly and with a gurgling sound. Hydrocele gives no impulse on coughing ; hernia usually does. Lastly, in feeling for the inguinal ring in hernia it is found to be filled with the DISEASES OF THE NEW-BORN. 305 neck of the tumor ; in hydrocele it is either empty or filled by a narrow stalk. Treatment. — Most of the hernias that will be met with in children are easily reducible, but Ave should remember that in attempting to get them back into the abdominal cavity we must use the greatest care, as nowhere can a little rough manipulation do more harm. If the hernia cannot be- easily replaced, we should not think of leaving it where it is, simply be- cause it gives rise to no alarming symptoms on the part of the child. No infant is safe with an irreducible hernia, and the sooner such a case is placed in the hands of a surgeon the better. Although the treatment of inguinal hernia, whether by actual operation or by the application of the usual trusses, should be in surgical hands, yet one method of treating these herniae is so simple and safe that every medical man should know about it ; in fact, in our children's clinics in Boston it is much used for all children under a year and a half. This method is the application of a worsted truss made of a skein of yarn which is passed under the back. The separated loop is around the side where the hernia is, and the un- separated end of the skein is brought forward and passed through the loop in the groin and up on to the back where it is fastened. In this way a soft slip-knot is made which lies directly over the inguinal ring and makes an excellent truss. Femoral Hernia. — In femoral hernia the gut escapes from the pelvis under Poupart's ligament, and, making its way through the femoral canal, shows itself as a tumor directly under the saphenous opening. It can be diagnosticated at once from inguinal hernia by putting the finger on the spine of the pubes and noticing whether the origin of the tumor is to the outer or the inner side of that point. If outside, one is sure the hernia came through the femoral canal, no matter how far it may have extended up on to the abdomen. Femoral hernia is, however, extremely rare in young children, even in girls. In infancy the spine of the pubes, Poupart's ligament, and the anterior superior spine of the ilium are all much nearer together than in the adult. As a consequence, the femoral opening is so small and so well protected that it is usually impossible for the hernia to force its way through. Hydrocele. — Several anatomical varieties are met with in hydrocele, as in hernia. Thus, if the collection of fluid occupies a freely open funicular process, we have the congenital variety, and the fluid can easily be returned to the abdominal cavity by placing the child on its back and elevating the scrotum. This is true also of funicular hydrocele, in which the fluid occupies an open funicular process, but is bounded below at the point where the tunica vaginalis has become walled off, leaving the testi- cle in a separate compartment underneath. When the funicular process has become walled off from the abdomen, but is still in communication with the tunica vaginalis, there may be a collection of fluid, which is then known as an infantile hydrocele; in this form the fluid is irreducible. 20 306 PEDIATRICS. True hydrocele of the tunica vaginalis may be met with in children as well as in adults, but it is rare. Encysted Hydrocele of the Cord. — There is another form of hydrocele which often escapes recognition, but perhaps still oftener is diagnosticated as hernia and treated with a truss. This is the encysted hydrocele of the cord. If in the course of the spermatic cord a hard, rounded swelling appears, and the testicle is found in its proper position in the scrotum and the inguinal ring clear, one is very surely dealing with a hydrocele of this kind. Having made the diagnosis, it should be evacuated with a fine aspirating needle. About 4 c.c. (1 drachm) of clear straw-colored fluid is generally drawn off. and the tumor usually disappears. Encysted Hydrocele of the Caned of XucJ:. — Analogous to hydrocele of the cord in boys is an accumulation of fluid in the canal of Nuck in girls. The appearance of the swelling is the same in both cases, and the treatment should be the same. Treatment. — The treatment of all forms of irreducible hydrocele is first by aseptic evacuation of the fluid with a fine canula and trocar, or by an aspirating needle. If this, after repeated trials, fails to effect a cure, extirpation of the sac is the only sure method, although the injec- tion of a weak solution of iodine is highly recommended by many au- thors. It is. however, dangerous in children, as the occasional connection of the hydrocele sac with the abdomen is not to be forgotten. Reducible forms of hydrocele are generally to be treated by a truss, in the same manner as herniae. to try to effect a closure of the neck of the canal. If this is successful they can then be treated in the ordinary way. The outlook, however, is poor, and such treatment is generally unsatisfactory. Undescended Testicle. — The testicle should descend into the scro- tum at about the eighth month of intra-uterine life. In certain cases it does not descend, and if the descent does not take place within the first few years of life its function is lost from atrophy. It is, therefore, im- portant in those cases in which the testicle descends and returns to the abdominal cavity to retain it in the scrotum by means of apparatus. Operation for this condition is not often successful. At times an unde- scended testicle is found in combination with an inguinal hernia. The following case of this kind came under my care about two years ago : A boy. four years old. was discovered to have an inguinal hernia. The testicle was also found at times to be absent on the side of the hernia. Sometimes the her- nia would descend and the testicle remain in the abdominal cavity, and again the testi- cle would come down with the hernia. It was exceedingly difficult to maintain the testicle in the scrotum, even when it was found to be there, as it would slip back with the greatest facility. Dr. Lovett finally succeeded in seeing the boy at a time when both the testicle and the hernia were down, and in reducing the hernia while the testi- cle was kept in the scrotum. A carefully adapted truss was then applied so as to pre- vent the testicle from returning to the abdominal cavity and the hernia from entering the scrotum. DISEASES OF THE NEW-BORN. 307 Tumors of the Testis. — We may at birth find an enlargement of the testis due to sarcoma, teratoma, or carcinoma. The former is much the more common. Malformations about the Rectum. — At an early stage of develop- ment of the embryo the intestinal canal ends blindly, and afterwards by an invagination of the outside wall a communication is brought about and the stomoda?um formed. An analogous process of development goes on at the other end of the intestinal tube, and results in the formation of the rectum and anus. The hind-gut at first ends blindly, then as it descends it is met by an ascending dimple, and usually these two fuse and the protodceum is formed. As in the mouth a series of malformations may arise from a failure in the completion of this process, so in the anal region we may meet with a similar series. The rectum may have come into its normal relations and the anal depression have failed to form, or it may have gone the whole of the distance between the end of the intestine and the skin and yet the final step, the fusion of the membranes, have failed to take place. To both of these, and to any intermediate condition, the name of imperforate rectum is given. On the other hand, with the rectum and the anus fused we may, nevertheless, find a thin parchment-like membrane spread over the exter- nal orifice just where the skin and the mucous membrane join. This is called imperforate anus. Treatment. — When an infant is born the physician should carefully examine it, in order to determine whether it has any malformation. The most important malformations which it is necessary to recognize are those at the anus. Unless an infant has a passage of meconium soon after its birth, an examination should be made in the rectum with the finger, and if the anal opening is found to be closed, either just at the outlet or higher up, we must consider what is to be done to relieve this condition. If nothing but a web obstructs the anus, we can easily break it through with a director and then dilate the orifice with the finger. If there is more than the thinnest bulging membrane, a cutting operation will have to be done, and perhaps a severe one, so that the case should at once be placed in the hands of a surgeon. Occlusion of the Vagina. — Sometimes we find a thin gray velum ex- tending across the mouth of the vagina from just below the urethral open- ing to the posterior commissure and blocking up the vagina. It may be complete or partial. Treatment. — This condition should be dealt with while the infant is still young, as, if left until puberty, it will cause a retention of the menses, and, moreover, by that time will have become much thicker and perhaps quite vascular. It is easily broken through in the young child, and if a piece of carbolized cotton be put between the torn edges to prevent them from adhering, the malformation can be cured permanently. Atresia from inflammation of the labia is said to occur in rare instances. 308 PEDIATRICS. Hypospadias. — The malformation known as hypospadias is the result of an arrest of development in the formation of the urethra and of the corpus spongiosum. The urethral groove should normally be converted into a canal by the growth and joining together of its sides. This process begins at the base and extends to the end of the penis. By an interrup- tion of this process the urethra may be brought to an end and open at any point between the peno-scrotal angle and the base of the glans. In the most common forms of hypospadias the glans alone is imperforate. Treatment. — The treatment is wholly by plastic operation, and it re- quires the most delicate surgery to obtain a good result in the face of the many serious obstacles that this malformation presents. - Epispadias. — The malformation of epispadias, in which the urethral canal opens upon the dorsum of the penis, is still more difficult to deal with than is hypospadias. It is commonly associated with extroversion of the bladder, and is very rare. Treatment. — A partial plastic operation and the wearing of some form of urinal constitute about all that can be done for these cases. Congenital Obliteration of the Bile-Ducts. — One of the rarer forms of congenital malformations in new-born infants is represented by the ob- literation of the bile-ducts. The most extended work which has appeared in the literature of this subject is that of Dr. John Thompson, of Edin- burgh. Pathology. — There are a number of different morbid processes which have been supposed to produce this pathological lesion of the ducts. Each of these processes has in certain cases, in all probability, had much to do with causing the disease, but it is usually the combination of one or more of them which must be considered in determining its etiology. Thus, the results of intra-uterine peritonitis, by compressing the ducts, or by being a source of inflammation which has spread to the walls of the ducts, may finally cause their obliteration. A primary inflammation or lesion of the ducts themselves may produce this result, or it may arise from an actual arrest or defect of development. In this connection congenital syphilis should be referred to as in some cases producing lesions of the ducts, but this and other causes do not necessarily play an important part in the dis- ease. The complete discussion of the causes of congenital malformation of the bile-ducts would hardly have a place in a general work on clinical mec[icine, but it is sufficient to say that in the great majority of cases the evidence is in favor of defective development as being the chief cause. This malformation probably affects to a considerable extent the walls of the ducts, and, as Thompson has stated, it consists in the narrowing of their lumen. The interference which is thus caused to the outflow of bile gives rise to a catarrhal condition which finally blocks and obliterates the ducts, owing to the inflammatory process spreading to the walls of the ducts and the gall-bladder. This progressive inflammation goes on slowly DISEASES OF THE NEW-BORN. 309 spreading, the local condition gradually becoming worse during many months if the patients live. The obliterated ducts or gall-bladder, or portions of them, may entirely disappear, not even leaving a distinct band of fibrous tissue to indicate their original position. The obliteration gen- erally becomes complete at a variable but early period of intra-uterine life : occasionally it does not occur until after birth. The occurrence of peritonitis is probably in most cases secondary to the blocking of the ducts. When the lumen of the duct has become so narrowed that the bile does not pass freely into the intestine, a cirrhotic condition begins in the tissues of the liver, and as it progresses interferes with the functions of that organ. At the post-mortem examinations of these cases the liver usually is found to be much enlarged and its tissues to be increased in consistency ; it is of a dark-brown color, owing to the presence of numerous masses of inspissated bile in the smaller bile-ducts. In a large number of cases there is found a complete obliteration of some part or parts of the hepatic, common, or cystic ducts, or of the gall-bladder, while, with very few ex- ceptions, implication of the blood-vessels is conspicuously absent. In speaking of the explanation which may be given for the occurrence of the symptoms just mentioned, Thompson remarks that the reappear- ance of the disease in several members of the same family can be ex- plained only by the theory that a congenital defect of development is in these cases the cause of the malformation. The fact that the onset of the jaundice is not contemporaneous with the blocking of the bile-ducts, and usually begins several days after birth, he explains as the effect on the hepatic cells produced by the great changes in the hepatic circulation which occur in new-born infants. The presence of colored meconium in some cases and of only white discharges in others is due to the blocking of the ducts having occurred at different periods of intra-uterine life. When in combination with the colorless faecal discharges green material is passed during the progress of the disease, this occurrence is probably due to the chemical action on the contents of the intestine, pro- duced in various ways, one of which may arise if mercury has been administered. The tendency to spontaneous hemorrhages may be due to the occurrence of a condition of chronic blood-poisoning, since the arrest of the outflow of bile damages the liver to such an extent that its func- tions are interfered with and organic fluids of a poisonous nature may thus pass into the circulation. The enlargement of the spleen, the con- vulsions, and the vomiting are probably more or less connected with the same condition of blood-poisoning. The fact that the children live as long as they do, and usually do not become emaciated in the early days of life, is to be explained on the ground that the presence of bile in the intestine is not absolutely necessary for digestion. When the nutrition and general health begin to suffer, it is probably due to the interference 310 PEDIATRICS. which the secondary changes in the tissues of the liver are causing with the more important functions of that organ. Symptoms. — The infants who are born with this disease are either icteric at first or become so within the first few weeks of life. They often appear otherwise healthy and well nourished. In some cases there is a discharge of normal meconium followed by colorless dejections. In other cases the faecal movements are clay-colored from the very first and remain so. The urine is deeply stained with bile. The jaundice is of a dark-greenish tinge, lasting until death. Spontaneous hemorrhage from the umbilical cord commonly occurs within the first two weeks, and in other localities in those infants who survive this early period. The liver and spleen are increased in size. If the infants survive for some months they become more or less emaciated. Convulsions and vomiting are apt to occur, and death usually takes place from exhaustion or from some trifling intercurrent disease. Treatment. — The treatment must necessarily be symptomatic, there being no known means by which we can counteract the results of this malformation. Congenital Obliteration of the Intestine. — I shall merely refer to a malformation which is represented by an obliteration of the intestine. Malformations of this kind may arise from constrictions of the parts affected by fibrous bands, probably the remains of peritoneal adhesions. Congenital Malformations of the CEsophagus and Stomach. — Congenital malformations of the oesophagus and stomach are rare, and are described, in connection with diseases of these parts, on page 274. Malformations of the Heart and the Blood- Vessels. — The various anomalies of the heart and blood-vessels are described on page 720. DISEASES OF THE EXTREMITIES. Fingers. — Various malformations of the extremities are met with in new-born infants, one of these is six instead of five fingers. Another malformation of this kind, called webbed fingers, is quite common. Surgical interference is indicated in both cases. Toes. — Infants are at times born with extra toes and webbed toes, and it becomes a surgical question to determine whether they shall be operated upon. This, of course, is a question of orthopaedics, and is one which we need not deal with except so far as to appreciate the importance of preparing the foot properly for future use. The greater freedom of move- ment required for the fingers, and the fact that the hand is always in sight, render surgical interference much more necessary in malformations of the hand than in those of the foot. Congenital hypertrophy of the feet and hands, and congenital deficiency of one or more extremities, may be spoken of in this connection, but are too rare to be more than referred to. These malformations have been thoroughly described by Thomas Annandale. DISEASES OF THE NEW-BORN. 311 Club-Hand and Club-Foot. — Club-hand and club-foot are congenital malformations which may be due to an undeveloped condition of either the bones, the ligaments, or the muscles. In the more simple forms the extremity is pulled into the malposition by the action of contracted mus- cles and tendons, while in the severe forms the bony framework may* be so misshapen that the separate segments are almost unrecognizable. Club-hand is often accompanied by absence of the radius. Treatment. — The treatment of this class of deformities is, of course, purely in the province of the orthopaedic surgeon. All that I wish to do in referring to them is to suggest how much may be accomplished by simple manipulations with the hand. The mother should be instructed to rub the foot and leg twice daily, and to make firm pressure against the shortened muscles by trying to bring the hand and foot into the normal position. I have seen slight cases cured by this simple means, and even moderately severe ones so much benefited that subsequent treatment with orthopaedic apparatus became much easier. Congenital Dislocation of the Hip. — Congenital dislocations of all the joints are sometimes found, the most frequent and most important being dislocation of the hip. This is now thought to be caused by a faulty development of the acetabulum and the head of the femur. Symptoms. — The symptoms are of a kind that readily escape notice during infancy, and are first seen when the child should begin to walk. It is then noticed, if he can hold himself on his feet at all, that the abdo- men is very prominent, the back arched, and the buttocks seemingly en- larged : at least this is the case if the deformity is bilateral, which is the form usually met with. On examining the joint we find that the trochan- ter is above Nelaton's line, but it can by traction on the leg be drawn down to its proper place without causing any discomfort to the child. If the deformity is unilateral, one leg will appear shorter than the other, and the child will walk with a rolling limp. This condition should be care- fully looked for when an infant at the age of fourteen or fifteen months has made no especial attempt to walk, or when on attempting to do so it does not succeed. Treatment. — As operative treatment has not proved very successful in these cases and is not to be employed until the child is over three years old, the best method of treatment is by massage. If the disease is unilat- eral it should in addition to the massage be treated with a high shoe. Congenital Dislocation of the Knee. — Next in order of frequency to congenital dislocation of the hip, but rare in comparison, is a dislocation, or rather a partial dislocation, of the knee. In this condition the tibia is found riding forward upon the condyles of the femur, so that the knee- joint can readily be put into hyperextension and the toes made to point towards the forehead. Birth Paralysis. — Birth paralysis will be considered in connection with diseases of the nervous system. It may be present either in the 312 PEDIATRICS. muscles of the face or in those of the extremities, and is due to pressure upon the nerves made by the forceps or by too great traction. GENERAL. DISEASES. Asphyxia. — The earliest pathological condition which is brought to our notice at birth, and one which requires immediate treatment, is as- phyxia. This condition, which is a failure of the circulatory mechanism to assume its extra-uterine function of oxygenating the blood, endangers the life of the infant from carbonic acid poisoning. It may arise either from mechanical pressure, as from winding of the cord around the neck, from an incomplete expansion of the pulmonary alveoli, atelectasis, or from other causes connected with the imperfect oxygenation of the blood, of which we have very little knowledge. In any case the cause, if known, must be quickly removed. This class of cases belongs so directly to the province of obstetrics that it need hardly be more than mentioned. Prompt measures for performing artificial respiration, as by Crede's method, and the stimulation of the pneumogastric nerve by the application of heat, cold, and electricity, should be borne in mind : they are well described in Dr. Edward Reynolds's work on practical midwifery. Acute Patty Degeneration of the New-Born (Buhl's disease). — An affection which has been called acute fatty degeneration of the new-born was described by Buhl in 1861. It is not a disease of common occur- rence, and its etiology and pathology have not yet been satisfactorily de- termined. Runge, of Dorpat, has written more fully on this disease than any other author, and I am indebted to him for the careful description which he has made of the affection and the literature which he has col- lected concerning it. As the anatomical diagnosis can be made only by using the microscope, the disease has probably often been overlooked, and the cause of death ascribed on the one hand to inanition and on the other to such especial forms of hemorrhage in the new-born as omphalorrhagia and melaena. If the numerous causes of hemorrhage from the cord had been more care- fully examined anatomically, the disease would probably not have re- mained so long unknown. Etiology. — The etiology of acute fatty degeneration of the new-born is very obscure. The disease occurs in animals as well as in human beings, but the investigations made by different observers both on animals and on infants are so varied in their results that we cannot at present consider that we know much about the cause of the disease. It is significant, however, that Buhl in his classic description of the disease states emphati- cally that the vessels of the cord are not affected, so that if it is due to sepsis the sepsis must have occurred in intra-uterine life through the mouth, the intestinal canal, or the umbilicus, but without producing any change in the umbilical vessels. This can scarcely be considered proba- DISEASES OF THE NEW-BORN. 313 ble. We know nothing concerning the etiology of this disease, not even whether it is of intra- or extra-uterine origin. Pathology. — The pathological conditions which represent the disease consist of a parenchymatous inflammation, followed by a fatty degenera- tion of the tissues of the heart, liver, and kidneys, and hemorrhages in the various organs. The post-mortem examination of infants dying of this disease, as a rule, shows the following changes. The cadaver is livid and usually icteric. Hemorrhages and oedema are often found in the skin. The umbilicus and the tissues surrounding it are at times stained with blood, but, as a rule, are otherwise normal. The umbilical vessels are in most cases normal. These hemorrhages are especially found in the dura and pia mater, in the pleura and pericardium, and in the con- nective tissue of the mediastinum : they also occur in the thymus gland, in the peritoneum, in the muscles, and in most of the mucous membranes. The brain is found to be soft, usually full of blood, and, if icterus is present, is stained yellow. The lungs often show hemorrhagic infarction, and in the bronchi bloody mucus or pure blood. The alveolar epithelium is in a condition of fatty degeneration. The muscles of the heart are friable. In the early stages they are rigid and dark red, while in the later stages they become softer and paler. In almost all of them the pro- cess of fatty degeneration is found. In recent cases the tissues of the liver are blood-red, while in the later stages they are pale and icteric. The liver-cells contain fat-drops and granules of biliary coloring matter. The spleen is usually found to be enlarged, and its parenchyma is soft and almost fluid. Hemorrhages may be found in the walls of the stomach and intestine, and their cavities are often found to be filled with blood. Multiple hemorrhages are found in the parenchyma of the kidney. The cortex is swollen in the early stages, is filled with blood, and is pale and yellowish. The epithelium of the convoluted tubules shows marked fatty degeneration, and the canals are often filled with fatty degenerated mate- rial. The process of fatty degeneration does not in all cases affect all the organs. In some the changes may be absent or a parenchymatous con- dition may be present Symptoms. — The infants who are affected by this disease are usually born in a condition of extreme asphyxia without any apparent cause for it. Attempts at resuscitation are, as a rule, only partially successful, and at times not at all so, many of the cases dying at once. Diarrhoea is commonly present, and is often accompanied by blood from the rectum. There is sometimes vomiting of blood. Often, after the cord has separated, there may be a parenchymatous hemorrhage, which, although small in amount, is at times sufficient to cause death. There is usually a bluish color of the skin, which changes gradually to yellow or a mixture of yel- low and blue. Hemorrhages occur frequently in the skin, the conjunctivae, the mucous membranes of the mouth and nose, and sometimes the outer ear. Icterus may be present in these cases, and at times may become 314 PEDIATRICS. intense. Sometimes oedema occurs, and without any noticeable rise of temperature there may be a rapid collapse, followed by death, commonly within the first fourteen days of lite. These symptoms are not always so well marked as I have just described them. The external hemorrhages may not occur, and the cyanosis, slight at first, may rapidly increase and be followed by sudden death. This sometimes happens so quickly that we are reminded of the conditions which are met with in cases of death by violence. Diagnosis. — A definite diagnosis cannot be made without a careful microscopic examination. This disease must not be confounded with phos- phorus or arsenic poisoning, in which the organs undergo similar path- ological changes. The history of the case and a chemical examination of the organs will enable you to eliminate these other causes of fatty de- generation. The differential diagnosis between this disease and cases of sepsis in which hemorrhages and parenchymatous changes occur is very difficult When the vessels of the cord are affected, we must in most cases consider the cause to be septic : when the cases occur in groups, as is seen at times in hospitals or other places where a number of infants are gathered together, this same cause must be suspected : also when putrefactive changes have progressed rapidly in the cadaver we should be inclined to regard the case as one of septic poisoning, as these changes. according to Hecker, do not occur in the specific disease called fatty degeneration. Fatty degeneration at times simulates so closely the appearances caused by death from suffocation that its presence becomes a question of great importance from a medico-legal stand-point. The cyanosis, the condition of the lungs, and the eechymoses, also the absence macroscopi- cally of other organic changes, can easily suggest suffocation. For this reason in all cases of death among new-born children where there is a suspicion of asphyxia, a careful microscopic examination should be made of ah the organs. Prognosis. — The prognosis in this disease is very unfavorable ; all the cases in which the symptoms are pronounced die. It is possible that the milder forms of the disease can recover, but as yet we do not know enough about this class of cases to state what proportion of them liVeS. Treatment. — From what has been said concerning this disease it will be readily understood that the treatment is usually unsuccessful. Stimu- lants should be used and the food carefully regulated. Infectious Hgemog-lobinsemia of the New-born | infectious hcemo- globinuria; WinheCs disease). — Infectious haemoglobinaemia is an affec- tion which is met with in new-born infants usually in the early days of life. and. as a rule, arises as an endemic disease in hospitals. A specific micro-organism has not yet been discovered, yet the endemic character of the malady and the changes which are produced in the DISEASES OF THE NEW-BORN. 315 blood warrant us in supposing that it is an infections disease. Al- though it had been described at an earlier date, yet the most systematic description of it which had appeared up to the year 1879 was that by Winckel, who in that year reported twenty-three cases of an endemic affection observed by him at the Dresden Lying-in Hospital. The disease was characterized by extreme cyanosis, icterus, haemoglobinuria, somno- lence, rapid collapse, and the absence of fever. Although in many re- spects it resembled closely the acute fatty degeneration described on page 312. yet it had such characteristic symptoms and conditions of its own that for the present it should be kept separate from that disease. I am in- debted to Runge for a description of this disease. An analysis of Winckel's cases shows that it usually begins on the fourth day of life, and that it may attack strong, well-developed infants. The course of the affection is very rapid, its average duration being about thirty-two hours. Twenty- five and a half per cent, of all the children born at the time when this epidemic occurred had the disease, and of these nineteen per cent. died. Etiology. — The etiology of this disease is obscure. Winckel had the organs carefully examined chemically for poisons, such as phosphorus, arsenic, and chlorate of potash, but with negative results. Examinations in regard to carbolic acid poisoning have also been made in these cases, with negative results. The resemblance of this disease to acute fatty degeneration of the new-born is very striking. Most of the symptoms are common to both diseases. Larger hemorrhages are also not uncommon in this disease, but are not so marked as in acute fatty degeneration. The striking points of difference are the presence of haemoglobinuria and the fact that large numbers are affected at the same time in infectious haemoglobingemia, while these conditions have not been found to occur in acute fatty de- generation. In studying the literature of this disease we find a number of observations by different authors. Dr. W. S. Bigelow describes an epidemic at the Boston Lying-in Hospital in which the chief symptoms were a dark color of the skin resembling somewhat that produced by the administration of nitrate of silver, hsemoglobinuria, diphtheritic deposits on certain of the mucous membranes, and dark brown faecal dejections. In this epidemic ten infants were attacked and eight died, the average du- ration of the disease being five days. In one of these cases phlebitis umbilicalis occurred. Similar cases have been reported by Parrot and Herz, in which the urine was brown and strongly tinged with blood, and the kidneys and liver showed the condition of fatty degeneration. Epstein, of Prague, mentions similar cases in which prominent features were the thickening of the blood, which made it impossible to get a drop to examine, and the dark brown-red color of the urine. Epstein thinks that this disease is a septic process which probably starts in the gastro- enteric tract. He believes that he can controvert the apparent absence of fever by the fact that in the diseases of new-born infants great and 316 PEDIATRICS. sudden variations of temperature occur, and in consequence the tem- perature, for its record to be of value, should be taken very often. Whether this is so or not, the disease has certain peculiarities, pointing in some cases to an apparent relation with sepsis, and in others to acute fatty degeneration. The obscurity as to the etiology of the disease has been rendered still greater by the incomplete examinations which have been made of this class of cases, with the exception of those by Winckel and Birch-Hirschfeld. Pathology. — A careful post-mortem examination of Winckel's cases showed that there was cyanosis of the external and internal organs. Except in one instance, no pathological condition of the vessels of the cord was described. The cortex of the kidney was found to be wider than normal, to be of a brownish color, and to present numerous minute hemorrhages. In some places the pyramids were entirely black-red in color, and in other places numerous black streaks were found which con- verged to the papillae. This color was caused by the filling of the straight tubules with granules of haemoglobin. Intact erythrocytes were never found. The bladder was found to contain greenish-brown urine. The spleen was strikingly enlarged and hard. Its length was about 7.5 cm. (3 inches), and its weight 25 grammes (f ounce). It was black-red in color, and on section the surface was smooth. Microscopic examination showed a considerable accumulation of brownish coloring matter, partly free and partly in the pulp-cells. In addition to these appearances in special organs, minute hemor- rhages were found in nearly all the organs, but especially in the pleura, pericardium, endocardium, mucous membranes of the stomach and small intestine, and kidney : they were also found in the dura and pia mater and under the capsule of the liver. The lymph-follicles were swollen, especially Peyer's patches and the mesenteric lymph-glands. A micro- scopic examination showed fatty degeneration of many important organs, especially the liver, and at times of the muscles of the heart. The bac- teriological examinations were, as a rule, negative, especially as regards the tissues of the intestine. Clumps of bacteria were found only once in the liver and once in the kidney. Symptoms. — The first symptoms were generally restlessness and cyano- sis, not only of the face but also of the body and extremities, and especi- ally of the back. The color increased progressively until it became a deep blue. To this was added an icteric color, which when death did not occur within twenty-four hours became very marked. The respiration was rapid ; the pulse was not especially increased in rate. The rectal temperature never rose higher than 38.1° C. (100.6° F.). The skin generally felt cool. Vomiting and diarrhoea occurred in some cases. The most striking symptom was the appearance of the urine. It had a pale- brownish color, and was passed frequently, and often with considerable straining. An examination showed that the color was due not to bile, DISEASES OF THE NEW-BORN. 317 but to haemoglobin. In the sediment were found numerous epithelial cells from the walls of the kidney, granular casts with blood-corpuscles adherent to them, micrococci, masses of detritus, and urate of ammonia. A small quantity of albumin was present. Later in the disease con- vulsions occurred, followed rapidly by death. It was noticed that if the skin, where the cyanosis was most marked, was scratched and then pressed hard, a tenacious, almost black-brown fluid exuded. An examination of the blood showed a marked increase of leucocytes and numerous gran- ules. In other cases besides those of WinckeFs in which the blood was ex- amined the condition was found to be one of haemoglobinaemia. The per- centage of haemoglobin was high, and free haemoglobin was found in the blood-serum, while the erythrocytes were greatly reduced in number, at times amounting to only 1,700,000 or even less. Treatment. — The treatment should be the administration of oxygen and stimulants, and forced feeding by means of a dropper where the infant is too weak to suck. Hemorrhage in Early Life. — Spontaneous hemorrhage occurring at some period during the early years of life is not uncommon. These hemorrhages may occur either in the skin or from some trifling traumatic lesion, or they may take place in various internal organs, and especially from the mucous membrane of the mouth and the gastro-enteric tract. A definite division of this class of cases has never been thoroughly made, so that the subject has always been somewhat involved in obscurity. The probability is that these spontaneous hemorrhages are simply symptomatic of different specific diseases, and that as our knowledge of these diseases increases we shall find it necessary to make a clear distinction between cases which now are spoken of under one head. The propriety of sepa- rating cases of spontaneous hemorrhage which occur in the early days and weeks of life from those which arise later has been shown by Town- send. He has by a series of observations corroborated the now generally accepted opinion that the hemorrhages which occur in the new-born should be separated from those met with in connection with the haemophilia of a later period of childhood and of adults. He has called this disease the hemorrhagic disease of the new-born. The hemorrhages which occur in new-born infants are so general in their distribution, and yet so uniform in their general symptoms, that they can well be classed under this one heading. These hemorrhages occurring in the early weeks of life run a definite course, and end in death or in complete recovery. The self- limited nature of this affection corresponds to what is seen in the acute infectious diseases, and suggests a relationship to them. The hemorrhage may arise from the gastro-enteric tract, from the mouth, the nose, or the umbilicus, also from the skin, and in the latter case may show itself in the form of ecchymoses. Again, it may occur in the form of hemorrhages in the abdominal cavity, the meninges of the brain, the pleura, the lung. 318 PEDIATRICS. and the thymus gland. Townsend has collected fifty cases of this disease, and has tabulated the sources of the hemorrhage, as follows : Locality. Cases. Intestines 20 Stomach 14 Mouth 14 Nose 12 Umbilicus 18 Ecehymosis in skin 21 Scratch of skin 1 Cephalhematoma 3 Meninges 4 Abdominal cavity 2 Pleural cavity 1 Lung 1 Thymus gland 1 From the gastro-enteric tract, nose, and umbilicus, accompanied by ecehy- mosis in the skin 3 From the gastro-enteric tract alone 19 From the umbilicus alone 3 From ecehymosis in the skin alone 6 The mortality in these cases was 62 per cent. The bleeding first showed itself in all but three within the first seven days of life, the ex- ceptions being on the eighth, ninth, and fourteenth days. The hemor- rhage in the majority of these cases began on the second or third day, thirteen starting on the second and sixteen on the third day. while only eight began on the fourth and two on the first day. One-half of the fatal cases lasted one day or less, and all the others died within a week, except one case, in which death took place from the effects of the hemor- rhage on the eighth day and several days after the bleeding had ceased. The cases that lived recovered within nine days, and two-thirds of them within five days. The cases of pseudo-menstruation which occur not uncommonly in the early days of life should not be included in the cases which are classed under the heading of hemorrhagic disease. The hemorrhagic disease is apparently infectious and is a general and not a local one. and is found more frequently in hospitals than in private practice. This fact is well exemplified by comparing the percentage of hemorrhagic cases which occurred among 7225 infants observed in the Boston Lying-in Hos- pital and its out-patient department. The percentage of the disease in the hospital itself was represented by 0.57, Avhile 0.10 represented the pro- portion outside of the hospital. In Townsend's fifty cases the proportion of females to males was as 20 to 30. In four of Townsend's cases the hemorrhage took place in several other places as well as at the base of the cord, bat the patients recovered and the cord separated, in one case in two days and in the other three in four days after the cessation of the disease, without a fresh hemorrhage occurring. In fourteen of these fifty cases the temperature was carefully observed, DISEASES OF THE NEW-BORN. 319 and in all but two was found to be elevated at first from 38.3° C. <101° F.) to 39.5° C. (103.1° F.), and in one case to 41.1° C. (106° F.). After the cessation of the hemorrhages the temperature was normal, and often subnormal. To recapitulate: it would seem that we are warranted in considering the disease as one of a general nature, and infectious, for the following reasons. (1) It occurs usually in hospitals. (2) It is self-limited in its course, and. although a dangerous disease, may be completely recovered from in one or two weeks and never return. (3) The temperature is raised during the continuation of the chief symptoms, and becomes normal or subnormal when the hemorrhage has ceased. Ritter at the Prague Foundling Hospital has also noticed a great pre- ponderance of cases occurring in hospital deliveries over those which were met with outside of the hospitals. In connection with the hemorrhage which occurs in the gastro-enteric tract, the tar-color of the intestinal dejections, arising from the hemor- rhage taking place high up in the intestine, is noticeable. The resem- blance of the color of the dejections to that of meconium may cause the disease to be overlooked. A slightly pink tinge on the napkin around the dejection is often, however, seen, and where there is a doubt as to whether the stain is from blood or not, it can usually be determined by means of the microscope. When the corpuscles have become disinte- grated, as at times occurs, the hsemin crystals may be recognized by means of a simple test which I shall speak of later. The post-mortem examina- tion which was made in nine of these cases throws no additional light upon the nature of the affection. The source of the hemorrhage was found, but in no case were there any gross lesions of the mucous mem- brane or the blood-vessels. In all these cases the infants looked very anaemic. In one case cultures were made by Professor Councilman from the blood, with negative results. We do not know what the cause of this disease is, but it is probable that in the great majority of cases it has an infectious origin. The following case is especially interesting, as it shows an unusual result of the blood examination. The infant was three days old, and presented a blanched appearance of the skin, with stains on the napkin around the intestinal discharges. These stains were ex- amined in the following way. A drop of the semi-liquid dejection was mixed with a little glacial acetic acid and a few crystals of common salt on a glass slide and heated to boiling. On drying the preparation and examining it under the microscope, the dark rhombic crystals of haemin were easily recognized, showing us that we were dealing with a case of hemorrhage taking place probably high up in the intestine. An examination of the blood by Dr. Wentworth gave the following results : Erythrocytes 6,245,000 Haemoglobin 125 per cent. The blood spread very thickly and stained poorly, but the polynuclear leucocytes appeared greatly in excess of the other forms. 320 PEDIATRICS. The cases which are commonly designated as melcena neonatorum should be classed under this heading of the hemorrhagic disease of the new-born. An interesting case of this disease was seen by me in consultation with Dr. Bush. A male infant apparently healthy at birth developed on the third day of its life ecchymoses on its head, groins, and one foot. There was also hemorrhage from the upper part of the intestine on the fifth and sixth day, the dejections being tar-colored from altered blood which simulated meconium. On the fifth day the child developed a marked paralysis of the left side of the face, and to a less degree of the left arm and leg, presumably from a meningeal hemorrhage. On the seventh day of the disease the hemorrhage had apparently ceased, as the paralysis was beginning to disappear. On the twelfth day the paralysis of the left arm and leg had improved : there was, how- ever, still some paralysis on the left side of the face, but this did not continue to any great extent, and in the third and fourth weeks decided improvement took place in the child's condition, and there were no longer any evidences of hemorrhage nor any paral- ysis. The infant improved rapidly during its first year, and became healthy and strong. It learned to walk and talk rather later than usual, but at four years of age was in a normal condition both mentally and physically. I have met with a number of cases in which these hemorrhages oc- curred which varied greatly as to extent and persistence. The cases in which umbilical hemorrhage was present showed this same tendency to self-limitation, and could be distinguished from those which are classed under haemophilia. In fact, it is probable that most cases of umbilical hemorrhage are caused by infection and are not especially connected with haemophilia. The following case of umbilical hemorrhage in a male illustrates what has been said concerning the desirability of separating the hemorrhages taking place in the early days and weeks of infancy from those which occur later and in childhood. The parents of the infant were well and strong, and were Russian Poles. They had another child, eighteen months old, which was healthy. The mother had never had any miscarriages, and stated that her parents were healthy, as were also those of the father. The labor was a normal one, the child presenting in the first position, and nothing abnormal was noticed, except that the placental end of the cord continued to bleed quite freely notwithstanding the application of two ligatures. On the day follow- ing the delivery the mother and infant were both doing well ; the latter showed slight signs of icterus, but nursed well, and the former had plenty of good breast-milk. The infant continued to thrive, except that there was a slight hemorrhage around the inser- tion of the cord, which fell off on the eighth day. After the separation of the cord a slight hemorrhage from the umbilicus continued. On the thirteenth day the hemor- rhage increased, and became very extensive. The infant was then found to be de- cidedly jaundiced, though not deeply so. It was nursing well, but looked thin and puny. Nothing abnormal was discovered in the physical examination. Pale watery-looking blood was oozing from the umbilicus, and quite a large cloth had been soaked with the blood, giving evidence of a considerable hemorrhage. The umbilicus was plugged with small pieces of lint soaked in perchloride of iron, firmly compressed by a bandage, DISEASES OF THE NEW-BORN. 321 and alternate drop doses of fluid extract of ergot and tincture of chloride of iron were ordered to be given three times a day. On the fifteenth day the hemorrhage had somewhat abated, but it was not thought advisable to remove the bandage ; the ergot was omitted, on account of nausea and vomiting. On the sixteenth day the infant was reported to have vomited and cried a great deal, and the plugs of lint had been forced out of the umbilicus, leaving a bleed- ing surface : the umbilicus was then tamponed with Monsel's solution of subsulphate of iron ; the tincture of chloride of iron was omitted, as it caused vomiting. The hemorrhage then lessened and at times ceased. On the seventeenth day the older child pricked the infant's lip with a pin, and on the eighteenth day the lip was found to be still bleeding. The point of hemorrhage was cauterized with a stick of nitrate of silver. This controlled the flow of blood for about two hours, when it returned and continued. Compression of the lip finally stopped the bleeding on the twenty- fourth day. On the nineteenth day the hemorrhage had ceased at the umbilicus, and the child continued to nurse well. On the twenty-ninth day the bandage and lint were removed from the umbilicus, and the abdomen was washed. There was no bleed- ing ; the child looked better, and there was not so much icterus. On the thirtieth day the infant was reported to be perfectly well. It continued to thrive from this time, with no recurrence of the hemorrhage. On the sixtieth day, although I advised that the operation should not be performed, the infant, in accordance with the Jewish cus- tom, was circumcised. I was present at the circumcision, to see if the hemorrhage would be easily arrested. The circumcision was performed without accident, and the hemorrhage was immediately arrested by a weak solution of iron. From this time there was no hemorrhage, and the child continued to be strong and well. This case is an instance of the self-limitation of the hemorrhagic disease of the new- born, since, although it was a pronounced case of umbilical and general hemorrhage at the beginning of the infant's life, this tendency had ceased by the end of the second month, as was evidenced by the ready control of the hemorrhage after the circumcision. In another case which came under my notice the hemorrhage took place from the umbilicus in the early days of life at the time of the separation of the cord, and was completely uncontrolled even by ligatures passed around needles introduced through the skin of the abdomen on either side of the umbilicus. This case eventually recovered. In none of these cases has a tendency to bleeding developed in later life. At times we meet with what are apparently very mild cases of this disease. The following case was seen in consultation with Dr. George Haven. The infant, a girl, well developed, and weighing 3358 grammes (about 7 pounds 6 ounces), was born at 12.45 a.m. Nothing abnormal was found on examining it, and it was perfectly quiet until fourteen hours after its birth, when it began to be very rest- less. This restlessness continued, and the temperature, which at birth was 38.6° C. (101.5° F.) in the rectum, began to rise, until at the end of twenty-four hours it had reached 39.4° C. (103° F.). When it was thirty-six hours old, minute hemorrhagic maculae were noticed, first on the back of its right hand and arm and then on the right side of its back. A few hours later a number of these maculae also appeared on the right side of the chest, near the arm. It nursed vigorously, and did not show any signs of weakness, but its respirations were at times quite irregular. From this time no new lesions of the skin appeared, and no hemorrhages from any other locality, the maculae gradually fading away in ten days. After the first day the temperature fell gradually, and on the fifth day was again normal. Whether there was any loss of weight during the first ten days of life was not known, as it was considered unwise in the infant's precarious condition to weigh it. 21 322 PEDIATRICS. The cord separated on the tenth day without hemorrhage, and subsequently no abnormal symptoms arose, and the infant continued to thrive during the whole period of its lactation. Sclerema Neonatorum.- — Sclerema neonatorum is a disease which occurs in the early days of life, and usually among those who are born in the midst of exceedingly poor hygienic surroundings and in cold weather. It is characterized by a hardening of the skin and the subcu- taneous cellular tissue and by a great reduction in the temperature. The tissues continue to grow cooler and harder until death, which occurs usually about the ninth day. It is a rare and exceedingly, fatal disease. It should not be looked upon as a local disease of the skin, but as some obscure constitutional affection of the respiratory and circulatory systems, as shown by the shallow respirations and the diminished activity of the circulation. A number of cases of this disease have been reported in Europe, and several in this country, notably by Osier. Some investigators think that they have found characteristic changes in the skin. The observations of Northrup, however, who published the first report of a typical case of this kind in America, seem to show that there is no definite lesion of the skin. Northrup made a careful study of his case, and has plainly shown by sections of the skin compared with normal control specimens that the histology of the disease does not reveal any change which can be regarded as characteristic. This case embodied every feature of the typical scle- rema of the new-born. The infant was a foundling, born in a wretched, damp habitation, and was the weaker of twins. On the fifth day of its life the feet were found to be swollen, and soon began to give on palpa- tion a feeling of hardness like that of a board. This condition soon spread upward to the legs, thighs, hips, shoulders, arms, face, and scalp. The whole body felt as though it were half frozen. The temperature in the rectum was under 35° C. (95° F.). The infant died on the ninth day. Symptoms. — Soon after birth, spots of circumscribed hardness appear on the skin. These spots soon become diffuse, and the disease, starting, as it usually does, in the feet or the calves of the legs, passes up the thighs to the trunk. It may, however, first appear upon the face and upper extremities, though not commonly. The skin is waxy and glisten- ing, and is hard and cold ; the limbs become thick, stiff, and misshapen. The infant soon grows weak and somnolent, and refuses to take its food ; the breathing becomes rapid and superficial, the voice is weak and whimpering, and the pulse small and retarded. Towards the end of life a discharge of bloody serum from the mouth and nose often occurs, and death takes place seemingly from inanition. Treatment. — There is no treatment which has been especially success- ful in this disease, but the affection should be recognized at once, and DISEASES OF THE NEW-BORN. 323 energetically treated with inunctions of hot oil and by massage and stimu- lants. CEdema Neonatorum. — (Edema neonatorum is a rare disease, which some authorities describe as distinct from sclerema neonatorum, the chief difference being that the skin pits on pressure and is not so hard as in the latter disease. The general symptoms of the two diseases resemble one another very closely. Icterus Neonatorum. — Icterus occurs from a number of causes in the new-born infant as symptomatic of disease. There is one form, how- ever, which is of so slight a grade and is characterized by so entire an absence of pathological symptoms that it is usually looked upon as repre- senting a physiological condition occurring in the transition from the intra- uterine to the extra-uterine ciculatory mechanism. It is to this condition that the name icterus neonatorum is given. It occurs in the first few days of life, and may not entirely disappear for several weeks. The most common time for it to begin is from the second to the third day, and, ac- cording to its intensity, the usual time of its continuation is from eight to fourteen days. It is not accompanied by any special symptoms. The conjunctivae are somewhat tinged with yellow in a certain number of cases, but it does not seem to affect the color of the faecal discharges or to appear in any quantity in the urine. Careful examinations of the blood in cases of icterus neonatorum fail to show any changes beyond what would be expected in the early transi- tional stage of blood development commonly found at this age. Plate II., facing page 80, represents a healthy male, ten days old, with the charac- teristic pigmentation of this disease. Its weight at birth was 3400 grammes (7 J pounds). At ten days it weighed 3200 grammes (7 pounds). It was perfectly healthy at birth, and its skin was of the usual pink color which is seen in healthy new-born infants. On the fourth day of its life the skin began to show a yellow color, which soon became intensified, representing very well the picture of a physiological icterus neonatorum. The yellowish-brown color of the abdomen, and the slightly icteric color of the conjunctivae are to be noticed especially. The urine in this case was apparently normal, and the faecal discharges were tinged with the dark color of the meconium. In a week this yellow color will usually almost entirely disappear, and the skin will assume the natural pink color of a healthy infant in the first month of life. Later it will become whiter and more like the skin of the older child. As to the cause of icterus neonatorum, the investigations of Birch- Hirschfeld seem to be the most thorough and to offer the most rational explanation. This author says that it is difficult to avoid associating the icterus in some way with a disturbance of the hepatic circulation, owing to the transfer of its chief blood-supply from the umbilical vein. This is especially to be seen when we consider the very evident congestion and oedema of the liver which occur in cases in which the circulation through 324 PEDIATRICS. the umbilical cord is interrupted before the respiratory movements, by their effect on the right side of the heart, afford an adequate compensation. This explanation of the cause of icterus neonatorum must not, how- ever, be regarded as conclusive ; for Cohnheim has in a number of autop- sies made on this class of cases failed to substantiate the conditions de- scribed by Birch-Hirschfeld. Treatment. — The ordinary bathing of the infant's skin is all that is necessary in these cases of icterus neonatorum, and I have never seen any indication for especial treatment of this condition beyond great care in establishing the equilibrium between the food and the digestion. Erythema Neonatorum. — At birth the skin is exceedingly sensitive to external influences, and in every case shows variations in color according to the degree of this sensitiveness, and to the greater or less amount of irritation, whether from temperature or from mechanical causes, to which it is exposed. The delicate layers of epithelium are commonly thrown off to such a degree as almost to represent a physiological desquamation, and it is often several weeks before the normal infantile condition of the skin is reached. In quite a number of cases this natural condition becomes intensified, and we find a uniform redness of the whole skin, which usually appears in the first two or three days of life. In a considerable number this hyper- semic condition of the skin gradually fades away in about a week, and is replaced by a normal pink color. In many other cases, however, the red color may be complicated by an icteric condition, or it may change with many intermediate shades of red and yellow into a pronounced icterus neonatorum. Plate II., facing page 80, represents a typical case of an uncomplicated erythema neonatorum. The infant, a female, weighed at birth 3000 grammes (6f pounds). It began to turn red when it was twenty hours old, and four hours later was of a dull but pro- nounced red color all over its face, head, thorax, and extremities. Its temperature and respirations were normal, and it seemed perfectly well. Symptoms. — There are usually no constitutional symptoms in these cases. When the hyperaemia is very intense a slight desquamation is at times noticed. It is well, therefore, to study this rather peculiar red tinge of the skin in comparison with the redness of simple erythema, ec- zema, erysipelas, and scarlet fever, which, owing to the different degree of sensitiveness of the individual skin, may at times simulate erythema neonatorum as well as each other. The possibility of this error must be accepted, since these other diseases have been known to appear as early in life as in the above case, although it is unusual for them to do so. In one instance, at least, to my knowledge, a case of scarlet fever, which ultimately proved fatal to another child in the family, was considered by the attending physician, when he first saw it, to be a case of erythema DISEASES OF THE NEW-BORN. 325 neonatorum in the second week of life, and yet eventually he admitted it to be the source of infection of the other members of the family and of the death of one of them. Treatment. — The application of a simple powder, such as is given below, with the use of water without soap on the skin, using enough only for cleanliness, until the redness has disappeared, is generally all the treatment that is necessary in these cases. R Metric. Pulv. zinci oxidi Pulv. atnvli trit. . Prescription 51. Apothecary. Gramma. . . . . 301 R Pulv. zinci oxidi .... 120 Pulv. amyli trit .... Ji; ... giv. M. M. Naevus. — There are two forms of pathological disturbance in connec- tion with the blood-vessels of the skin which, appearing at birth, consti- tute a disease called naevus. Both these forms can appear on the skin of any part of the infant, but its occurrence is especially unfortunate when it is located on the face. The first form is very superficial in its distribution, and is the one which is usually called " port- wine mark." This form can in a number of cases be destroyed by the use of electricity. The second form, which is deep in its distribution, as a rule needs to be treated by the knife or by the Paquelin cautery. Cases of the superficial form of naevus are quite common and vary greatly in degree. A frequent locality is between the eyes at the bridge of the nose, and another is on one of the eyelids. Often in these cases the disturbance disappears of itself after a few weeks or months and does not return. In other cases the lesion remains, often in- creases and continues, unless treated, through life. In the second form much can be done by operative interference. This form also varies greatly in size and in the degree of the telangiectasis. In operating on these cases it should be remembered that at times the hemorrhage is great, and that the infants are liable to die from exhaustion. DIVISION VI. DISEASES OF NUTRITION. There are three diseases which so essentially belong to the early years of life, and so far as our knowledge of them goes are so obscure in their etiology, while presenting each in its own peculiar manifestations a clear picture of a vice of nutrition, that for the present we must classify them by themselves as dieases of nutrition. These diseases are rhachitis, osteoma- lacia, infantile scorbutus, and infantile atrophy. Of these, rhachitis and infantile atrophy are diseases of the first two years of life. Infantile scor- butus, while having its counterpart in the scorbutus of a later period, especially in its pathology and treatment, shows in its symptoms and course such a characteristic picture in the middle period of infancy that it may be considered at least as forming a special form of scorbutus. RHACHITIS (Rickets). Rhachitis is a disease closely connected with impaired nutrition. It occurs usually in infancy, rarely in early childhood, and appears at a time when the bones are in the process of development. It is chronic in its course, and although its chief lesions are in the bones, it involves all the tissues and organs of the body. Its chief characteristic is a local or gen- eral disturbance of the normal process of ossification, but exactly how the dietetic and hygienic causes which are supposed to produce these osseous changes accomplish their results is still unknown. The uniform and defi- nite changes in the bones in rhachitis lead us to consider it a disease' of itself and one which, although connected with nutrition, is not merely a form of malnutrition. Etiology and Occurrence. — There is no evidence that rhachitis is hereditary. Although the disease seldom begins before the sixth month or later than the third year, there is no doubt that it is met with at both an earlier and a later period, and cases have been reported in Avhich the rhachitic rosary was seen as early as the fourth week after birth. The tendency of the disease to occur in the first two years of life is shown in the following collection of 1876 cases compiled by Guerin, Brunische, Rittershain, Ritsche, and Baginsky. 326 DISEASES OF NUTRITION. 327 Cases. Per Cent. First year '. 710 37.8 Second rear 831 44.3 Third year 232 12.4 Fourth year 50 2. 7 Fifth year 27 1.4 Over five years 26 1.4 1876 ~ioao There does not seem to be any marked difference in the frequency with which boys and girls are affected by rhachitis. Out of 2595 cases reported by various authors, there were 1337 boys and 1258 girls. Such authors as Ziegler and Vierordt consider that foetal rhachitis is doubtful, but whatever the pathological point of view may be, a condition closely simulating rhachitis from a clinical stand-point exists occasion- ally during fcetal life. At about the age of puberty also, in certain in- dividuals, the physical signs of rhachitis, with the exception of a lesser degree of epiphyseal enlargement, occur, and in these cases albuminuria is usually present. These cases are called the rhachitis of adolescence or late rhachitis. Certain races, such as the lower classes in Italy and Eng- land, are notably affected by rhachitis. The disease, on the contrary, in a marked form is not common among native-born Americans, nor is it as a rule, of so severe a type in America as in England ; and, except in colored children, or in Italians and Portuguese, great deformities are rare in America. Greeks and Gypsies seem to be almost exempt. The prev- alence of rhachitis among the colored population in Northern cities is most striking, and the disease is not so common among the negro population in the Southern States. The great predisposition to rhachitis which has been shown by the people in Southern Europe has never been accounted for. The most severe cases occur in cold, moist climates ; it is rare in sub-tropical, almost absent in tropical, regions, and almost unknown in the Arctic regions. It is seldom met with in China, Japan, Turkey, and the southern portions of Italy and Spain (Palm). Even in the regions where it is prevalent it is not common in the high altitudes. It is probable that a great number of cases occur very early in life, but are so mild in form that the rhachitic lesions do not become sufficiently marked for recog- nition until later. It is certainly much more common in its occurrence among all classes of life than was formerly supposed, and this is especially true of the population of large cities and towns. Out of 400 cases examined at the Infant's Hospital in a children's out-patient clinic by Morse, 80 per cent, showed distinct changes in the bones characteristic of rhachitis. This percentage is, however, undoubt- edly too low, as besides the fact that large numbers of cases of rhachitis do not present marked deformities of the head or extremities, and are. therefore, not always recognized, it was the case also that many infants only a few days old were included in the 400, and only those cases were called rhachitic in which changes in the bones were evident. 328 PEDIATRICS. As a congenital disease it is probably associated with lack of proper intra-uterine development, corresponding to the rhachitis which is met with in cases of prolonged lactation. Like all diseases associated with impairment of nutrition, it is less likely to occur among breast-fed infants .than among those who are deprived of their natural food, but if the breast- milk is deficient in fat and proteids the disease may develop, and it has been noted in New York (Holt) that among the Italians it is very common to see marked rhachitis in infants who are getting no food but that from the breast. In like manner it is more likely to develop in the latter part of the first year than in the earlier months, since in so many cases the breast-milk deteriorates in quality after the first six or seven months of lactation. The disease also seems to occur when the food is not properly adapted to the especial age, and the later children of large families are more apt to contract the disease than the earlier ones. According to the investigations of Konig, Forster, Gomp, and Besanez, it was found that there was not a deficiency of lime in the food taken by rhachitic children. It is most probable, however, that rhachitis is closely connected with some- thing which interferes with the assimilation of the lime-salts. In regard to the especial elements of the food which hold a prominent place in the production of the disease, it seems as though a low percentage of fat, es- pecially when combined with a low percentage of proteids, was conducive to the production of rhachitis. It is therefore very evident how the pro- prietary foods become a prominent factor in the production of the disease, for all of them contain a notably small amount of fat. Next to the food, the general hygiene is of the greatest importance, and the disease is es- pecially noticeable in the crowded tenement districts of large cities. The actual cause and nature of rhachitis is unknown. The disease is not hereditary, but is most apt to develop in children who have inherited a weak constitution. Rhachitis is a general disease, and there seems to be some change in the metabolism, possibly from the circulation of some substance, in conse- quence of which there are local changes in the metabolism with a lessened deposition of lime combined with a certain amount of resorption of bone. Whatever the other causes of rhachitis may be, it is evident that inter- ference with nutrition by improper food and lack of suitable hygienic sur- roundings play a prominent role in its production. An infectious cause for the disease, though still to be considered, has as yet in no way been proved. The theories of a lack of lime in the cir- culation, or the circulation of an acid, or a diminished alkalinity of the blood can be eliminated as causes. The growth of cartilage and of osteoid tissue may be the result of lack of lime, or may perhaps be pri- marily produced and may be an agent of bone change, but there is no proof of this. The vascular inflammatory theory of Kassowitz is not probable, and Oppenheimer's theory of malaria is without foundation. In addition to the causes of rhachitis, in which the etiology is some- DISEASES OF NUTRITION. 329 what obscure, many cases occur which evidently are secondary to and result from a number of diseases which affect the general nutrition of the infant. Thus, diseases of the gastro-enteric tract, when they are prolonged for some time, lead to the condition of rhachitis. We also meet with it in cases of syphilis in which the nutrition is much reduced ; but beyond this relation between syphilis and rhachitis, — namely, that rhachitis is secondary to syphilis, as it might be to any wasting disease, the two diseases are essentially distinct. It is to be noted in this con- nection that cases of infantile atrophy, no matter how much they are wasted, do not present the lesions of rhachitis, although in some cases we find the two conditions associated. We must also remember that the nutrition of all the tissues is profoundly affected, and that the equilibrium of the nervous system in rhachitis is very unstable. Pathology. — Bone Lesions. — The pathological lesions of rhachitis are represented chiefly in the bones, and occur during the period in which the normal processes of ossification are most active, — that is, during the first year and the first part of the second year of life. The normal growth of bone depends upon four conditions : (a) multi- plication of cartilaginous cells in definite lines, followed by (6) calcifica- Fig. 82. -z.p. Z. P. I. Normal Done : Z. P., zone of proliferation. II. Bone of a cretin : Z. P., zone of proliferation. III. Rhachi tic bone : Z. P., zone of proliferation. tion of the intercellular spaces ; (c) the formation of medullary spaces by the penetration of blood-vessels, with subsequent absorption of tissue ; and, (d) finally, the concentric deposition of bone within the medullary spaces. The bones grow in length by the production of bone-tissue in the cartilage between the epiphysis and the diaphysis, and in thickness by 330 PEDIATRICS. the growth of bone from the inner layers of the periosteum. At the same time the medullary canal is enlarged in proportion to the growth of the bone by the absorption of its inner layer. These processes progress in definite order and in clearly defined zones. In rhachitis the chief microscopic features are the changes which occur in the zones of growth and the asymmetrical character of the proliferative processes. The cartilaginous and sub-periosteal cell-growth which pro- duces ossification goes on with increased rapidity and in an irregular manner both between the epiphysis and the diaphysis and beneath the periosteum. If we examine microscopically the region between the epiph- ysis and the diaphysis, usually called the zone of proliferation, we find that the cartilaginous cells are not regularly arranged in rows around a definite zone in advance of the ring of ossification, as in normal tissue, but that there is an irregular heaping up of cartilaginous cells, sometimes in rows, sometimes not, covering an ill-defined irregular area. This zone of proliferation also, instead of being narrow and sharply defined, is quite lacking in uniformity. It presents a broad, reddish-gray appearance, with marked thickening and hyperemia. The medullary spaces are much more vascular than normal, and are so increased in area as to extend into the zone of calcification, and sometimes through it. The deposit of bone-tissue within these spaces is, however, either absent or very irregular, and is for the most part replaced by a soft, friable substance, consisting of a bone-tissue that is very lacking in lime-salts, with cells of various kinds embedded in a fibrillated ground-substance. This tissue is called " osteoid," and is similar to that formed by osteoblasts. In the region of ossification (ends of diaphysis and epiphysis) there is microscopically a pronounced increase of blood-vessels and cartilage- cells, with lengthening of cell columns, and disturbance of calcification of the intercellular substance. Calcification, if present, may be isolated in the region of the proliferating cartilaginous cells, or may be altogether absent over considerable areas. The sub-periosteal layer of cells which is normally thin and scarcely noticeable macroscopically, becomes hyper- asmic and thickened with an appearance similar to that of spleen-pulp. Beneath this periosteum is also to be found the " osteoid" tissue seen in the zones of proliferation. The medulla of the bone is more hypersemic even than normal. Its tissue is rich in cells, and, like the foetal medulla, contains dilated vessels and fat. The intercellular substance may show mucoid degeneration or even be of fluid consistency. In such a condition it does not seem that lime is dissolved from the bone tissue by the blood, but it is the resorp- tion of such bone in toto that is the important factor in the process. Resorption at the age at which rhachitis occurs is normal. Pimmes, especially, believes that resorption in rhachitis is not increased. Muller and Virchow seem to hold the same views, while Kassowitz and Ziegler think it is increased. Clinically, certain extremely rapid cases of softening DISEASES OF NUTRITION. 331 seem to show increased resorption (Vierordt). Ordinarily, with a resorp- tion not greatly increased, the formation of fresh bone containing but little lime results in loss of strength. In the skull, in some places, ab- sorption predominates (occiput) ; in other cases accretion of osteoid tissues (frontal and parietal eminences). Deficient bone-growth simply deter- mines open fontanelles. In convalescence lime is deposited in the previous limeless osteoid tissue, and the result is a thick and heavy bone. In frac- tures at this period callus-formation is intense and excessive. An excessive proliferation of cells in the inner layers of the periosteum, the irregular calcifica- tion which occurs about them, and the absence of uniformity in the elaboration of the structure of the bone, produce an irregular, spongy bone-tissue instead of the compact lamellated tissue which is so necessary for the uniformity of the structure. The increased cell-growth between the epiphysis and the diaphysis produces the peculiar knobby swellings which are characteristic of rhachitis. At the same time the medullary cavity increases rapidly in size, and the inner layers of the bone become spongy. The result of these processes is to diminish the solidity of the bones so that they cannot resist the strain of the muscles, or outside pressure. After a time the rhachitic process may stop and the bones may assume a more normal character. The porous bone-tissue becomes com- pact, and even unnaturally dense, so that in later childhood the rhachitic bone is unusually hard, like ivory, a condition noticed by those who have to operate on these bones. Fig. 82, I., represents a section of a normal bone taken from an infant, and shows the normal zone of proliferation (Z. P.) between the epiphysis and the diaphysis. Fig. 82, III., represents a section of a rhachitic bone, and shows the broad, irregular, and abnor- mal zone of proliferation (Z. P.) just described. Fig. 83 represents a section of a rhachitic bone, illustrating the great enlargement of cartilage at the epiphysis, with the irregular foci of calcification. The diaphysis of the bone shows perios- teal thickening to such an extent that it encroaches on the medullary cavity, which is much diminished. Visceral Lesions; Spleen. — The investigations made by Sasuchin (Jahrb. fur Kinderhl., March 13, 1900) have shown that in cases of rha- chitis wmich come to autopsy the spleen is invariably enlarged, with the Spindle-shaped rhachitic bone. 332 PEDIATRICS. exception of the cases of clearly pronounced general atrophy, in which the spleen is of normal size and weight or below normal. A second marked characteristic is the more or less significant thickening of the capsule and the increase in the consistency of the organ. The third peculiarity of the rhachitic spleen is the anaemia of the organ and the diminution in the number of Malpighian bodies, which in children are otherwise well developed, but in these conditions are smooth and hardly perceptible. On section, the spleen has a blood-red color, the trabeculae are clearly marked by interlacing threads, and on drawing the knife over the cut surface there remains upon the edge blood and pulp-tissue. The characteristics described hold true in all cases of rhachitis, and, in gen- eral, indicate approximately the intensity of the changes in the bones. The microscopic appearances are those of an interstitial splenitis. Whether the inflammatory appearances are directly dependent upon the rhachitis or are due to the complicating diseases which caused the death of the patient has not been definitely determined. The uniform appear- ances in all the cases examined by Sasuchin, irrespective of the cause of death, seem to give weight to the opinion that the lesions are directly connected with the rhachitis. Symptoms. — Constitutional. — The symptoms of rhachitis are those of a slowly developing constitutional disease. The early symptoms are the same as may occur in a number of diseases in which the nutrition is affected. The most common early symptoms are restlessness at night, profuse sweating, especially of the head, when asleep, and constipation alternating at times with diarrhoea. The appetite is impaired and ca- pricious ; the infants are fretful, the abdomen becomes prominent, and although they often grow fat they are anaemic and their muscles are soft. The increase in weight depends mostly on an increase in fat, the normal relative proportion between fat and muscle being altered. The infants do not learn to walk as early as they should ; their fontanelles do not close at the usual time ; dentition is delayed and irregular, and soft areas ap- pear in the cranial bones, especially in the occiput. At this stage the characteristic tenderness of the body may occur, but many cases never present this symptom. This is usually due to a periosteal tenderness at the insertions of the muscles, and is sometimes confined to the bones. It is manifested only on trifling pressure, while at other times the muscles are tender and the gentlest effort to lift the child may cause him to shriek with pain. It must, however, be remem- bered that pain in rhachitis may be connected with an early manifesta- tion of scorbutus, which is not an uncommon complication of rhachitis. The so-called paralysis of rhachitis, which is an accompaniment of this stage, and. as a rule, precedes any marked osseous change, is generally brought to notice by the child's inability or disinclination to walk or to stand. At other times it may be more severe and take the form of ina- bility to use the arms as well as the legs. There may be a slight and DISEASES OF NUTRITION. 333 irregular heightening of the temperature apart from any complications which can he detected. Convulsions may occur, especially when there is a tendency to cranio- tabes. In certain cases these symptoms are all so acute that some writers would make them a separate class under the head of acute rhachitis, but the anatomical lesions and the symptoms are the same, except for their greater severity, and would seem to belong clearly enough to the same group as the less pronounced cases. There has also been much dis- cussion as to whether a form of acute rhachitis exists apart from the dis- ease scorbutus. But cases presenting the symptoms to be described under the heading of scorbutus should not be considered necessarily as acute forms of rhachitis on account of the severity of the symptoms, but should be classed as scorbutus supervening on rhachitis. The later and more characteristic symptoms of the disease soon appear and are represented chiefly in the osseous system. The facial expression is usually intelligent. After these general premonitory symptoms have continued for some time the characteristic changes in the osseous system become prominent and are found in those parts of the bones which are in the most active stage of development. In the early days of extra-uterine life the skull undergoes the most marked changes. Head. — The typical head of rhachitis has a high, square, prow- shaped forehead, with a decided prominence of the lateral parts of the frontal bones (frontal eminences), and sometimes there are also eminences on the parietal bones. (Fig. 86, page 337.) The normal thickness of the bones is increased by means of a large amount of new periosteal soft growth between the periosteum and the bones. The head is somewhat lengthened beyond the normal shape, and is usually larger in circumfer- ence than normal. The posterior fontanelle may remain open for a month, and the anterior fontanelle remains widely open, and may not ossify until the third year, or even later. The sutures also remain open longer than normal, and in such cases may result in leaving a depression in the course of the sagittal suture. Sometimes, however, a prominence is found instead of a depression. The square, lengthened, rhachitic head is shown in Fig. 86, page 337, and in Fig. 87, opposite page 342. Flattening of the back and top of the head and asymmetry of the head may result from softening of the bones. The normal shape is usually regained when the disease is cured. The bones may be soft, porous, and hyperaemic, while at their edges there may be rough bony projections beneath the periosteum. The name craniotabes is applied to an abnormal thinness of portions of the parietal and occipital bones, which are filled only with a fibrous mem- brane, and which yield to gentle pressure and give a sensation of crack- ling parchment. Hyperemia of the brain and meninges, of course, may be an accompaniment of any affection of the skull so severe as this. With this hyperaemia comes the likelihood of hydrocephalus, either external or 334 PEDIATRICS. internal, and the accompanying cerebral changes, so that hydrocephalus becomes a complication which is not very rare. This condition of the bone may be only temporary, and the areas of thickening are often ab- sorbed ; but if there is much deposit under the periosteum it will some- times remain, and where calcification takes place quickly the thickened areas of the bone will remain unabsorbed throughout life. At times the jaw-bones are affected ; the upper jaw is then found to spread behind, and to be pointed in front, while the lower jaw is flat in front and bent in at the sides, making an angle at the site of the canine teeth. Thorax. — The rhachitic thorax is narrow and is compressed laterally, — that is, there is a tendency to a flattening of the sides of the chest and to an increase of the antero-posterior diameter. The forces which pro- duce deformities of the thorax are dependent on the muscular action on the soft bones by pulling, atmospheric pressure from without, and the pressure exerted on the bony structures by growing organs. A transverse depression may also occur, starting at the junction of the ensiform cartilage to the sternum, extending laterally on the thorax, and corresponding to the insertion of the diaphragm. This is called Harri- son's groove. The diaphragm, by its strong muscular action along the line of its insertion, may also cause a furrow in the lower part of the chest. The lower ribs may also be elevated by the underlying distention caused by the prominent abdomen and the liver, which is always, even in normal cases, large in proportion to the other organs. Softening of the ribs is said to occur (Vierordt) after the changes in the skull and before the changes in the extremities. In a typical rhachitic thorax the clavicles are shorter and more curved than normal, and the clavicular deformities may be unilateral, as seen in Fig. 87, I. and II., facing page 342. Fractures of the clavicles in rhachitis are not uncommon on the forward curve, and may possibly occur when the infant is being dressed. When there is unusual lateral compression and narrowing of the thorax, the sternum is made to project forward, and this is called pigeon- breast, or pectus carinatum. The weakest part of the thorax is at the junction of the cartilages and ribs, and the sternum is thus naturally pushed forward. In another series of cases, in which the ribs are pushed together laterally and the sternum depressed, as where there is inter- ference with the entrance of air into the lungs by adenoid growths and enlarged tonsils, the condition of funnel chest is produced, as seen in Fig. 77, page 297. Again, there may be greater compression on one side than on the other, Avith a resulting prominence or depression on one side of the sternum. The costal cartilages are frequently enlarged at their junction with the ribs, and can be felt and often seen as a line of rounded prominences. These prominences are called the rhachitic rosary, and, though most com- monly occurring in the latter part of the first year, have also been met with in the early weeks of life. The rhachitic rosary, according to DISEASES OF NUTRITION. 335 Morse's observations on four hundred cases at the Infants 1 Hospital, is the earliest of the physical signs of rhachitis to develop, and is the most Fig. 84. Inner surface of sternum, with cartilages and portions of ribs attached, showing rachitic rosary. common abnormality in rhachitis. It does not occur in normal chil- dren, and its presence justifies the diagnosis of rhachitis. The rosary Pig. 85. Rhachitic kyphosis. Female, 3 years old. is sometimes present only on the internal surface of the ribs, as seen in Fig. 84, which represents a case in which the rhachitic rosary could not 336 PEDIATRICS. be detected on the outer surface. As the pathological process is more pronounced in the lower ribs, especially the lower five, than the upper, the rosary is more distinct in the lower ribs. , Spine. — Deformity of the spine is quite constant in rhachitis and results mostly from muscular weakness, but the vertebrae may be affected by the rhachitic process, and in cases of recovery may be found thickened. The most common deformity is kyphosis, which consists of a gradual bowing backward in the dorsal and lumbar regions, as seen in Fig. 85. The prominence of these vertebral spines is often quite sharp, and sim- ulates Pott's disease, but the rhachitic spine should be flexible to passive manipulation. In certain cases, however, it is rigid. Scoliosis (lateral curvature) and lordosis (forward curvature) are common deformities oc- curring in rhachitis. Extremities. — Deformities of the long bones may arise in the epiphy- ses and in the shafts : the former show enlargement, the latter bending. Enlargement of the epiphyses appears especially at the wrists and at the anterior ends of the ribs ; enlargement of the lower end of the radius and ulna is practically universal, whereas the enlargement of the lower end of the tibia and fibula occurred in four hundred out of a series of one thousand cases. The increase of the epiphyses at the wrists is greater than elsewhere. These enlargements do not involve the joints. In the deep-seated epiphyses, like the hip and the shoulder, the changes are not noticed so readily. The proliferating layer between the epiphyses and the bone may become so thick and softened that consequent deformity and separation of the epiphyses may occur, but such an event is uncom- mon. When fractures occur they are on the concave side of the bone. In rhachitis of the extremities the curve of the forearm may be due to the pull of the muscles, and there may be a special bend of the radius about the ulna, probably secondary to the antero-posterior curve. It prevents full supination. The humerus rarely bends. Fractures are not rare. In the acute forms of rhachitis the legs rotate outward in bed. Any considerable increase in the ankle epiphysis is rare. The curve of the femur is forward or forward anteriorly, so that in the latter case there may be no curve on the posterior surface. Fractures may occur with excessive callus. In the lower leg fracture takes place most often with anterior bow-legs, and the resulting callus is less than in the thigh. Fractures of the long bones, however, are uncommon, but their arrested development may cause permanent shortening. Bowing of the legs, knock-knee, and flat-foot are all very common symptoms of rhachitis. Coxa vara may be present. Localized rhachitis, as of the legs, is pos- sible and quite frequently met with in children with no symptoms of general rhachitis. It is not unusual to find hydrocephalus combined with rhachitis. Signs of previous rhachitis are suggested by a caput quadratum with a thick skull, irregularity of the teeth, eversion of the lower edges of the PLATE V. A. PLATK V B DISEASES OF NUTRITION. 337 thorax, pigeon-breast, pelvic deformity, deformities of the clavicles and ex- tremities, and thickened epiphyses, which may persist, as thickened epiphy- ses in general are slow in disappearing and outlast the active process. The existence of flat-foot in children over two years old should lead to an examination for knock-knee. The combination of these two conditions will in most cases be found to be dependent upon present or previously existing rhachitis. Muscles. — There is a weak and relaxed condition of the muscles, but microscopically the muscles are only pale and their fibres infiltrated with fat, although in some cases there may be atrophy from disuse. Nervous System. — The nervous system is in an exceedingly unstable and sensitive condition. Convulsions are quite common, especially in connection with craniotabes. The condition of spasm of the glottis (laryngospasmus), although it may occur in other diseases, is especially characteristic of rhachitis. The infants hold their breath, grow cyanotic, are seemingly unconscious, fall back entirely limp, and after a few min- utes recover. Tetany at times is met with as a complication. Lungs. — Owing to deformities of the thoracic walls there is a tendency to atelectasis of portions of the lung from pressure. There is also a great tendency to bronchitis and to broncho-pneumonia. Heart. — The heart often shows signs of mechanical irritation, repre- sented by irregularity and caused by deformities of the thorax. Fig. 86. Male, 3 years old. Rhachitis, with enlarged spleen. Blood. — Unless rhachitis is accompanied by a secondary anaemia, the blood is practically normal, and presents no other characteristic changes. Hock and Schlesinger found that if the secondary anaemia was moderate in intensity, and diarrhoea and vomiting occurred, it simply made the anaemia more acute. The majority of the leucocytes were found to be mononuclear and about the size of the erythrocytes. There is a mod- erate permanent leucocytosis in most of these cases, and at times the mononuclear leucocytes seem to be the most numerous form. Spleen. — In some cases the spleen is found to be enlarged, but it is rarely very large. 22 338 PEDIATRICS. The following case, Fig. 86, p. 337, is interesting as an illustration of rhachitis with a secondary anaemia of high grade, accompanied by enlargement of the spleen. The child was three years old, and was fairly well nourished. It had, however, enlarged epiphyses, a rachitic rosary, the square rhachitic head, and marked bowing of the legs. On physical examination no indication of enlargement of the liver or glands was found. The spleen was very much enlarged, and the position of its out- line and its notch is indicated in black. The blood examination showed a severe secondary anaemia, but no evidence of a leucaemia. Liver. — The liver often shows fatty infiltration, and is at times en- larged but less frequently than the spleen. A distinction must be made in these cases between an enlarged liver and a depressed liver, caused by rhachitic compression of the thorax and narrowing, or from relaxation of the natural ligamentous supports as a result of the weakness from the general inanition which affects all the tissues of the body. Lymph-nodes. — The lymph-nodes are very frequently found to be enlarged from simple hyperplasia. Stomach and Intestine. — There is usually, though not necessarily, functional disturbance of digestion ; also a subacute catarrhal condition and a tendency to gastric dilatation. The symptoms vary very much and diarrhoea and constipation alternate. Marfan thinks that the intestine is elongated in rhachitis. The distended abdomen results from weakness of the muscles of the abdominal wall and of the intestine, and a resulting umbilical hernia is quite common. In like manner atonic constipation is common. Diagnosis. — The diagnosis of rhachitis cannot be made by the pre- monitory symptoms, as the disease is so often the result of impaired nutrition arising from many causes, that it is difficult to determine when the rhachitic symptoms begin. The differential diagnosis has to be made from a number of diseases in which the general nutrition of the child is profoundly disturbed, these diseases being especially represented by func- tional disorders connected with the gastro-enteric tract. When the patho- genic changes in the bones have progressed sufficiently for physical detec- tion, and the disease is fully developed, the diagnosis is not difficult. In its early stages, therefore, the manifestations of rhachitis may be so slight that the diagnosis must often be held in abeyance. The differential diagnosis of rhachitis is to be made from scorbutus, rheumatism, osteomalacia, osteomyelitis, syphilis, paralysis of central ori- gin, Pott's disease, and from the disability to use the limbs, clue to simple weakness in infants who are not rhachitic. Scorbutus is eliminated in the diagnosis by the presence of the various osseous lesions which have just been described as symptoms of rhachitis and by the absence of the characteristic features of scorbutus, represented by tenderness and swelling just above the joints, without much fever, sub-periosteal hemorrhages, and stomatitis ulcerosa. DISEASES OF NUTRITION. 339 Rheumatism in its articular form would present such marked symp- toms of acute tenderness, swelling, and pain in the joints, combined with a heightened temperature, that it could easily be distinguished from the general tenderness of the bones without much fever, together with the subacute or chronic course and the characteristic enlargement of the epiphyses in rhachitis. Osteomyelitis. — The clinical symptoms of an acute infectious disease, with sudden onset, and represented by severe constitutional disturbance, heightened temperature, pain, localized tenderness, and rapid exhaustion, serve to distinguish osteomyelitis from the slow development and slight amount of fever met with in rhachitis. In osteomyelitis, moreover, vari- ous foci of infection will appear in one or more bones with tenderness at these points and a tendency to suppuration which is not met with in rhachitis. Osteomalacia. — In very rare cases osteomalacia occurs in children, but it can seldom be differentiated from rhachitis during life. Hereditary Syphilis. — The diagnosis of rhachitis from hereditary syph- ilis is, as a rule, not difficult. Syphilis and rhachitis have no direct con- nection with each other, but are both chronic constitutional diseases, and it is possible to have both diseases occur in the same individual. While in rhachitis the enlargement of the long bones is limited to the epiphyses, in syphilis it is not so limited, but involves the ends of the diaphyses. This enlargement is often accompanied by a condition which closely simu- lates a callus, and there is a distinct tendency to fracture in syphilis rather than to the bending which is common in rhachitis. The notched teeth and the craniotabes may occur in both diseases, while the lesions of the mouth and lips described on page 527, and the lesions of the skin on page 525, are distinctive of syphilis. Cerebral Paralysis and Poliomyelitis. — In certain cases of rhachitis, es- pecially in the earlier stages, the so-called paralysis of rhachitis occurs, and must be distinguished from paralysis of central origin, especially from poliomyelitis of the cord. The differential diagnosis must be made by the absence of the symptoms described under cerebral paralysis and polio- myelitis described on pages 950 and 958, and by an examination of the child in a recumbent posture, which in rhachitis will show that the muscu- lar movements are but little impaired, that the apparent inability to move the limbs and the disinclination to walk are caused by tenderness of the bones and muscular weakness, that the electrical reaction is normal, and that the reflexes are not affected. This pseudo-paralysis is certain to pass off if the child lives. Cases of rhachitis which do not walk until late, on account either of muscular weakness or of tenderness, may resemble cases of organic nervous disease with true paralysis. The diagnosis must rest on the presence of the general signs of these nervous diseases. Pott's Disease. — When rhachitis causes kyphosis of the spine it may simulate Pott's disease very closely. A prominence maybe present at the 340 PEDIATRICS. dorso-lumbar junction, which is a frequent seat of the deformity in Pott's disease, and which, involving several vertebrae, may or may not be oblit- erated when the child lies on its face and is lifted by its feet from the table. The spine is held rigidly in severe cases, just as in Pott's disease, and the deformity may be angular rather than the usual gradual curve. The co-existence of enlarged epiphyses and other rhachitic conditions makes it very probable that the affection is rhachitic : but both diseases may coexist. In general, the age of the child, under eighteen months, the absence of much pain, and the existence of other signs establish the diagnosis of rhachitis. Rhachitis is, moreover, in children under two, much more common than Pott's disease. In doubtful cases the diagnosis can be made only after several examinations and a period of two or three weeks of recumbency, under which conditions the rhachitic spine becomes somewhat more flexible. In doubtful cases time alone will establish the diagnosis. Weakness. — In certain infants who are not rhachitic the power of walking is lost for variable periods, and is due to weakness following any disease, whether acute or chronic, which for a time may interfere with the infant's vitality. This condition is difficult to distinguish from rhachitis, but must be differentiated by the absence of other symptoms of rhachitis. Delay in learning to walk should lead us to carefully ex- amine for other symptoms of rhachitis, as it is quite often one of the manifestations of this disease. An open fontanelle after the nineteenth or twentieth month suggests rhachitis, and delayed dentition is also signifi- cant. If there are no teeth at the ninth or tenth month, the infant should be carefully examined for rhachitis ; at one year absence of teeth almost always indicates the disease. Finally, the rhachitic attitude of an infant with well-marked rhachitis is characteristic, and is shown in Fig. 87, facing page 342. The infant stands with its thighs flexed, knees bent, back arched, shoulders thrown back, prominent abdomen, head rather rigid, legs apart, and varying degrees and combinations of bow-legs and knock-knee with flat-foot. The cause of this attitude, according to Lovett, may in a measure be a persistence of the infantile position which children assume when they are learning to walk. Children with rhachitis have weak muscles as well as weak bones, and the condition of such a child approaches that of one who stands and walks with the least expenditure of muscular force. Hydrocephalus. — The diagnosis between the rhachitic head and the hydrocephalic is usually not difficult. The former is irregularly enlarged, flattened on top, square-looking, and has a normally tense or depressed fontanelle. The latter is regularly enlarged and rounded, with a tense and bulging fontanelle. Prognosis. — The prognosis of rhachitis is favorable, provided no com- DISEASES OF NUTRITION. 341 plications arise. When left untreated the disease may, after a decided de- gree of deformity has occurred, be arrested spontaneously, the pathologi- cal process in the bones cease, and the bones harden in their deformed condition (Lovett). In these untreated cases the younger the child the more unfavorable is the prognosis. A spontaneous arrest of the disease may take place in any of its stages, but, as a rule, if the affection is at all pronounced, serious deformities are usually produced. If a hydrocephalic condition, which at times appears in rhachitis, is present to any degree, if there is much diarrhoea, or if the infant is subject to frequent attacks of bronchitis, the prognosis is very unfavorable. Rhachitic children are more liable to die than other children when they are attacked by such diseases as pneumonia or bronchitis. Attacks of the acute exanthemata are of serious import in these cases. Rhachitic children are especially liable to the invasion of the tubercle bacillus. According to Bradford and Lovett, kyphosis disappears under proper treatment. Lateral curvature is per- manent when not treated. As a rule, the epiphyseal enlargements diminish with growth, but to a certain degree remain through life. The craniotabes, laryngismus stridulus, bronchitis, diarrhoea, and paralysis gradually in the favorable cases pass away. Although rarely, death may occur in attacks of laryngospasmus and convulsions in rhachitic infants. When properly treated, the health of rhachitic children improves slowly, and, unless the deformities which have occurred in the bones have advanced too far, more or less complete recovery usually takes place in the third or fourth year. The arrest of the disease at an early stage is important. Treatment. — The treatment of rhachitis is essentially dietetic and hygienic. The infants should be kept in the open air as much as pos- sible, and should live in rooms accessible to sunlight. The food should be adapted to the age, according to the rules given for the feeding of normal infants during the first two years of life. There does not appear to be any drug which produces a specific effect upon the osseous changes which take place in rhachitis. Phosphorus is considered by some ob- servers to be a valuable adjunct to the general dietetic and hygienic treat- ment, but, according to our experience at the Children's Hospital, it has not proved to be of any especial benefit. When the anaemia is marked, iron in some form should be given, and at times an increase in the fat in the food seems to be beneficial. Espe- cial attention should be paid to the correction of deformities by exercises and if necessary by surgical interference. Whenever any tenderness or pain is noticed, the infant should at once have orange-juice given to it, as directed in scorbutus (page 347). Laryngospasmus should be promptly treated by sprinkling the face and chest with cold water and by lightly slapping the back. - Convulsions should be treated with unusual care in a rhachitic child, in whom they usually arise from depression and resulting over-sensitive 3-t2 PEDIATRICS. condition of the nervous system. Stimulants are usually indicated in these cases. Fig. 87. I. and II., represents unusually well the deformities in the bones which may arise as a result of rhachitis. The boy was six years old. He was nursed from the breast for two years, and then given a general diet. He began to walk when fourteen months old, and the mother noticed that his legs began to bend at about that time, but could give very little information about the course of the disease. The physical examination showed the heart's impulse to be about on the level with the sixth rib and in the mammillary line. The heart's sounds were clear and loud. Nothing abnormal was detected in the throat or lungs. The abdomen was large, prominent, and tympanitic : the liver was palpable three fingers' breadth below the ribs in the mammillary line ; the spleen was not palpable. Looking at the child from in front, as represented in Fig. 87. I., the head was square with enlarged frontal prominences. There was a decided bowing of the left clavi- cle with enlarged epiphyses of the wrists and ankles, outward bowing of the femora, and flat-foot with extreme pronation. The side view, as represented in Fig. 87, II.. shows the flattened top of the skull, rhachitic rosary, distended abdomen, lordosis, an- terior bowing of the tibiae, and flat-foot. CONGENITAL OR FCETAL RHAOHTTTS. Foetal or congenital rhachitis shows a general similarity to the bone changes of rhachitis. There have been a number of cases. Kaufmann lately reports cases of his own and suggests the name chondrodystrophia fcetalis. These cases are by some writers considered not to be rhachitis at all. Some of the cases reported show histological conditions similar to those found in acquired rhachitis. Vierordt, however, is inclined to think that this is hardly evidence enough, as we know that similar changes may be produced experimentally which are not actually rhachitic, and he con- siders the existence of a fcetal or congenital rhachitis as very doubtful. Congenital rhachitis is, therefore, a very rare affection. Ziegler de- scribes various fcetal cases of several prosyllabic types corresponding to Parrot's achondroplasia and Kaufmann 's chondrodystrophia. In these cases of fcetal origin the periosteal changes are absent, and the epiphyseal changes do not correspond accurately to the rhachitis of extra- uterine life. I have seen a case of supposed congenital rhachitis in which the rhachitic process had run its course and the hardening of the bones had apparently been completed before the infant was born. Another case of congenital rhachitis was seen by me in consultation with Dr. Townsend. The parents were young and healthy, and there was no history of syphilis or rha- chitis. The father was American, the mother Scotch. There was one other child, three years old. strong and well. The mother during her pregnancy was much wor- ried, and her nourishment was both insufficient and poor. The infant, a male, was one month premature. The labor was easy. The infant weighed seven pounds and was 43.3 cm. (17 inches) in length. Fig. 87. Rhachitis. Age, 6 vcars. DISEASES OF NUTRITION. 343 Fig. 88 represents a photograph taken on the fourth day of the infant's life. The head was square in front, was much flattened behind, and measured 33.8 cm. (13|- inches). The sutures were all widely open. The ossified portions of all the bones of the skull were small, particularly of the occipital bone, which presented a large area of Fig. 88. 1 j£ Qt| -/ ■ . l Congenital rhachitis. craniotabes. In the widely opened sagittal suture just back of the anterior fontanelle was a large Wormian bone 2.7 cm. (1 inch) long. In the squamous and coronal su- tures on the right side at least eight small Wormian bones could be easily felt, and on the left side eleven were counted. The thorax was 30 cm. (llf inches) in circum- ference, and was depressed laterally, the depression increasing with each inspiration, owing to an accompanying atelectasis in the lower portions of the lungs. There was considerable cyanosis. No cardiac murmur was detected. A rhachitic rosary was present. The abdomen measured at the level of the umbilicus 28.7 cm. (11^ inches). There was a large double inguinal hernia. The spleen could not be detected on ex- amination. The liver could be felt below the edge of the ribs, but was apparently not enlarged. There were marked enlargement of all the epiphyses, curvature of all the long bones, and numerous fractures. The humeri showed a slight anterior curvature. The bones of each forearm were also bent anteriorly. The femora were curved outward and forward. The lower legs showed marked angular curvatures for- ward at the junction of the middle and lower thirds. The fractures were apparently of as recent origin as the birth, as some of them proceeded to unite very quickly. On the eighth day the fracture of the right tibia was quite firmly united ; and only a slight crepitus could still be felt over the left tibia. The fracture of the left hu- merus was firmly united with a ring of callus. The right humerus at birth showed a callus about the middle of the shaft : this was evidently the repair of an intra-uterine fracture. The child died on the ninth day after birth. OSTEOMALACIA. Osteomalacia is a disease which occasionally occurs in children, but not so frequently as in adults. It causes softening of the bones, and in this respect is somewhat similar to rhachitis. Etiology. — Nothing definite is known about the cause, and it is simply 344 PEDIATRICS. spoken of in connection with diseases of nutrition on account of its re- semblance to rhachitis. Pathology. — There is, according to Ziegler, an absorption of lime-salts, beginning first at the medullary cavity and proceeding outward. The epiphyses are not notably affected by the continuance of the absorptive pro- cess, the cortical bone becomes spongy and decalcified, and in the severest cases there may remain little but marrow and periosteum (J. C. Warren, " Surgical Pathology"). The opinion is generally held that in osteomalacia the layer of osteoid tissue results from decalcification, while in rhachitis a similar layer repre- sents a new growth deficient in lime-salts. The periosteum is likely to be thickened and vascular, and the medulla resembles that in infancy in its gross appearance. Symptoms. — Spontaneous fractures and various distortions may occur in osteomalacia, and the thorax is flattened laterally. Treatment. — The treatment is the same as in rhachitis (page 341). SCORBUTUS. Scorbutus (scum 7 ) is a constitutional disease closely associated with imperfect nutrition and having a definite relation to the deprivation of the individual of fresh food. It is characterized by anaemia and a ten- dency to hemorrhage, and in most cases is accompanied by the condition of the gums which is present in stomatitis ulcerosa. Etiology. — In addition to the view that the cause of scorbutus is of chemical origin, owing to the significant relation which the disease has to a lack of fresh food, it is supposed that there may be a special micro- organism which causes the disease. This, however, has not been proved, and we have no further knowledge regarding the etiology of scorbutus. In my experience there is no evidence that sterilized milk is a cause of scorbutus. If the milk is properly modified it can be heated to 75° C. (167° F.). or even to 100° C. (212° F.), without, so far as I am aware, having a deleterious effect upon the osseous system. Pathology. — So few post-mortem examinations have as yet been made on infants dying of scorbutus that the pathological lesions have not been finally established. A sufficient number of autopsies, however, has been reported by Barlow and others, notably Northrup, to settle at least the more important features in the pathology of infantile scorbutus. There are no alterations in the blood, either anatomical, chemical, or bacteriological, which can be considered peculiar to scorbutus. There are deep hemorrhages into the muscles and occasionally about or even into the joints, but the hemorrhage in infantile scorbutus is essentially subperiosteal and chiefly of the long bones. The femora are most com- monly affected, and there is a tendency to separation of the epiphyses. There may also be a varying amount of interstitial hemorrhage in the lungs, spleen, kidney, and intestinal glands. Hematuria has been noticed Fig. Vertical section of leg in a case of infantile scorbutus. The red areas around the femur and tibia represent subperiosteal hemorrhages. (Specimen preserved in the Museum of the College of Physi- cians and Surgeons, New York.; (Page 345. DISEASES OF NUTRITION. 345 in a certain number of cases of scorbutus, and it is well to examine the urine in cases in which the disease is suspected. Hemorrhages into the mucous surfaces are usually present, the gums being chiefly affected and presenting the condition of stomatitis ulcerosa. Fig. 89 represents a section of the bones of the leg in a case of infantile scor- butus which was under the care of Dr. Northrup. On examination it will be seen that the femur is normal at its upper extremity. The lower half is invested with a black, grumous, sub-periosteal layer of blood. The lower epiphysis is detached, and the lower end of the shaft, macerated, eroded, and soft, is lying loose in the black, disin- tegrating blood-clot. The tibia is surrounded by thin, dark, hemorrhagic layers be- neath the periosteum, and the proximal portions are congested. The fibulae and the bones of the upper extremities were normal. Fig. 90 represents a microscopic section of this bone, which shows no syphilitic or rhachitic changes in the bone or the periosteum. Fig. 90. Hem. Per. Section of scorbutic bone. Med., medulla; B, bone ; Hem., hemorrhage ; Per., periosteum. The soft macerated bone gave no evidence of suppuration, but there was a mod- erate congestion of the femur and the upper extremity of the tibia. Symptoms. — The symptoms of infantile scorbutus are those of a slow and progressive cachexia. The infants become anaemic, and show more or less gastro-enteric disturbance of a subacute functional type. Profuse sweating, especially about the head, at times slight feverish attacks, and lessened appetite, are among the early symptoms. The temperature may be from time to time slightly raised, but not significantly so. The first symptom, however, which especially attracts the attention is a sensitive condition of the bones. The infant cries when the affected parts are touched. It does not seem to suffer pain when it is allowed to remain quiet, but as the disease advances the expression of its face indicates the 346 PEDIATRICS. fear of being handled. My individual experience with infantile scorbutus has been derived from seventy to eighty cases, all of which, with few ex- ceptions, were from eight to twelve months of age. I met with no cases later than the first half of the second year, and with none earlier than the second half of the first year. As the disease progresses, more marked symptoms develop. Swellings of the limbs, usually of the diaphyses just above the epiphyses, appear. These swellings are most common and most prominent in the legs, but may also appear in the bones of the forearm. They are usually pyri- form and symmetrical in shape, the skin over the swelling being more or less tense, but not fluctuating. There is commonly some tenderness on pressure, but, as a rule, no especial heat of the affected part. The pain and swelling do not seem to be in the joint, but in the diaphysis and epiphysis. Signs of hemorrhage may occur in the skin over the affected parts, appearing at first as small blue maculae and later involving larger areas, as though a deep hemorrhage were coming to the surface. In advanced cases hemorrhage may take place to such an extent in the deeper parts around the eyes that the eyes will be pushed forward (proptosis). When the infant has not cut any teeth, the mucous membrane of the gums, according to my experience, has not been affected ; but when a tooth is pressing on the gum and is almost through, or even when a small portion of a tooth has penetrated the gum, small areas of congested mu- cous membrane appear, and are of great aid in the diagnosis. In some cases a few hemorrhagic maculae appear in other parts of the skin, as in that of the forehead. In addition to the symptoms of epiphyseal pain, the infant keeps the affected limb perfectly still, so that, unless it were understood that it is pain which prevents it from moving the limb, it might be supposed that it was paralysis ; in fact, this symptom in scorbutus has been termed pseudo-paralysis. It has nothing to do with true paralysis, and corre- sponds to what is seen in rheumatic affections of the joints. Diagnosis. — The diagnosis of infantile scorbutus is to be made from rheumatism, rhachitis, purpura, syphilis, and acute anterior poliomyelitis. Rheumatism. — In the diagnosis from rheumatism the absence of heat and tenderness of the joint and of a pronounced rise of temperature is usually sufficient to distinguish the two diseases. Rhachitis. — The diagnosis from rhachitis is to be made by the presence of hemorrhages, the intense pain in the region above the epiphyses, the absence of a rhachitic rosary, and the absence of symptoms of rhachitis when it is not coexistent. If teeth are present, the occurrence of stoma- titis ulcerosa usually makes the diagnosis clear. In the cases in which rhachitis is present the symptoms of scorbutus appear to complicate a primary rhachitis, and when the scorbutic symptoms pass away the rha- chitic manifestations remain. DISEASES OF NUTRITION. 347 Purpura. — Purpura, except in the severe forms in which the joints are affected, is easily differentiated by the absence of the peculiar osseous symptoms of scorbutus. Syphilis. — Scorbutus is differentiated from syphilis by the extreme tenderness, the hemorrhages, and the commonly occurring stomatitis ulcerosa which occur in the former disease, while syphilis has distinctive symptoms which are not found in scorbutus, which will be described under the former disease. Acute Anterior Poliomyelitis. — The differential diagnosis between scor- butus and acute anterior poliomyelitis is made by the presence in the former of enlargement and tenderness in the neighborhood of the epiph- yses. Pain is present only in the initial stage of acute anterior polio- myelitis, and tenderness is absent. In acute anterior poliomyelitis, also, the onset is sudden, and there are no premonitory symptoms. Prognosis. — Scorbutus is very variable in its duration. If left un- treated, all the symptoms may become more pronounced and the infant finally die of exhaustion. When properly treated, and uncomplicated by any other disease, the prognosis is very favorable if treatment is begun early in the attack, before the vitality of the infant has been too much reduced. Treatment. — The treatment of infantile scorbutus is essentially by changing the improper food which in most cases is being given, to fresh milk and orange-juice. Under this treatment the pain and tenderness of the limbs rapidly disappear, sometimes Avithin a few days, as does also the stomatitis ulcerosa. In the beginning the juice of one orange should be given during the twenty-four hours. It usually is well to dilute the orange- juice one-third with water. If a rapid improvement does not take place, a still larger dose should be given within a few days. These scorbutic in- fants usually take orange-juice with avidity, but they should be forced to take it if they do not like it. The nurse should be cautioned to move the affected limbs as little as possible, and the infant should be kept on a comfortable pillow on which it can be carried about. In my earlier cases, before I recognized the scorbutic element in the disease, I treated these infants with a number of drugs, none of which appeared to have the slightest beneficial effect. In some of these cases the symptoms grew progressively worse, and the infants died. In one of them, however, in whom the hemorrhages in the skin were extensive and proptosis was marked, the infant recovered entirely when a properly modified milk was substituted for the artificial food which it had been taking. In some of the later cases which I have seen in consultation, where infants living in the country with good hygienic surroundings were being fed on one of the many artificial foods, the disease had progressed to such an extent that the infants were extremely anaemic, had hemorrhages in various parts of the skin, were unable to take any food, and were seemingly dying ; in fact, they were as much reduced as were the cases 348 PEDIATRICS. which I have just spoken of as having terminated fatally. These infants, after taking orange-juice for a few days, invariably improved rapidly, and usually recovered entirely in two or three weeks. All my cases have presented in different degrees the symptoms which I have just described, and which are well represented in the following case and in Fig. 91 : The infant, a female, ten months old, was healthy at birth and weighed 3636 grammes (8 pounds). It was nursed at first, but later was fed on a patent food, on which it did not gain. When it was eight months old it lost somewhat in weight, had profuse sweating, and began to have tenderness in its limbs. It had six teeth. There was an expression of fear on its face, and it kept its arms and legs perfectly motion- less. Fig. 91. Infantile scorbutus. (Second month of disease.) Female, 10 months old. Whenever it thought that its legs or arms were going to be touched it cried with fear. There was no evidence of rhachitis in this infant. There was a swelling of the diaphysis just above the epiphyses of the bones of the right wrist, and also in the lower part of the femur of each leg and the lower part of the tibia. The swelling did not fluctuate, had a hard, tense feeling, and apparently was not connected with the joints. There was no increased heat of the skin, but there were certain circumscribed areas of hemorrhage in the skin over the swellings. The gums showed the condition of stomatitis ulcerosa to so marked a degree that they almost covered the teeth. They were purple, bled easily, and were very similar to those represented in Plate XL, facing page 620. The infant's diet was changed to a modified milk, and it was given the juice of one orange daily. Within two days it moved its legs and arms freely, the anxious ex- pression left its face, and in a few weeks it had gained much in weight and was perfectly well. An examination of the blood in this case showed only a secondary anaemia. INFANTILE ATROPHY. Infantile atrophy (marasmus, athrepsia) is essentially a disease of in- fancy and early childhood, and occurs most frequently in the first six months of life. It is a condition in which extreme atrophy of all the soft tissues takes place without demonstrable disease of any of the organs. It is apparently the result of a vice of absorption, although this has by no DISEASES OF NUTRITION. 349 means been clearly proved. The wasting which occurs as the result of malformations of the mouth and throat preventing the entrance of suffi- cient food, or when insufficient food is given, should be considered as the result of starvation. The name infantile atrophy should be restricted to the cases in which such causes do not exist. In like manner the wasting which occurs in the course of constitutional diseases, such as tuberculosis or syphilis, or as the result of severe gastro-enteric disturbance, is not to be considered under the name of infantile atrophy. Etiology. — The cause of the primary cases of infantile atrophy is un- known. In a number of cases the disease seems to be secondary to grave intestinal disturbance, whether of toxic or of organic origin. The disease appears to depend upon improper diet or bad hygienic surroundings, either separately or in combination. Thus infants may develop the disease whose food is seemingly good but whose surroundings in crowded cities or districts are unhygienic as to light, warmth, pure air, and air space. On the other hand, the disease is at times met with in the country where the hygiene is good but the food poor. Pathology. — The pathological conditions which are found in cases of infantile atrophy are exceedingly unsatisfactory, and have not given us much information concerning the disease. Nothing abnormal is found in the various organs which can be said to be characteristic of this disease. It is supposed by some pathologists that the lymph-glands are enlarged, but this enlargement does not seem to be a prominent feature, and is chiefly confined to the superficial glands of the neck, axillae, and groins. No pathological condition of the mesenteric lymph-glands has been found, and the atrophy of the mesentery around them is so great that their increase in size may be seeming rather than real. In the intestine, although in some cases there is considerable atrophy of the mucous membrane and the submucous tissue, no characteristic lesion has been proved to be pres- ent. Therefore, until our knowledge of the pathology of this disease be- comes more definite, it is better for us to consider its pathology as simply atrophy. Certain secondary morbid conditions are frequently found. Prominent among these are anaemia, atelectasis in the lungs, bronchitis, broncho-pneumonia, fatty liver, and intestinal catarrh. Symptoms. — The essential symptom of infantile atrophy is extreme wasting. An infant which has perhaps been weak and delicate, or may have been seemingly well nourished, begins to emaciate. The prominent feature of the disease is the progressive and extreme loss of weight. The loss of subcutaneous adipose tissue is excessive, the skin is dry and wrin- kled, and hangs in folds on the bones, giving the appearance of a living skeleton or advanced old age. The extremities are cool. The abdomen soon becomes sunken. The tongue is dry and usually reddened. The pulse is feeble and usually rapid. The temperature is normal, or more commonly subnormal, but in some cases is raised. The respirations are generally normal. Although secondary anaemia is quite a prominent con- 350 PEDIATRICS. dition, extreme pallor is not usual. The appetite is usually lessened, but may be at times voracious. In many cases the food is well digested, and the discharges yellow and smooth. In some cases the total amount of the fsecal discharges in twenty-four hours is abnormally large. Regurgitation of food is common, and at times vomiting of a reflex nature becomes prominent. The normal faecal discharges at times are abnormal in color and consistency. In advanced cases ecchymoses may appear in the skin, sometimes covering the entire thorax. Diagnosis. — The diagnosis of infantile atrophy is chiefly to be made from ordinary starvation and from general tuberculosis. From the former it is soon differentiated by its lack of response to good food and improved hygiene. In the ordinary cases of starvation which result either from improper food, or from lack of food, a diet carefully adapted to the age of the infant or child is soon followed by rapid improvement. The cases of wasting from mechanical causes are recognized by detecting the special malformation which is present. Those cases which are secondary to other diseases are differentiated from the primary cases of infantile atrophy by the prominence in the history of the essential symptoms of such dis- eases. In other words, in these cases the wasting is not the one essential symptom. The differential diagnosis from general tuberculosis is at times exceed- ingly difficult. I have had under my care in the hospital in adjacent beds an infant with infantile atrophy and one with general tuberculosis. In these two cases the symptoms and courses of the diseases were iden- tical, and it was impossible to differentiate the two diseases except at the autopsy. On physical examination nothing abnormal could be found in either case except extreme emaciation. In both cases the temperature was slightly raised. The physical examination from tuberculosis, there- fore, if the temperature is raised, is almost impossible, as complicating processes in the lungs may produce evidence of solidification in infantile atrophy. Where, however, solidification is prominent in the front of the lungs, it is most likely to arise from tuberculosis. The presence or ab- sence of the tuberculin reaction will in many cases be needed to differ- entiate the two diseases. Prognosis. — The prognosis of infantile atrophy is bad, especially during the first year of life. Even under the most careful treatment it is always a very intractable disease. Even the most exact modification of the food at times entirely fails to cure the disease. When, however, the infant recovers, the recovery is usually complete, and perhaps within a year the child may show no signs of the previous serious condition. Treatment. — The treatment of infantile atrophy is essentially by such modification of the milk as to promote intestinal absorption, and without drugs. Especial attention should be paid to keeping up the bodily tempera- ture by external warmth and by the administration of stimulants. Small doses of brandy can often be given for weeks with great benefit. DISEASES OF NUTRITION. 351 Although, as has already been stated, it is not entirely proved that the morbid condition is that of a lack of absorption, yet my clinical results are most favorable when the disease has been treated on this principle. After experimenting in a large number of cases by modifying the different con- stituents of the milk in various ways, I have arrived at the following con- clusion : a mixture should be given which contains a low percentage of fat, a high percentage of sugar, and a moderate percentage of proteids. The low percentage of fat is given on the supposition that the infant will increase in weight and thrive on a small proportion of fat, provided it is absorbed. I have found that when higher percentages of fat are given the infant continues to lose in weight. The administration of cod-liver oil is not indicated in these cases, for it is only by a precise adjustment of the percentage of the fat in the food to the individual power of absorption that good results can be obtained. The sugar of high percentage and the proteids of normal percentage seem to be digested and absorbed provided they are combined with a low percentage of fat, since by this combina- tion the nutritive properties of the sugar and of the proteids are made use of. The prescription which I usually write in the beginning of the treat- ment of these cases, when they occur in the first year of life, is the fol- lowing : Prescription 52. Fat 0.50 Sugar 6.00 Proteids (lactalbumin 0.75, caseinogen 0.25) 1.00 Lime-water 5.00 After the infant has begun to gain in weight I usually increase the percentage of the fat, but for a number of weeks I do not raise this per- centage above 1 or 2. When the infant has once begun to gain steadily the power of absorbing fat is rapidly regained, and percentages such as are in the following prescription can then be given : Prescription 53. Fat 3.00 Sugar 7.00 Proteids 2.00 Lime-water 5.00 The same treatment can be carried out when the disease occurs in children in their second and third years, but in these cases it is usually possible to increase the percentages of the different elements more rapidly, and after two or three weeks to begin with other articles of diet, such as beef-juice, broths of various kinds, and finally, with caution, cereals. These special modifications of the milk do not, of course, suit every individual infant or child, and when the treatment with them is not suc- cessful, each of the elements of the milk must be carefully changed and different combinations of these elements tried until the individual idiosyn- crasy of absorption in the special case has been discovered. A very im- 352 PEDIATRICS. portant part of the treatment is the general hygiene, especially sufficient air space and pure air. The following cases illustrate infantile atrophy of high grade. An infant nine months old had been fed on foods of various kinds, all of which contained a considerable percentage of starch. She is said to have been healthy and plump at birth and during the early months of life while she was nursed. After she was weaned and placed on starchy foods she began to lose progressively in weight, and became extremely emaciated. Physical examination showed nothing abnormal. She had four teeth. Her temperature was slightly subnormal, her pulse was regular but weak, her respirations normal. On first entering the hospital the bowels were consti- Fig. 92. Infantile atrophy. Female, 9 months old. pated and the faecal movements were brown and looked poorly digested. On being placed on a diet of modified milk the movements became well digested and of normal color, but the total amount in twenty-four hours was greater than usual. She was very fretful, and at times vomited, but when her diet was regulated she became less fretful and somewhat apathetic. On entering the hospital she weighed 2966 grammes (6J pounds). She was in the hospital two weeks, and gained in that time 1000 grammes. The food which was found to suit her powers of absorption contained fat 1, sugar 5, proteids 1, lime-water 5, and 60 to 120 c.c. (2 to 4 ounces) were given every two hours. She did not increase progressively in weight, but sometimes lost considerably, and once it seemed as though she could not possibly live. After the food had been modi- fied in various ways, she finally began to improve, and when she was able to digest and absorb 150 c.c. (5 ounces) of milk so modified as to contain fat 3.5, sugar 6.5, and proteids 1.5, she improved rapidly, and eventually recovered entirely. Her tempera- ture, with few exceptions, was normal or subnormal through the whole course of the attack. Fig. 93. Infantile atrophy. Female, 10 months old. This next case was also one of infantile atrophy of high grade. An infant 10 months old entered the hospital with a history of having been fed on various foods containing starch from the earliest months of its life. It was said DISEASES OF NUTRITION. 353 to have been healthy at birth and of average weight. On entering the hospital it weighed 2593 grammes (of pounds). It was extremely emaciated, and illustrated the more advanced stage of infantile atrophy. It was unable to raise its head and was apathetic ; its skin was cool and dry ; its respirations were shallow ; its pulse was weak, and its temperature was slightly subnormal. It looked as though it could not live many days. A physical examination showed nothing abnormal in any of the organs. The faecal movements were rather large in amount, but when its food was carefully regulated, became fairly well digested. On entering the hospital they were still larger in amount and were of a brownish color. It weighed, after being in the hos- pital one week. 2570 grammes (about 5* pounds), which was slightly less than its weight on entrance. It was fed on a modified milk in which the percentage of fat was 2. sugar 6. proteids 1, lime-water 10. In two weeks the infant began to gain in weight and to absorb its food. Although it had a number of relapses, in which it lost considerably in weight, it finally began to gain steadily. At the end of three months it had recovered entirely, and was quite plump. In this case the percentage of the fat was finally raised to 4, and that of the sugar to 7, but the proteids had to be kept at 1 ; the lime-water was reduced to 5. The next case was a female, one and a half years old, who,, on entering the hos- pital, weighed 4281 grammes (9h pounds). She was said to have weighed but 900 grammes (2 pounds) at birth. She was nursed by her mother, who apparently had plenty of good breast-milk, and who had two other children whom she had nursed Fig. 94. Infantile atrophy. Female, 1% years old. that were healthy and strong. As the infant did not gain, she was nursed for only a short time, and was then fed on various artificial foods. She began to lose in weight, and this loss continued so that her emaciation was extreme. On physical examination the anterior fontanelle was found to be widely open. There was no enlargement of the epiphyses of the ankles or wrists, but there was a slight rhachitic rosary. Nothing abnormal could be detected in any of the organs. She had four upper and two lower incisors. She was very apathetic, and seemed hungry, but when food was given to her she vomited. After entering the hospital she lost 519 grammes (It pounds) in two weeks. Her skin was dry, harsh, and at times quite cold. The faecal movements were very large in amount, but after entering the hos- pital were fairly digested. The cervical and inguinal glands were slightly enlarged and she had a slight cough. She lost steadily in weight, did not respond to the various modifications of the milk given to her, and died three weeks after entering the hospital. The post-mortem examination showed the following condition : There was ex- 23 354 PEDIATRICS. treme atrophy of all the muscles. There were no changes in the mesenteric glands, and they were not enlarged, although the extreme atrophy of the mesentery around them made them appear so. The liver was normal and its tissue showed little evidence of atrophy. The spleen was normal. Sections made from various places in Pig Infantile atrophy, showing extreme emaciation of arms, back, and hips. the stomach and the intestines showed no changes beyond considerable atrophy of the mucous membrane of the submucous tissues. The thyroid gland was atrophied. There was an extensive bronchitis in the posterior portion of the lungs, while in some parts there was a partial, and in others, a complete atelectasis. DIVISION VII. DISEASES OF THE SKIN. The rule that the child should be inspected in every part is very im- portant, and is especially applicable to cases in which there is disease of the skin. The lesions of the skin in children differ somewhat from those which occur in adults, and these variations, both in degree and in kind, often make a differential diagnosis more difficult. Every practitioner has doubt- less been struck by the similarity which at times is seen in the cutaneous lesions of the various forms of erythema to such diseases as syphilis, scar- let fever, and erysipelas. I have known the delicate pink of an abdomi- nal erysipelas in a young infant mistaken so completely for scarlet fever that the precaution of removing the carpet in the room had already been taken. In like manner a slight grade of the efflorescence of scarlet fever may be mistaken for that of erythema neonatorum. I have also seen a harmless papular erythema closely simulating and mistaken for one of the papular efflorescences of syphilis. The efflorescences which follow the administration of antitoxin also closely simulate scarlet fever, measles, and the different forms of erythema. Another rule, and one of equal importance, is that no single dermal lesion, whether it be a macule, a papule, a vesicle, or a pustule, makes it justifiable for us to decide that an especial disease is present. We must remember that the same cutaneous lesion may appear in almost any dis- ease, and that it is the combination of dermal lesions and general symptoms which makes up the entire picture of the disease and justifies us in making a diagnosis. It is very important, therefore, to have a fair, general knowledge of the local diseases of the skin as they appear in children, in order that a correct differential diagnosis can be made from the constitutional diseases with dermal lesions, which have to be treated by those who practise among children. SCABIES. Scabies represents the purest type of a primary disease of the skin. It is caused by an especial parasite, the Acarus seabiei. The following case illustrates the disease : 855 356 PEDIATRICS. The child, two and a half years old, was healthy and well developed. For two weeks it had been very irritable, and its mother brought it to the hospital to inquire about an efflorescence which had appeared on its skin. On investigating the lesions a number of small papules and a -few pustules scattered irregularly over the arms and chest, and one or two small pustules on the soles of the feet were found. The fingers were not especially affected, but in one or two places at the base of the fingers the efflo- rescence could be plainly seen. In addition to the papules and pustules there were numerous lesions of the skin caused by scratching. On the delicate skin of the abdomen was a minute black line with a vesicle at one end of it. On removing carefully with a needle a little of the fluid in this vesicle and placing it under the microscope, the para- site, which evidently had its habitat in the vesicle, could be seen. This organism, which I shall not describe more fully, as it is best studied in works especially devoted to diseases of the skin, is called the Acarus scabiei, and is the cause of this special dermal lesion. The black line represented the burrow by which it enters and through which it travels as far as the vesicle, where it lodges and produces irritation, causing first, a minute papule, and then a minute vesicle. Finally the vesicle may become pustular. In this case, the child's mother showed the lesions of scabies between her fingers. In contradistinction to the effects of the Acarus scabiei on the skin of adults we find in infants and young children that the parasite may attack the soft skin of the soles of the feet, while in the adult we do not find the lesions on the soles, as in walking the skin has become toughened in that locality. In adults efflorescences on the soles of the feet and the palms of the hands are rather unusual unless they are connected with syphilis or artificial eczema. Infants and young children are usually in- fected by the Acarus scabiei from sleeping in the bed. with some adult who has scabies. Treatment. — In the treatment of this disease it is very important to treat it in the mother as well as in the child. The clothes of the bed, of the mother, and of the infant should first be thoroughly steamed, in order to kill the parasite, and it should be impressed upon the mother that the treatment must be carried out very carefully, and that all the clothes which have come in contact with the skin must be thoroughly cleansed. The treatment of scabies in the child should differ somewhat from that which is employed when the disease occurs in the adult, because the skin of the former is much more sensitive than that of the latter. The severe remedies which can properly be used in treating the adult should not be employed in the treatment of infants and young children. A simple and effective ointment recommended by Bowen is as follows : Prescription 54. Metric. Apothecary. Gramma. R Balsami Peruviani, R Balsami Peruviani, Petrolati aa 60 l Petrolati aa ^ ii. M. M. For older infants and children an ointment containing some sulphur may be employed without much danger of irritating the skin. DISEASES OF THE SKIN. 357 Pre SCRIPTION 55. Metric. Gramma. Apothecary. R Sulphuris sublimati ~ R Sulphuris sublimati 5 i Balsami Peruviani, Balsami Peruviani, Petrolati . . . aft 30 Petrolati M. ... aa 1'\ M. In the use of either of these ointments the following technique should be employed. The child is to be first thoroughly washed with warm water and soap. The skin is then dried, and the ointment is applied over the whole body, avoiding the head, which is seldom attacked by the parasite. The face especially might be irritated by the ointment. The ointment is allowed to remain on the child during the night, and in the morning is washed off with warm water and soap. The skin is then thoroughly powdered with the zinc and starch powder mentioned on page 98. This treatment is continued for three or four days, and then, if the disease is not entirely cured, it can be repeated for a few days more. A certain amount of eczema usually follows the treatment, owing to the irritation produced by scratching, which is very difficult to prevent. This eczema should be treated by soothing applications. PEDICULOSIS. A parasite whose nidus is on the head appears quite frequently in children as well as in adults. It is especially met with among the poor and ill cared-for. This parasite, the pediculus capitis, causes extreme irri- tation of the skin, which often results in eczema and in enlarged glands. Although the pediculus itself is in the hair, yet by its irritating action on the scalp of the child it frequently gives rise by reflex influence to patches of eczema grouped about the nose and ears. Treatment. — In treating these cases the hair and scalp should first be saturated with petroleum. This application is allowed to remain on the head for several hours, and later is thoroughly washed off with soap and water. The nits should then be carefully removed by means of a fine comb wet with vinegar. It is usually necessary to repeat the treatment for two or three days. IMPETIGO CONTAGIOSA. Impetigo contagiosa is a disease which usually occurs in children, but it may be found in adults. It sometimes appears as an epidemic, and in these cases, in all probability, is caused by the same micro-organism as in the isolated cases. It is usually met with among the poorly cared-for, but it may attack the healthy as well as the sick and weak. Symptoms. — The form of the efflorescence is variable. Beginning as small vesicles, the lesions soon spread over a larger area, coalesce, usu- ally form pustules, and later become rapidly covered with a thick yellowish crust. The lesion may occur on any part of the body, but is especially common on the face and hands. The itching is very slight in these cases, 358 PEDIATRICS. and there is no constitutional disturbance caused directly by the parasite. In accordance with the idea that it is of parasitic origin, the prognosis is favorable, and the disease can usually be cured in a week or ten days. Treatment. — The treatment of impetigo contagiosa is very simple, and consists in cleanliness, exposure to sunlight, and the application of an ointment such as the following : Prescription 56. Metric. Apothecary. Granima. R Acidi borici 3 75 R Acidi boriei 3 i ; Adipis 30 00 Adipis 3 i. M. M. FURUNOULOSIS. Closely connected with impetigo contagiosa is furunculosis. which is supposed to be caused by the same micro-organisms that give rise to im- petigo contagiosa, but which affects a different part of the skin, such as the deeper portions of the hair-follicle, in contradistinction to the upper layers of the skin, the part affected by impetigo contagiosa. These micro- organisms are called the " pus organisms," and are usually represented by the staphylococcus pyogenes aureus. Treatment. — The treatment should be with an antiparasitical oint- ment or solution preferably containing boracic acid. In many cases in addition to this local treatment some form of constitutional treatment should be employed, as the children are usually in an abnormal condition. The lesions should be bathed every day with the folloAving solution : Prescription 57. Metric. Apothecary. Gramma. R Acidi borici 15 R Acidi borici ^ ss ; Aq. destil 240 Aq. destil 3 viii. M M. After the parts have been thoroughly bathed with this solution the fol- lowing ointment should be spread on linen compresses and applied to the lesions : Prescription 58. Metric. Apothecary. Gramma. R Acidi boraci 3 75 R Acidi borici 3 i ; Petrolati 30 00 Petrolati 3 i. M. M. MOLLTTSCUM CONTAGIOSUM. Another probably parasitic disease which is rare, but which is more frequent in children than in adults, is molluscum contagiosum. It occurs most commonly on the face, although it may be found on other parts of the body. The lesions consist of small, firm nodules of a whitish color. with a central depression from which matter of a sebaceous consistency may be pressed. The diagnosis is not difficult for one who has once seen DISEASES OF THE SKIN. 359 the efflorescence, the only condition with which it might possibly be con- fused being verruca, which, however, does not occur commonly on the face, has no central depression, and does not contain any substance which can be squeezed out. Treatment. — The treatment of these lesions is to puncture them, squeeze out their contents, and dress them with the same ointment as in Prescription bS. SEBORRHCEA CAPITIS OF INFANTS. Seborrhcea capitis consists of a collection of brownish-yellow crusts formed by a mixture of sebaceous matter and epithelial scales on the top of infants 1 heads. It is simply a tendency to over-production by the seba- ceous glands of their secretion, which, mixed with dirt, produces this con- dition. The whole scalp of the infant should be perfectly clean, and in all cases it is safe and best to remove the crusts, as they are frequently the starting-point for eczema. Plate III., B, facing page 84, represents this condition. The crusts should be gently and gradually removed by first soaking them with warm sweet oil, and then washing them off with soap and warm water. Some simple ointment should be kept continuously on the part affected, to prevent the reaccumulation of the crusts until the ten- dencv has ceased. TINEA TRICOPHYTINA. The disease called tinea tricophytina, or ringworm, occurs clinically in two forms. The first form affects the scalp, and is called tinea tonsurans. The other form attacks the non-hairy portions of the body, and is called tinea cirdnata. The disease itself is called tinea tricophytina, and the parasite which causes it is called the tricophyton tonsurans. Tinea tricophytina has the peculiarity of not appearing on the scalp except in children, but is the same disease that occurs in adults in various localities, as on the face in men, destroying parts of the beard. It may also occur on any part of the body both in children and in adults. Its cause can usually be traced to the same parasitic affection in some other person or some animal. The second form of tricophytina, tinea cirdnata, may at times appear as numerous multiple lesions in different parts of the body, and is easily affected by anti-parasitic applications. Treatment. — The treatment of this disease should be active, and it is usually necessary to continue it for a long time, especially in cases in which the parasite has attacked the head. The treatment should be with the following ointment : Prescription 59. Metric. Apothecary. Gramma. R Acidi salicylici, | R Acidi salicylici, Sulphuris aa 3175 Sulphuris aa gi ; Lanolini 30100 Lanolini 51. M. M. 360 PEDIATRICS. It should be applied twice daily, and should be thoroughly rubbed into the bald spots, the skin first having been washed with soap and water. When the case proves to be somewhat intractable, still stronger appli- cations can be used, and, if necessary, a certain amount of carbolic acid Fig. 9( can be mixed with the ointment, from one-half to one drachm to the ounce of ointment. Fig. 96 represents a boy. eight years old, with two bald spots on the back of his head. The hair over the rest of his head was thick, and there were no appearances of loss of hair anywhere else on his scalp. The areas of scalp attacked by this disease vary in size. In this special case, however, the spots were about 2.5 cm. (1 inch) in diameter. As a rule, they have a fairly regular circumference. On examining the spots- one will notice that there are little short hairs on their surfaces, which evidently have broken off from lack of nutrition. On the edges of the spots this is especially noticeable. If one of the hairs is placed under the micro- scope, one will find a specific organism which has been determined to be the cause of this disease. It is of vegetable origin, and consists of masses of spores composed of threads of mycelium, some long and some short, which are divided into numerous segments. Tinea tonsurans. Male. 8 years old. TTNEA FAVOSA. Tinea favosa, or favus, is a parasitic disease. Its favorite seat is the scalp, although it may attack any part of the body. It appears in the form of small, bright yellow, cup-shaped crusts, which upon their removal leave a permanent but superficial cicatrix. These yellow crusts penetrate the hair-follicle and destroy the growth of the hair. When placed under the microscope they are found to consist almost entirely of mycelium and spores of the form called Achorion schoenleinii The crusts often become confluent, forming a large thick covering over an extensive area. Treatmext. — The treatment is the application of an ointment to soften and remove the crusts, epilation, and anti-parasitic ointments such as described for ringworm. TTNEA VERSICOLOR. This is a very rare disease in children. A case seven and a half years old has been reported. It is a parasitic disease caused by the microsporon furfur. The lesions consist of patches of fine yellowish scales, usually situated on the trunk. There are no subjective symptoms. Paraciticicles combined as in Prescription 55. page 357. remove the disease very quickly, but it is prone to recur. DISEASES OF THE SKIN. 361 ALOPECIA AREATA. The nature of the disease alopecia areata has not yet been determined. The lesion of alopecia areata consists of an irregular surface of the scalp entirely free from hair up to where the long hair begins to grow on its edges; The appearance of the skin over this spot is normal. The diagnosis is made by finding a bald spot on the head having the appearance just described. The remaining part of the scalp is found to be in a healthy condition and well covered with hair. Alopecia areata is to be differentiated especially from tinea tricophytina. In contradistinction to the sound and healthy-looking skin of the former, we find in the latter numerous short hairs, which are broken off through the action of the parasite. Alopecia areata is somewhat intractable to treatment and runs a rather long course, but, as a rule, in children can be cured. Treatment. — The treatment is the continual application of stimulating remedies, such as the following ointments of sulphur and tar : R Sulphuris . Petrolati . M. R 01 ei cadini Petrolati . , M. Metric. Metric. Prescription 60. Gramma. Apothecary. 30 75 R Sulphuris gi ; 00 Petrolati % i. M. Prescription 81. Gramma, g .. 30 Apothecary. 75 R Olei cadini ^i ; 00 Petrolati g i. M. These remedies should be used so as to produce a slight rubefaction, but not inflammation. PEMPHIGUS NEONATORUM. In addition to the true pemphigus of adults, the pemphigus which is secondary to diseases of a debilitating nature, and the epidemic pemphigus infantilis, we at times meet with a form of pemphigus which seems to be caused by a parasite of the skin. These cases have been described by Blomberg, but they have not yet been fully accepted by dermatologists, and it is well to remember that on the delicate skin of infants and younp; children impetigo contagiosa may cause the lesion of pemphigus through the activity of the parasite and the great vulnerability of the skin. PEMPHIGUS. Pemphigus is a disease of a constitutional character, and is represented by large blebs and bullae. It occurs at times in infants and children as it does in adults, but is very rare. There is a form of pemphigus, however. 362 PEDIATRICS. which I have met with in infants and children in which bullae of various sizes appear upon the limbs and trunk, and which is not connected with syphilis. It usually occurs in poorly nourished children, and can come not only as a disease of itself, but also as one of the sequelae of debilita- ting diseases, such as pneumonia, rheumatism, and others. When it is secondary to other diseases it represents a condition of malnutrition, and in all probability is not connected with the real disease pemphigus. In my expedience this class of cases is not especially serious, but merely represents a greater or less degree of lack of vitality of the skin. This form of pemphigus, in which the efflorescence is secondary to other diseases, is not usually seen upon the soles of the feet or in the palms of the hands, and this is of considerable aid in distinguishing the disease from the bullous form of syphilis. Treatment, — There is no especial local treatment which appears to benefit this condition of the skin, but it soon disappears when the general nutrition of the child has again become normal under appropriate feeding. EPIDEMIC PEMPHIGUS INFANTILIS. Where pemphigus occurs as an epidemic among infants in foundling hospitals it is of a more serious nature, and is accompanied by constitu- tional symptoms, represented by fever, sometimes lasting from three to six weeks. In these cases it is usually acute, but it may become chronic, and last, with intervals of recurrence, for many weeks or months. These cases are more apt to be fatal than the other forms. The true epidemic form of purulent pemphigus, as it has been called, is almost always fatal, and in cases in which it is not secondary to any other disease has a grave prognosis. Many of the reported cases of this epidemic form, as well as of the other forms of pemphigus, may really be only manifestations of the staphylococcus invasion. DERMATITIS EXFOLIATIVA NEONATORUM (Ritter's Disease). In the year 1878 Ritter gave the first complete description of the dis- ease dermatitis exfoliativa neonatorum. Previous to this date cases of this affection had been reported, but many of them were regarded as some rare or unusual manifestation of pemphigus. Ritter studied and reported the cases which he saw at the Foundling Asylum in Prague from 1868 to 1878. A careful review of Ritter's original observations of these cases has been made by Elliot. The majority of cases were in male infants, and the mortality was found to be 48.82 per cent. The disease is very rare. It occurred rarely before the end of the first week, and usually appeared between the second and the fifth week of life. It was found to vary greatly in the intensity of its symptoms. In some cases a dry scaly condition of the skin preceded the subsequent lesions, which had ap- parently lasted after the physiological desquamation of the epidermis had taken place. DISEASES OF THE SKIN. 363 Symptoms. — The first symptom noticeable in these cases was a diffuse redness, usually over the lower half of the face about the mouth, some- times, however, beginning in some other portion of the body, and at times being universal from the beginning. This hyperemia of the skin spread rapidly, and in a few days became universal, the extremities, as a rule, being the last parts affected. The mucous membrane of the mouth and nose was at times affected, and the conjunctivae usually participated in the hyperemia. The color of the efflorescence varied from a light to a dark purple-red. As the hyperemia extended to new surfaces, those which were first affected began to desquamate. This desquamation at times gave no evidence of exudation, the epidermis being simply thickened, and the loosened epithelium separating easily. At times other lesions appeared, such as milia, and sometimes the horny layer of the skin was raised above an intensely reddened base, and large, irregularly shaped bullae filled with fluid were formed. After the desquamation had taken place the skin re- covered its normal condition, occasionally very rapidly, but it remained for some time rough and irritable. In the cases in which there was no exu- dation a longer time was necessary for the separation and regeneration of the epithelium. Usually the disease was found to run its course in from seven to ten days. Relapses were sometimes observed ten or twelve days after the first attack, but were always mild. In typical cases the process was unaccompanied by any fever or sys- temic disturbances unless some complication existed. The functions were normal, and the weight of the infant remained stationary or was even at times increased. The fatal cases resulted either from the intensity of the attack or from some intercurrent affection or sequela, such as furunculosis. The disease is usually recognized as a local septic infection of the skin, and it would seem that it should be distinguished from the pemphigus which occurs in the early weeks of life. I have myself seen but one case in which it seemed that this diagnosis of dermatitis exfoliativa could reasonably be made. This case was a male infant, who at the fourth or fifth day of its life presented a marked condition of erythema neonatorum. After a few days this erythema began to desquamate slightly, but somewhat later a pronounced dermatitis appeared and ran its course for a week. During the course of the disease there were lesions of various kinds represented by a few pustules and bullae, but mostly by an intense erythema. The lesions gradually grew less intense, a profuse desquamation took place, and the skin then presented a normal appearance. During the course of the disease the infant did not show any constitutional symptoms, and gained somewhat in weight. The parents were healthy, strong people, with good hygienic surroundings. DERMATITIS. Dermatitis is an inflammatory affection of the skin, produced by some recognized cause. The lesions are, as a rule, fugitive, and with a few ex- ceptions are not characterized by an especial and peculiar form of eftlo- 364 PEDIATRICS. rescence. The course of the disease, and the recognition of some definite exciting cause, enables us to distinguish this condition from others which resemble it Clinically the group may be divided into a dermatitis traumatica, derma- titis venenata, dermatitis calorica, and dermatitis medicamentosa. Dermatitis Traumatica. — Dermatitis traumatica is the term applied to the local reaction which takes place in the skin, following some trauma, either slight or severe, such as may result from pressure, friction, or direct blows. The lesions vary from a simple, temporary erythema to deep and extensive ulcers, as in certain bed-sores. Dermatitis Venenata. — Dermatitis venenata is the name applied to those dermal lesions which are caused by the external application or con- tact of irritating substances. The inflammatory condition may be due to simple mechanical irritation, such as is sometimes caused by the lodgement in the skin of small particles of matter ; or it may be due to a poison, arising either from emanation of a poisonous volatile principle or from actual contact. Ivy poisoning is one of the most common and important examples of this class of affections. It is caused by contact with the leaves of the rhus toxicodendron. The cases are most common in the autumn, probably owing to the fact that people are tempted to gather the leaves because of their brilliant coloring at this season of the year. There is some difference of opinion as to the volatility of the poisonous active principle. Rhus venenata, or poisonous oak, is another common cause of ivy poisoning. Some of the more important irritants which may produce a dermatitis venenata are chrysarobin, an effective remedy in psoriasis, preparations of carbolic add, turpentine, iodine, mercury, and sinapis. There are sixty or more drugs (White) cited as more or less frequent causes of a dermatitis. Knowing the great delicacy of an infant's skin, we cannot be too cautious in prescribing ointments and applications, or in seeking for the cause of a dermatitis in some article which is of common use perhaps, but at times an undoubted source of irritation to the skin. Symptoms of Ivy Poisoning. — The eruption appears generally within a day or two after exposure, with redness, oedema, and papules, which pass rapidly to the stage of vesicles, which may become pustular from a second- ary infection. The course of the disease is from two to six weeks. The face, hands, and genitals are especially liable to be the seat of the disease, the extension to other parts of the body taking place by means of the hands. Diagnosis. — The lesions of ivy poisoning resemble those of an acute eczema. In making the diagnosis especial attention should be paid to a history of exposure to ivy, the time of year, the asymmetry in the dis- tribution of the lesions, and the history of previous attacks, and especial susceptibility will often aid in the exclusion of other similar conditions, es- pecially eczema. DISEASES OF THE SKIN. 365 Treatment. — There is no specific remedy. The treatment is the same as in an acute eczema, except that it is well to begin by washing the skin thoroughly with soap and water. Prescription 66, page 370, maybe used as a wash, and some simple ointment, as Prescription 68, page 372, may be applied. Dermatitis Calorica. — Dermatitis calorica is a form of dermal inflam- mation produced by the milder degrees of heat. The action of the sun's rays is the simplest and most common type met with in children. The lesions vary from a simple erythema to vesicles and bullae, depending upon the intensity of the heat, the duration of exposure, and the suscep- tibility of the skin in an individual case. Diminution of heat may pro- duce lesions the character and course of which are very similar to those which result from an excess of heat. Chilblains are a common example of the result of a diminution of heat. They occur chiefly in children with feeble circulation who wet or chill their feet, and suddenly heat them. In such instances the skin is red, soft, and boggy. The boggy areas may break down and form indolent ulcers, which are difficult to cure. Treatment. — The treatment of these cases of dermatitis calorica is the application of some simple lotion, as in Prescription 63, page 367, or of an ointment, as in Prescription 68, page 372. Dermatitis Medicamentosa. — Dermatitis medicamentosa is a general term including a great variety of lesions produced by the action of certain drugs administered internally. Arsenic may produce an efflorescence of a very complex character which may be erythematous, papular, urticarial, bullous, pustular, and even hemorrhagic. It may also give rise to a herpes zoster, as a result of certain changes in the nerve-endings. Belladonna often produces an efflorescence of an erythematous character resembling closely that which occurs in scarlet fever. The iodides are especially likely to cause an efflorescence of acne. The bromides often cause lesions of a papular or pustular character. Both the bromides and iodides occasion- ally cause lesions of a most unusual character. Chloral, digitalis, opium, quinine, the salicylates, and many of the recent new remedies sometimes cause an efflorescence. The erythematous, urticarial, and papular efflo- rescences which are seen at times after the administration of antitoxin will be more fully described under diphtheria. Treatment. — The treatment consists in discovering and discontinuing the drug the use of which is causing the irritation of the skin. SUDAMINA. Sudamina is a non-inflammatory condition of the skin caused by occlu- sion of the ducts of the sweat-glands. The lesion is represented by minute pearl-like vesicles occurring on the skin in crops, and is not apt to appear in febrile conditions. The disease is of no significance and requires no treatment. 366 PEDIATRICS. ERYTHEMA. Erythema plays an important part in the diseases of infants and young children. Although it is one of the most common and readily diagnosti- cated diseases of the skin which occur in early life, yet at times it is quite difficult to differentiate it from other diseases, owing to the variety of its forms. It may be divided into two broad classes : (1) the congestive form, or erythema simplex, which is caused by traumatism and by various drugs, and is also symptomatic of the acute exanthemata ; (2) the inflammatory form, erythema multiforme, which may affect any part of the body and either small or large surfaces. It has, however, a predilection for the backs of the hands and of the feet. Its lesions may be represented by maculae, or in the process of its evolution these maculae may develop into maculo-papules, vesico-papules, papules, vesicles, and even bullae. The lesions vary in size. The color varies from bright red to purplish red, and is sometimes very vivid. The delicate texture of the skin of young subjects is more likely to show variations in the color and the form of its lesions than is the fully developed and stronger skin of the adult. Erythema Simplex. — Symptoms. — The symptoms of the congestive form are varied, and they do not accompany each manifestation of the disease with any especial regularity. The slightest local irritation, whether from parasites or trauma of any kind, changes in temperature, reflex irri- tation from the close connection between the digestive organs and the skin, and many other reflex manifestations, may produce the disease. Erythema Multiforme. — Symptoms. — In erythema multiforme there may be pains in the joints simulating rheumatism, malaise, slight fever, nausea, coated tongue, loss of appetite, and a swollen, tender skin. These more marked symptoms are, however, often absent, and the lesions of an erythema multiforme commonly appear on the skin of young subjects without any special general symptoms accompanying them. It is better in nursery practice not to endeavor to classify this protean disease under special names which have been handed down from time immemorial in the text-books, and which have no particular significance. They have been used indefinitely by physicians, and the same form of lesion is sometimes called by one name and sometimes by another. Treatment. — The treatment of all forms of erythema is practically the same. It consists chiefly in the application of a simple poAvcler of oxide of zinc and starch, and of a lotion consisting of either lime-water or rose- water in which calamine and oxide of zinc are suspended. Prescription 62. Metric. Apothecary. Gramma. B: Zinci oxidi 7 5 R Zinci oxidi gii : Amyli tritici 60 Amvli tritici £ ii. M. 31. S. — For external application. DISEASES OF THE SKIN. 367 Prescription 68. Metric. Apothecary. Gramraa. R Zinci oxidi. R Zinci oxidi, Calaminae praeparatae aa 7 Aquae caleis 240 M. M. S. — For external application 5 Calaminae praeparatae aa gii ; Aquae caleis ^ viii. ERYTHEMA INTERTRIGO. This is a congestive form of erythema. It is represented in Plate III., A. opposite page 84. This form of erythema is that which occurs in infants in the folds of the groin, neck, and axillae. The lesion has already been described under erythema simplex. Napkins soaked with urine and allowed to remain for some time without being changed are a frequent cause of this condition. The treatment is to keep the skin clean and dry by the application of a simple powder such as is given above on page 366. No water should be used on the parts affected, but in its place equal parts of lime-water and water can be used for washing. In the more severe forms of this disease, in which the erythematous condition has become eczematous, and where the skin in the folds of the groins, of the neck, or of the axillae shows fissures and the moist con- dition represented by eczema madidans, I have found an application of boracic acid powder efficacious. ERYTHEMA NODOSUM. Another form of erythema, called erythema nodosum, is a disease which is closely allied to erythema multiforme. The general character- istics and symptoms of erythema nodosum are well represented in the following case : A little girl, five years old, was perfectly well until two days before she came under observation. At that time she began to have loss of appetite, fever, and malaise, fol- lowed by pain in both her legs. Following these general symptoms an efflorescence appeared in various places on her legs. It was found above and below the knees, but mostly over the tibiae and extending down as far as the ankles. These lesions were from 1.2 to 2.5 cm. (h to 1 inch) in diameter, and were of a somewhat irregular elliptical outline. They were of an erythematous type and had a delicate pink color. The skin over the lesions was hot in comparison with the unaffected portions of the skin around them. The lesions were tender on pressure, and their tissues were somewhat indurated, so that the feeling was that of a hard, raised swelling. The disease is self-limited, but is irregular in its course. It usually disappears in about two weeks. Its cause is not known. The treatment is simply palliative. ERYTHEMA URTJOATUM— URTICARIA. Nettle-Rash, Hives. — The term urticaria has been applied to an efflo- rescence characterized, as a rule, by wheals, which appear suddenly and disappear quickly. It is accompanied by intense itching and burning, and 368 PEDIATRICS. may show itself on any part of the skin, in lesions either small or large in number. It is commonly caused by irritation of the gastro-enteric tract. The disease may end in two or three days, but usually lasts for some weeks, and may become chronic ; it is essentially, however, an acute affection. If the lesion has been severe there may be slight desquamation, but this is rare. Sometimes there may be only one attack ; again there may be relapses, and in some forms and in certain skins it may occur from year to year. When seeking for the cause of an outbreak of urticaria it is necessary to investigate carefully as to whether there has been an error in diet. In children some simple article of food may cause an urticaria to appear, just as in some adults the disease occurs from an idiosyncrasy which pro- hibits them from eating oysters, lobsters, strawberries, or certain other articles of diet. Again, in some individuals, certain drugs, such as chloral, bromide of potash, chlorate of potash, and belladonna, may cause the dermal lesions of urticaria. The wheals of urticaria frequently occur as a symptom in the course of various diseases, such as scabies, or may be caused by the bites of insects. Treatment. — The treatment should be directed first to the removal of the cause of the dermal irritation. When this cause has been removed the dermal lesions will, as a rule, disappear, unless still further irritation has been produced by scratching the lesion or by its being too severely treated by the physician. The diet should be milk for a time, and experiments should be made with different articles of food to see which one may cause this especial form of irritation. The bowels should be carefully regulated. The local applications consist of remedies to relieve the itching and burning, in the wearing of unirritating clothing and soft linen next the skin, and in a powder of starch and zinc, made as described on page 366, frequently applied to the lesions at intervals during the day. When the itching is extreme, anti-pruritic lotions and ointments should be used, as in the following prescriptions : Prescription 64. Metric. Apothecary. R Pulv. calamine 7 Aq. calcis 240 Acidi carbolici 1 Gramma. 5 R Pulv. calamine 3 ii ; Aq. calcis ^ viii ; 87 Acidi carbolici 3 ss. M. M. When this lotion is not sufficient to allay the irritation and when the burning is extreme, the following ointment can be applied : Prescription 65. Metric. Apothecary. Gramma. R Menthol 016 R Menthol gv. x ; Adipis 3olo Adipis J i. M. M. DISEASES OF THE SKIN. 369 ECZEMA. Eczema is a disease of the skin which plays a much greater role in infancy and early childhood than in any other period of life. It is often very difficult to cure. Even in the milder forms of the disease we should be cautious about giving too favorable a prognosis at first, for the disease may extend and involve new areas of skin. Pathology. — The pathological changes which occur have been desig- nated by certain descriptive names, such as eczema erythematosum, generally secondary to other lesions ; eczema papillosum, which maybe a terminal or merely a secondary stage of the process ; eczema vesiculosum, which is never primary, but is preceded by a papular stage, and may end as such or pass on to the more advanced lesions ; eczema madidans, or " weeping eczema." in which the vesicles form large blisters containing sero-purulent or sero-hemorrhagic contents which exude and form crusts ; eczema pustu- losum, which may begin as a primary lesion or develop secondarily to the vesicular or madidans stage ; and, finally, eczema squamosum, which is never primary, but represents the final stage of the pathological process in which the epidermal scales are thrown off, leaving exposed a dry, itchy, reddened skin. After resolution, cicatrices rarely occur, unless from severe secondary changes. Symptoms. — Clinically the disease may be divided into the acute form, characterized by a sudden onset, short course, and frequent recurrence of any of the pathological conditions just mentioned ; and by the chronic form, which represents the more characteristic lesions of cell infiltration and thickening of the skin, scaling, fissures, and ulcers. The disease may begin as an acute or as a chronic process, starting as an erythema or as isolated and grouped papules, vesicles or pustules, either singly, simul- taneously, or in succession, resulting in redness, oozing, scaling, crusting, and infiltration. The intense itching and burning, without tenderness, are the important and characteristic points serving to distinguish the condition from a dermatitis. The disease may be divided into two types, regional or local eczema and universal eczema. Regional Eczema. — The most common form of regional eczema oc- curring in infants and young children is localized on the face, and com- monly extends to the neck. This form is especially distinctive of infancy, and is frequently very intractable. No one form of treatment or kind of application benefits every case, but one remedy after another may have to be tried. As the infant grows older this form of eczema passes away of itself and is not apt to return. Many instances of local eczema produced by some irritation at or near the place affected, or perhaps in an entirely different part of the body, are met with in children. This is usually called reflex eczema, an example of which may be found in the irritation of the scalp, such as occurs from pediculi, from which a local reflex eczema may develop on the back of the neck. 24 370 PEDIATRICS. Other varieties of regional eczema are limited to the eyes, giving rise to swelling, pustules, furuncles, and conjunctivitis, a condition which may easily be mistaken for erysipelas, but shows no tenderness and itches badly. The ears, genitals, legs, feet, and hands may all be the site of eczematous lesions. Universal Eczema. — Attacks of universal eczema may occur in chil- dren as they do in adults, and are often very intractable. The lesions are essentially the same as in regional eczema, but differ in that they are more universally distributed. Treatment. — The importance of the treatment of eczema does not de- pend so much on any particular ointment or drug as on the method of applying the remedy. The principal indication is to keep the child quiet and the skin free from the irritation of scratching, thus allowing it to recover its vitality. At times it is necessary to strap the child on its back in bed and to have a nurse in constant attendance until the more irritable stage of the disease has passed off. Scratching the lesions even for a few moments may retard the recovery for many weeks. If necessary in the early hours drugs of a soothing nature may be given to prevent undue nervous symptoms. The nurse should be gentle, and should endeavor continually to divert the child's mind. The treat- ment consists, then, first in allaying the itching by local applications, and of so covering the part affected that scratching is impossible. It is often necessary to pin the sleeves of the dress to the napkin in order to control the hands. The discomfort from the restraint will soon pass away, and the method of treatment is not cruel. Certain general precautions should be observed. Heat and excess of cold should be avoided, and the cloth- ing should be thin and as non-irritating as possible. The physical condition of the child should be carefully investigated in regard to the urine, blood, bowels, appetite, and nutrition, and appropriate symptomatic treatment should be given. Drugs. — Drugs may be administered as washes, powders, and oint- ments, but never as tinctures, in the acute forms of eczema. Water should never be used in the treatment of acute eczema. The list of drugs is long, and only a few of the more important ones need be mentioned. A sim- ple powder of starch and zinc oxide, such as is given on page 366, will be found most useful on moist surfaces. In all acute cases, and as an anti- pruritic, the following prescription will be found of value. Prescription 66. Metric. Apothecary. Gramma. R Zinci oxidi 15 00 R Zinci oxidi ^ ss ; G-lycerini 8 75 Glycerini 5 i ; Acid, carbol 1J88 Acidi carbolici (xtals) 3 ss ; Aq. calcis q.s. ad 240 00 Aqua? calcis q.s. ad ^ viii. M. M. Calamine may be used in the above prescription in place of the oxide of zinc, as in Prescription 64 on page 368, and it is often desirable to add DISEASES OF THE SKIN. 371 60 c.c. (2 ounces) of camphor-water to replace an equal quantity of lime- water. An ointment of sulphur and oxide of zinc, 1.88 gramme (J drachm) of each to 30 grammes (1 ounce) of vaseline, is very useful in eczema of the scalp. r Fig. 97. Eczema capitis. In the treatment of the dry, scaling, infiltrated form of chronic eczema, when there are no excoriations or acute lesions, the following prescription of White's may be used. Prescription 67. Metric. Apothecary,. Gramma. R Sapo viridis, R Sapo viridis, Alcohol aa 60 Alcohol aa ^ ij ; Filter and add Olei cadini ^ss-j. M. Filter and add Olei cadini 15-30 M. Fig. 97 represents a case of eczema of the scalp and face which illus- trates the disease very well. They consisted of papules, pus- Fig. 98. The lesions were confined to the head and face, tules, crusts, some excoriated patches caused by- scratching, and a thick, rather cedematous con- dition of the skin, especially around the lips, nose, and eyes. The hair was cut off, and various lesions were found on the scalp ; in cer- tain parts of the scalp a reddened moist con- dition, called eczema rubrum, was found. The treatment was as follows : the crusts and the thickened tissue of the face and scalp were first softened by means of a poultice. After the larger crusts had been removed, a mask, as shown in Fig. 98, was applied to the face and scalp. The inner surface of this mask was thickly spread with the following ointment : Method of treating eczema capitis. 372 PEDIATRICS. Prescription 68. Metric. Apothecary. Gramma. R Unguenti zinci oxidi, R Unguenti zinci oxidi, Lanolini aa 30|00 Lanolini aa ^ i. M. M. An interesting complication of universal eczema which may at times arise is illustrated in the following case : A girl came to the hospital to be treated for torticollis. The head was drawn to the left side and she could not straighten it. This condition had lasted for many months. On examining the child I found that she had the usual universal eczema of a chronic type affecting the head, face, and extremities. On examining the neck I found a num- ber of enlarged tender glands. These enlarged glands were evidently caused by reflex irritation from the eczema, and were the cause of the torticollis. She was treated with the zinc oxide ointment (Prescription 68) and the usual bandage and mask, and in a short time, although the eczema was not entirely cured, the irritation in connection with it had been so much lessened that the glands of the neck gradually subsided and disappeared, and the child was able to hold her head straight. We are often asked whether the eczema of infants is contagious. I have seen instances where the nurse who was taking care of a case of eczema developed the disease on her hands. The lesions were, however, ap- parently caused by washing the infant's napkins, as her hands were cured by local treatment, and the subsequent use of rubber gloves while washing the napkins prevented her from again contracting the disease. Cases of this kind give rise to the idea that eczema is contagious, but the proba- bility is that they are simply cases of artificial dermatitis caused by irri- tating substances of various kinds, and that there is no especial germ which causes eczema. We can, therefore, say that the disease is not con- tagious, and that simple cleanliness and protection of the hands by means of rubber gloves are all that is necessary to prevent the disease being contracted. PSORIASIS. Nothing is known of the real cause of psoriasis. So far as we can ascertain, it is not dependent on any micro-organism. When the disease is well developed the diagnosis is very simple, and its lesions correspond, as a rule, to those which are commonly met with in the adult. It begins with small papules, which almost immediately become covered with scales. These scales have a pearly white color, and on removing them we find a bleeding surface, showing that they are more closely connected with the corium than is the case in other diseases in which desquamation takes place, such as dermatitis or scarlet fever. The efflorescence of psoriasis is general, "and is, as a rule, marked on the elbows and knees, for in these places the lesions coalesce and the scales are especially thick. DISEASES OF THE SKIN. 373 I have noticed in the psoriasis of children that the type of the disease is often so mild that we can scarcely believe we are dealing with the same affection that we are accustomed to see in the adult. In some cases a few lesions scattered here and there, especially on the back over the scap- ulae, will be all that represent the disease, and are easily cured, even dis- appearing of themselves in a few months. Besides affecting the trunk and extremities, the efflorescence may occur on the scalp, especially along the edge of the hair on the forehead, but the disease is not very common on the face. Psoriasis is apt to recur even at intervals of years, so that we cannot say that it can be absolutely cured, although at times it may disappear under treatment and never return. Treatment. — The treatment of psoriasis in children should be milder in form than that employed in treating the adult. In the above case an ointment of chrysarobin applied to the lesions in the evening and washed off with soap and water in the morning was used, there being no treat- ment during the day. Prescription 69. Metric. Apothecary Gramma. 60 R Chrysarobini gr.x ; 00 Petrolati Ji. R Chrysarobini Petrolati 30 M. M This ointment stains the skin, but not permanently. It should never be applied to the face or the scalp, and should be used with great care, as it causes on some skins considerable irritation, and at times a severe der- matitis. With ordinary caution, however, this need not occur. In intractable cases in which this milder form of ointment is not effi- cacious, the strength may be increased to 1 or 1.5 grammes (15 or 20 grains) to the ounce. It should be remembered that chrysarobin stains the clothes black in- delibly, so that old sheets and night apparel should be used while the treatment is being carried out. In place of this ointment you can use on especially irritable skins, or on the face and scalp, the following prescription of sulphur and tar : Prescription 70. Metric. Apothecary. Gramma, R Sulphuris 3 Olei cadini 1 Adipis 30 75 R Sulphuris ^i; 87 Olei cadini 3 ss 00 Adipis 3 i. M. M. PRURIGO. Prurigo occurs in two forms in infants and children, — (1) prurigo mitis infantilis and (2) prurigo fer ox. (1) Prurigo Mitis Infantilis. — Prurigo mitis infantilis occurs in infants two or three months old, and may last for some years. It is closely allied 374 PEDIATRICS. to papular erythema, but is more chronic and has a greater tendency to recur. It is very rare in America. Symptoms. — It begins with little nodular infiltrations, especially marked on the anterior surface of the extremities, and is accompanied by great itching. It may appear on the face. It does not lead to an infiltration of the skin or to the formation of pus. Treatment. — The treatment consists in remedies to relieve the itching and allay the eczema with which it is usually complicated. (2) Prurigo Ferox. — Instead of this mild form a more severe type of prurigo occurs at times. This latter form is far more serious in its symp- toms and in its prognosis, and may continue through life. The disease, which is characterized by the same dermal lesion as that just described, is progressive from the beginning ; it usually starts on the legs, and the skin becomes thicker as it descends. The efflorescence is accompanied by enlarged glands, especially in the inguinal region. The disease is rare in America, but is common in Germany. Its etiology is very obscure, and it is a most intractable chronic affection. Treatment. — The treatment is palliative. For the extreme itching caused by the papules an application of the following ointment may be used : Prescription 71. Metric. Apothecary. Gramma. R Unguenti diachyli, R Unguenti diachyli. Petrolei aa 30|00 Petrolei aa ^ i. M. M. S. — To be applied on flannel three times a day for ten minutes, and to be followed by the application of this ointment : Prescription 72. Metric. Apothecary. Gramma. R Unguenti diachyli, R Unguenti diachyli, Petrolati aa 30 00 Petrolati aa ^ i. M. M. If there is much infiltration, sapo viridis should be applied at night and washed off the next morning. It must, however, be used with caution, as it is very irritating. HERPES ZOSTER. Herpes zoster is a disease which affects both children and adults. The cause of the disease has not as yet been determined, but it is a condition closely connected with the nerves. Symptoms. — The general symptoms of herpes zoster are fever, loss of appetite, and pain in some part of the head, trunk, or extremities. The pain is always located in the course of certain nerves. In some cases, however, the pain and constitutional symptoms are absent. DISEASES OF THE SKIN. 375 One of the characteristics of the efflorescence is that, as a rnle, it is unilateral. It is extremely rare for the affection to be bilateral and to ex- tend around the body. Cases of this kind, however, have occurred, and do not seem to be any more severe, except that larger surfaces are affected, than where the affection is unilateral. The character of the efflorescence is essentially vesicular, and is to be differentiated from varicella, which might be accompanied by the same general symptoms and is also essen- tially a vesicular disease. The efflorescence of varicella is general, is not limited to any special distribution of the nerves, nor is it painful, while the efflorescence of herpes zoster is limited to the distribution of a special set of nerves. The vesicles become somewhat pustular, and soon crusts are formed. The disease runs a definite course of about fourteen days, and from the beginning is accompanied by considerable pain, although according to my observations the pain is not so severe in children as in adults, nor is the itching so annoying. Diagnosis. — The diagnosis of this disease is very easily made from the general symptoms of pain, fever, and malaise, in combination with the characteristic efflorescence, and we at once know with what disease we are dealing, for no other affection of the skin has so definite a distribution. Prognosis. — The disease is usually benign in children, but the case of a child four years old who died during an attack of herpes zoster without other assignable cause has been reported. Treatment. — The treatment is simply palliative. What I am accus- tomed to do is to regulate carefully the child's diet, as I would in any disease with general constitutional symptoms, and to endeavor by the application of lotions to allay the pain. Sometimes merely a simple powder, such as the prescription on page 366, is sufficient to allay the local symptoms. PITYRIASIS. Pityriasis is a term that is now, like the word lichen, seldom used without an accompanying adjective. There are two recognized forms of the affection. (1) Pityriasis Rubra is a rare disease in children, characterized by hyperemia and fine scales affecting, as a rule, the whole cutaneous sur- face. It may be attended with great constitutional disturbance and lead to death. Its duration is always uncertain. (2) Pityriasis Maculata et Circinata, or Pityriasis, Rosea affects chil- dren as well as adults. It appears in the form of small patches of scales scattered over the trunk, legs, and arms. These patches either spread peripherally or unite to form larger patches while the centre undergoes involution ; we thus see a reddish scaling border and a characteristic yel- lowish centre. There may or may not be great pruritis accompanying it. In Vienna this affection is still regarded as a form of ringworm, a posi- tion that cannot, however, be maintained. Its etiology is obscure. It gets 376 PEDIATRICS. well spontaneously in from two to ten weeks, and is best treated by mild, soothing, and anti-parasitic applications. VERRUCA. Verrucas (warts) are circumscribed outgrowths of the papillae of the skin with an accompanying increase in the thickness of the epidermic layers. They are common in children, especially on the hands, and the old view that they are contagious and auto-inoculable has gained many adherents of late. They are of various aspects and shapes, and may be treated locally, as a rule, with success, although some are quite obstinate. The most efficacious method of treatment is to paint each wart with a solution of salicylic acid in flexible collodion (Prescription 73). Prescription 73. Metric. Apothecary. Gramma. R Acidi salicylici 3 75 R Acidi salicylici ^i ; Collodii . .". 30 00 Collodii gi. M. M. This is applied with a camel's-hair brush twice a day for three days. Then it is soaked off by prolonged bathing in warm water, with the addi- tion of pumice soap if there is no inflammation. This will usually remove a portion of the wart, and the process should be repeated as long as any of the growth is left. The treatment with salicylic acid is not always successful, and recourse may then be had to glacial acetic acid, or to some other caustic, carefully applied ; or the growth may be excised. LENTIGO. Lentigo (freckles) is a small aggregation of pigment deposited in the skin, and is commonly seen in children of ten years and upward, espe- cially in those of light complexion. They are usually situated on the face and hands, but may occur on the covered portions of the body, a fact that led Hebra to regard them as not due to the action of the sun. There can be no doubt, however, that the sun is the chief agent in their production. Their removal is often difficult and requires the use of strong irritants, such as corrosive sublimate. It is rarely advisable to attempt their re- moval in young children. MELANODERMA LENTTCTJLARIS PROGRESSIVA. Melanoderma lenticularis progressiva (Kaposi's disease) is a very rare disorder, and is seldom met with in this country. In this affection spots of pigment like freckles appear first on the uncovered parts of the body, finally extending more or less over the whole cutaneous surface. The pigment-spots are the first lesions seen, but later an atrophy of the skin and the formation of small angiomata dotted over the surface take place, DISEASES OF THE SKIN. 377 giving the child an extraordinary appearance. The disease is usually found in more than one child in the same family, and its etiology is very obscure. Malignant tumors with a fatal ending often result from this affection. I have had two cases under my observation for four or five years. One has lately died, and the autopsy showed no metastases in the interal organs, the disease proving purely a local affection of the skin ; the other has returned to the hospital in a worse condition than ever before. Xo treatment of any kind, medical or surgical, has had any effect on this case. LICHEN. Many of the affections that were formerly included under the head of lichen are now considered by most authorities to belong in other groups, notably in that of eczema. A diagnosis of lichen is never made by American dermatologists, but lichen planus is a well-marked skin disorder which retains a place of its own. It rarely occurs in children, but when present it follows about the same course as in adults. It is characterized by firm papules of an irregular shape and glistening appearance, of a peculiar reddish-blue or violet color, with usually a slight depression in the centre. The individual papules may coalesce, so as to form patches of greater or less extent, covered with fine scales. It is often accompanied by great itching and discomfort. It attacks all parts of the body, showing a predilection, however, for the flexor surfaces of the arms and legs. It may last for many months, and in the most favorable cases does not dis- appear for several weeks. The general health is not usually affected, ex- cept by the exhaustion that may be caused by intense itching. It may be confounded with a papular syphilide, which it often closely simulates, and sometimes it may be mistaken for an eczema. Arsenic is of value in chronic cases, and anti-parasitic lotions and ointments, especially those containing tar in some form, give relief as external applications. ICHTHYOSIS. The disease Ichthyosis as it occurs in infants and young children does not differ in its general pathology from that which is seen in adults. It may occur in intra-uterine life, and is then designated foetal ichthyosis. The most thorough work which has been done on the ichthyosis of infancy and childhood is that of Ballantyne of Edinburgh, who designates that form which has occurred in utero and is fully developed at birth as (1) foetal ichthyosis, while the form which begins in the early weeks of infancy he speaks of as (2) ichthyosis neonatorum. (1) Foetal Ichthyosis. — The severity of foetal ichthyosis varies greatly. (a) Severe Form. — The grave form, according to Ballantyne, is devel- oped probably about the fourth month of intra-uterine life, and is charac- terized at the time of birth by the existence all over the body of horny epi- dermic plates separated from one another by fissures and furrows, associated 378 PEDIATRICS. with deformities of the mouth, nose, eyes, lips, and limbs, and leading within a few days or even hours to the death of the infant. As in most cases infants with this disease are born alive, foetal ichthyosis cannot be considered to be a cause of intra-uterine death. The disease does not seem to affect especially the size and weight of the infant. As a rule, the viscera at the post-mortem show nothing abnormal except an unusual de- gree of congestion. The microscopic examination shows no extension of the keratinizing process on any of the mucous membranes, and the dis- ease is an abnormality in the development of the skin, there being an excessive proliferation of the layers of the epidermis. Symptoms. — In the early hours of life infants with this disease usually cry loudly and continuously, but sometimes the cry is feeble and often very peculiar. The respiration is usually impeded by the blocking of the nostrils with epidermal masses. Suction is rendered difficult or altogether impossible by the presence of ichthyotic plates around the mouth. They, are, however, usually able to swallow readily. As a rule, nothing abnor- mal is found in connection with the urine or the faeces. Insomnia is a marked symptom. These infants have a very repulsive appearance, and there is a cadav- eric odor arising from the abnormal condition of the skin. This ichthy- otic condition of the skin is usually universal, but is most evident upon the face. The mouth is ordinarily kept open by the contraction of the surrounding parts, and from its angles radiate fissures which simulate the rhagades of syphilis. The lips are thick and everted, so as to form an irregular entrance to the gaping buccal cavity. The chin is receding. The nose can scarcely be seen, it is covered so thickly with the epidermal plates around the nostrils. There is usually ectropion of both eyelids, but sometimes only of the upper one, the orbits seeming to be occupied by fleshy tumors. If, however, we separate the swollen eyelids, the normal eyeball is found to lie beneath. The external ear seems to have disappeared almost entirely. In contradistinction to the opinion formerly held that foetal ichthyosis was a general seborrhoea, it is now generally supposed to be connected with the disease as it occurs in the adult. Prognosis. — The prognosis of the disease is almost always unfavor- able. Treatment. — The treatment should be active and directed towards softening the epidermic scales by means of warm oil inunctions. (b) Mild Form. — Besides the grave form of foetal ichthyosis, there is a much milder form of the disease. It develops during intra-uterine life, and shows a continuous layer of a substance resembling collodion extend- ing over the whole body and falling off in small flakes resembling pieces of tissue-paper. These general appearances are sometimes accompanied by ectropion and eclabium. The disease is not, as a rule, fatal, and often terminates in complete or partial recovery. There have not been any DISEASES OF THE SKIN. 379 instances, so far as I know, of an infant being born dead with this form of ichthyosis. Treatment. — The treatment of this second form should be by continual stimulation of the child's general strength and by great care of the skin. (2) Ichthyosis Neonatorum. — Ichthyosis in the new-born infant, in whom at birth there was no sign of the disease, may occur. It presents the same appearances as the milder form of foetal ichthyosis and the ichthyosis of the older child and the adult. This is the common form of ichthyosis, which occurs at all ages. It begins for the most part in the early months of life, is essentially chronic, and is very intractable to treatment. Treatment. — It should be treated by the administration of a warm bath once daily, followed by an inunction with glycerite of starch. SCLERODERMA. Scleroderma is a disease which at times occurs in children as it does in adults. It consists of an induration of the skin either in bands or in patches, or is diffuse, having a board-like hardness, so that the skin can- not be raised by the fingers and feels as though it were tacked down. Scleroderma affects the motions of the joints, and when it occurs about the chest and throat may interfere with respiration. It appears to be a condensation of the fibrous layers of the skin, so that the bundles of connective-tissue fibres are packed closely together and are increased in number. It is chronic, is not very dangerous, and is best treated by massage and lubricating applications. ACUTE CIRCUMSCRIBED OR ANGIO-NEUROTIC CEDEMA. A lesion of the skin which has been termed acute circumscribed oedema is represented by the sudden appearance of circumscribed swellings of certain parts of the body, varying in intensity and size in different locali- ties. It is closely allied to urticaria, and was formerly described under the name of giant urticaria. We do not know much about either its cause or its pathology. I have sometimes met with it in children in whom it was evidently of reflex origin, depending, probably, upon irritation in various parts of the body, such as the mouth, the genitals, and the gastro- enteric tract. It is not dangerous, may occur at any age, and its treatment is simply symptomatic. The following cases illustrate the disease : A little boy, two and one-half years old, had had diarrhoea during the summer, and had been left in rather a weak, debilitated condition. He had for some weeks been pale, fretful, and constipated. His appetite had been capricious, and he had not cared to take any food but milk. When he was nineteen months old an egg had been given to him, which he vomited, and later a slight swelling of both eyes had occurred, lasting for a day or two. 380 PEDIATRICS. When I saw the child the history that was given me was that in the morning he had eaten an egg. Soon after he became rather dull and cross, but did not vomii. A slight swelling of both eyes was then noticed, and later, when I saw him, the right eye was very much swollen, so that the conjunctiva was corrugated, and the tissues of the eyelids and of the cheek under the eye were so swollen that the eye itself could be examined only with the greatest difficulty. Each time that the child had eaten an egg this swelling occurred in about fifteen minutes. In the course of a few hours the swelling passed off, and did not return. An examination of the urine showed nothing abnormal. Another instance of this kind occurred in a boy of three years, in whom the peripheral irritation was evidently dependent upon a tight and irritating prepuce. In this case sudden oedematous swellings of the fingers and backs of the hands would occur at irregular intervals, lasting for a few hours, and would then entirely disappear. These manifestations continued until the child was circumcised, since which time the symptoms have not returned. In this case, also, the urine was found to be normal. DIVISION VIII. SPECIFIC INFECTIOUS DISEASES. The number of infectious diseases which are supposed to be caused by some specific infection is so rapidly increasing that at present no defi- nite classification of them can be made. In like manner our knowledge of the specific organism which in an individual case produces the disease is so continually advancing that we can only make a provisional division into somewhat arbitrary groups of the diseases which we speak of as infectious. Thus, in certain diseases, tuberculosis, cerebro-spinal menin- gitis, typhoid fever, diphtheria, epidemic influenza, malaria, tetanus neo- natorum, erysipelas, certain forms of ileo-colitis, and cholera asiatica, the micro-organism is known ; while in others, such as epidemic parotitis, pertussis, syphilis, and acute articular rheumatism, which are evidently just as infectious, the specific micro-organism has not yet been discovered. Again, there are certain infectious diseases which have usually been classed in a group by themselves on account of the marked similarity which they present in their general characteristics. This group, as a whole, has been designated as the exanthemata, and comprises scarlet fever, measles, rubella, variola, and varicella. TUBERCULOSIS. Tuberculosis is an infectious disease due to the invasion of the tissues by the tubercle bacillus. General Etiology. — Intra-uterine infection of the foetus by a tu- berculous mother from direct infection may occur. Infection by the father from the mother, or from the ovum of the mother has not been proved. In the great majority of cases the child is infected after birth. This infection may be by direct inoculation from the mouth, as in the Jewish rite of circumcision, or, as is the most common means of trans- mission, from the inhalation of the bacilli contained in dry sputum. A less common mode of invasion is that from uncooked food. The bacillus tuberculosis may be present in cow's milk, and very exceptionally in the milk of human beings. The question of the relation of bovine tuberculosis to human tuber- culosis and the danger of infecting man from the milk of tuberculous cows 881 ? \ 382 PEDIATRICS. have received renewed attention of late. The researches of several in- vestigators, particularly those of Smith, seem to show that the bovine tubercle bacillus is more virulent for certain species of animals than the human tubercle bacillus. Whether the two organisms are distinct or whether the differences which have been noticed between them are simply modifications brought about by the adaptations of the bovine bacillus to the different conditions in the human body are points still to be deter- mined. The weight of evidence, however, in regard to infection from milk is quite sufficient to justify the following practical conclusions : (1) That tuberculosis in many cases may be transmitted to animals either through the ingestion or inoculation of the milk of cows that are tuberculous. (2) That the milk of such cows may be infectious even when there is no tubercular disease of the udders. (3) That, therefore, the milk of certain tuberculous cows contains living, virulent tubercle bacilli. (4) That, whereas, from the nature of the case, it is impossible by direct experimentation to prove that the milk of certain tuberculous cows is pathogenic for man, nevertheless the clinical evidence of compe- tent observers, strengthened by the results of animal experimentation, makes it practically certain that tuberculosis may be produced in man by the ingestion of the milk of infected cows. (5) That it is, therefore, of the utmost importance that the milk supply, especially that which is used as food for infants and young children, shall be from an absolutely relia- ble source. The infection of food by flies carrying the bacilli from one point to another is possible. Direct infection may also take place by the skin, and in these cases it produces a local lesion. The bacilli may pass through a mucous membrane without infecting it, and may be taken up by the lymphatics and carried to the lymph-nodes where their progress is usually arrested for some time. Tuberculosis is a very prevalent affection in early life. It is very rare in the new-born and infrequent in the first three months of life. After this age the number of cases increases rapidly, and the disease is very common in the latter part of the first year and in the second year, grad- ually growing less common as puberty is approached. The presence of tuberculosis in children is very much underestimated. In two hundred and twenty autopsies of diphtheria, tubercular lesions were found usually in the lungs, and sometimes in the lymph-nodes of the mesentery, in six- teen cases. The disease is very much more common in young children than has been supposed, and it may exist before there are any symptoms at ail. The bacilli find entrance into the body in various ways. The chief mode of entrance is probably through the respiratory tract. The organ- isms may also enter through the alimentary canal or by means of the skin. As a rule, where the bacillus finds an entrance into the tissue it produces at that point the characteristic lesion of the disease. In other SPECIFIC INFECTIOUS DISEASES. 383 eases elose examination fails to reveal any lesions at the point of entry, although this does not preclude the possibility that the lesions may be present. It is probable that the bacilli enter into the circulation in small numbers, and are conveyed to various tissues of the body, as the bones or joints, and the disease may appear as a primary infection in organs remote from the point of entrance. Frequently the bacilli, without apparently producing any lesions at the point of entry, enter into the lymphatics and are carried to the lymphatic glands in which the disease first appears. Having gained an entry into the tissue the disease always extends by means of the bacilli, which are carried from place to place through the natural canals or channels of the lymphatics which are in proximity to the diseased focus, or by means of the blood. In all cases of tuberculosis it is probable that there is some infection of the blood. A few bacilli find their way into the blood, and are deposited by it in those organs in which the circulation is most favorable for their arrest. We have an ex- ample of this in the almost constant miliary tuberculosis of the liver when the infection is elsewhere. At times the bacilli find their way into the blood in large numbers. This general infection of the blood is due either to a tuberculosis of the blood-vessels or to a tuberculosis of the thoracic duct. The bacilli, entering into the blood in large numbers, are conveyed into the different organs of the body and give rise to the condition known as acute miliary tuberculosis. Predisposition. — The predisposition to tuberculosis may be hereditary or acquired. It is hereditary in the sense that the individual inherits tissues which are more or less receptive to, and which provide a favorable material for the development of the tubercle bacillus. In diseases result- ing in a great reduction of the vitality, and in certain acute infectious dis- eases, such as measles, pertussis, and epidemic influenza, a tuberculous predisposition seems to be acquired. Bad food and poor hygienic surround- ings, especially absence of sunlight in the crowded tenement districts of large cities, render the tissues more vulnerable to the tubercle bacillus. In like manner any debilitating disease, by lowering the resistance of the tissues, acts as a predisposing cause. Repeated attacks of catarrhal in- flammation of the mucous membrane of the nose, throat, bronchi, or intestinal tract render these parts more vulnerable. Infectious diseases, especially those in which the respiratory organs are affected, predispose to tuberculosis. In these cases it would seem that the bacilli have been latent in the lymph-nodes surrounding the bronchi until, under the irrita- tion of the new disease, they become active again. General Pathology. — Tuberculosis is characterized by the production of tissue in which there is proliferation and an inflammatory exudation. The proliferation of tissue leads to the formation of epithelioid and giant cells. The inflammatory exudation may be serous, fibrinous, or purulent. Usually in the tubercular lesions there is both the tissue proliferation and the inflammatory exudation. The proliferation of tissue occurs in the 384 PEDIATRICS. form of small nodules which are called miliary tubercles. The tubercu- lous tissue is further characterized by a form of necrosis, and the necrotic tissue has a tendency to soften and break down. These miliary tubercles often coalesce so as to form what is known as conglomerate tubercles, in which the process of necrosis is especially marked, giving rise to the " cheesy" nodules so characteristic of the disease. Certain degenerative changes are common in tuberculosis. Thus fatty degeneration frequently occurs from the diminished oxygenation due to the destruction of lung tissue. Again, amyloid degeneration is common in those forms of tuber- culosis which run a chronic course, and in which there is marked de- struction and suppuration of tissue. The lesions of tuberculosis are very numerous, and in the child do not differ materially from those which are found in the adult. The ordinary chronic tubercular lesions met with in the adult are seldom seen in children. The younger the child the more likely is tuberculosis to be chiefly located in the lung. As the child grows older the meninges are commonly affected, and later the peritoneum, intestines, and joints. During the first two years of life the lesions of meningeal tuberculosis are rare in com- parison with the period beginning with the third year, and the pulmonary lesions usually result fatally before there has been extensive invasion of the intestines and joints. As the child passes into its third year the marked pulmonary lesions lessen in frequency and the meningeal forms become more common. Later the joints become a prominent nidus for meningeal infection, and in older children the peritoneum, intestines, and mesenteric lymph-nodes show, more commonly, marked lesions. At all ages, however, there are usually found pulmonary lesions more or less marked whenever infection has taken place with the tubercle bacillus. Prophylaxis. — In considering the question of prophylaxis in tubercu- losis, special attention should be paid to what has already been said of the modes of invasion and of predisposition. In all cases in which there is a family history of tuberculosis the child should, if possible, be surrounded with unusual precautions ; a change from a severe to a mild climate, especial care of even mild catarrhal affections of the mucous membranes, much fresh air, but dry, warm, fresh air, protection from inhalation of dust, rooms with a sunny exposure, and freedom from living in the house with a tuberculous individual, are precautions especially to be observed. Ex- posure to the diseases which have been mentioned as most likely to be followed by tuberculosis should be carefully avoided. Tuberculous nurses should never be allowed to take care of children, tuberculous individuals should not be allowed to kiss children, and the sputum from a tuberculous individual should be destroyed at once before it has become dried. A tuberculous mother or wet-nurse should not be allowed to nurse an infant. The animals which provide milk should, at stated intervals, be carefully tested with tuberculin, and when the source of the milk is not known or doubtful, the milk should be heated to 68.3° C. (155° F.) for half an hour. SPECIFIC INFECTIOUS DISEASES. 385 The following case, seen by me in consultation with Dr. W. L. Richardson and Dr. H. P. Jacques, illustrates the importance of prophy- laxis : A boy, five years old, died of tubercular meningitis. The autopsy showed exten- sive tubercular lesions of the meninges with enlarged bronchial lymph-glands and cheesy nodules at the apices of both lungs. The child up to the time of the attack had always been perfectly well. There was no history of tuberculosis in the family. There were several other children, none of whom had ever shown any symptoms con- nected with tuberculosis. This boy, at the age of fourteen months, was placed in the charge of a nurse, who remained with him until he was four and a half years old. Just before leaving the child, she was brought into especially close connection with him while his parents were away for some weeks. The child was very fond of her, insisted on being in her lap a great deal, kissed her on the mouth, slept in her bed, and kept her in the nursery with him continuously. The nurse, while taking care of the child, developed tuberculosis of the lungs and subsequently died of this disease. Other cases of this kind have been known to occur. General Symptomatology. — After a variable period of loss of weight and general health, which especially occurs in cases, in which acute mili- ary tuberculosis is secondary to measles or to pertussis, the infant begins to have an irregular type of fever, cough, and general symptoms, such as diarrhoea, capricious appetite, anaemia, and change of tempera- ment. In some cases the disease appears with a sudden rise of tempera- ture and advances very rapidly, but it is often of a subacute type, and frequently, unless the tuberculosis markedly affects some organ, such as the lung, the symptoms are very obscure, death finally taking place from exhaustion or from the development of some localized condition, such as tubercular meningitis or some acute pulmonary complication, broncho- pneumonia being especially common. General Diagnosis. — From what has been said concerning the symp- toms of tuberculosis, it is evident that when no localized tubercular lesions are found, the diagnosis, excepting by supposition, is not pos- sible. It is probable, however, that when more is known regarding the use of tuberculin in infants and in young children, this method of diagnosis will be more frequently used, and will prove of value by pro- viding us with a safe method for detecting an incipient tuberculosis, and thus aid us in preventing the development of later and more serious lesions. Tuberculin Test. — The technique of the tuberculin test as described by Koch is as follows : One c.c. of tuberculin added to 999 c.c. of distilled water equals T oVoi an d 1 c.c. of this solution equals 1 milli- gramme. The dose of this solution for an infant or young child is from J to 1 c.c. In using this test a record of the child's temperature must first be kept every two hours for twenty-four hours. If it is then found that the temperature is irregular or high the test is not of much value. If, however, the temperature is regular and not over 38.3° C. (101° F.). 25 386 PEDIATRICS. the test can be used, and has been found in my experience at the In- fants' Hospital to be of considerable value. After the part of the skin to be injected has been thoroughly washed first with soap and water, and then with alcohol, and the hands of the operator and the syringe disinfected, from J- to 1 c.c. of the solution are injected into the arm or leg. If the child is not tubercular no symptoms will be noticed. If it is tubercular the temperature will rise in from eight to twenty-four hours after the injection, and will fall again within about twenty-four hours. During the period of reaction there may be a certain amount of malaise, but in my experience there is little or no danger of serious results. General Prognosis. — The prognosis of tuberculosis in early life Is almost invariably bad. Even when the bacilli have been encapsulated they are liable at any time to become active. General Treatment. — Of especial importance in the treatment of children with tuberculosis in any form is the general hygiene, fresh, dry air, a warm, dry climate, and plenty of sunshine. The treatment by drugs is very unsatisfactory and usually without good results. In some cases cod-liver oil seems to be of temporary benefit. Cream is useful and should be given when cod-liver oil is not well borne or is especially distasteful. A general diet adapted to the age and condition of the especial child, and the treatment of symptoms which arise when special organs are involved, are the only rational procedures. Tuberculin has not as yet been proved to be sufficiently valuable as a therapeutic agent to be accepted by the medical profession in general. The following case illustrates how extremely latent and masked may be the symptoms of tuberculosis An infant, seven months old, was in the Infants' Hospital from October until December. During this time it became extremely emaciated, diarrhoea occurred from time to time, and there was an irregular and varying temperature., never especially high. It had a purulent discharge from the right ear, and a serous discharge from the left ear. There were no other symptoms and no abnormal physical signs. It failed rapidly and died. The autopsy showed miliary tuberculosis of the pleura, spleen, kidney, and liver, chronic tuberculosis of the bronchial lymph-glands and of the lung, and broncho- pneumonia. GENERAL TUBERCULOSIS. — General tuberculosis in early life may be acute or chronic. It is now believed that in every case there is a tubercular focus, usually in a gland or in the lung, from which the general infection has emanated. The early symptoms of a general tubercular in- vasion vary much and are often obscure. iVs a rule, they appear before the symptoms of local tuberculosis of an especial organ, and are repre- sented by irregular temperature, anaemia, and a general lowering of the nutrition and vitality. SPECIFIC INFECTIOUS DISEASES. 387 ACUTE MILIARY TUBERCULOSIS. The term acute, is somewhat misleading in speaking of miliary tuber- culosis, since this form of general tuberculosis varies greatly in the rapidity of its invasion and in the intensity of its symptoms, according to the rapidity with which the bacilli gain an entrance to the circulation, and in proportion to the susceptibility of the individual to their virulence. Some of these cases are extremely acute, while others are markedly chronic. There are certain organs of the body which are rarely affected. This must be attributed to the fact that the organs in question do not offer favorable conditions for the development of the bacillus. Thus, it is ex- tremely common for the bronchial lymph-nodes and the lungs to be affected, while it is rare for the stomach or the genito-iirinary organs to be markedly involved. Especially noticeable in comparison with those acute cases which occur usually in somewhat older children with pro- nounced symptoms, and representing the form which is called the typhoidal type of the disease, is the clinical picture represented by those cases which occur in early infancy, and which are markedly subacute rather than acute, simulating closely infantile atrophy. Pathology. — The disease is characterized by the formation of nodules, varying in size and character, in the different organs and tissues of the body. As a rule, the nodules (miliary tubercles) are larger and not so characteristic as in the adult. As compared with the adult, they vary somewhat in their distribution. They are much more numerous and larger in the liver in the case of the child than they are in the adult. The condition is produced by the entry of the tubercle bacillus in large numbers into the blood. They may enter the blood through a blood- vessel, or by means of infection of the thoracic duct following infection by the lymph-nodes. It is not probable that they multiply directly in the circulating blood, but they may multiply in the blood-vessels of organs in which the blood-stream is comparatively inactive, as in the liver. (1) Acute Miliary Tuberculosis Simulating- Typhoid Fever. — Symp- toms. — The symptoms of this type of the disease are very indefinite. There is rapidly progressive emaciation. The temperature is irregular, and fluctu- ates from 37.2° or 37.7° C. to 40° or 40.5° C. (99° or 100° F. to 104° or 105° F.), or even higher. The respirations are often accelerated beyond what can be explained by the fever, and physical signs are markedly absent in the lungs. The pulse is rapid. Certain cases of this class simulate typhoid fever by presenting symptoms of apathy, headache, slightly enlarged spleen, and tympanites. In making the differential diagnosis from typhoid fever it is well to take into consideration the family history in regard to tubercu- losis, and also whether the child has been living where typhoid was preva- lent. Although no leucocytosis is present in either disease, yet it has been held that while in typhoid there is a relative increase in the small mononu- clear cells, there is in tuberculosis a relative decrease. In other respects 388 PEDIATRICS. the blood simply shows the characteristics of a secondary anaemia. The Widal reaction is absent in tuberculosis. The tubercle bacillus may or may not be present in the sputum. In some cases the bacilli of typhoid and tuberculosis have been found in the urine. The tuberculin test is seldom of value in these cases, as the fever is continuous and usually sufficiently high to prevent the characteristic rise of temperature from being perceptible. The less regular temperature, the rapid respirations, and the absence of rose spots are significant of tuberculosis. Finally, in most cases the tendency of typhoid fever is gradually to recover, while tuberculosis shows progressive emaciation and the development of new symptoms according as other organs are involved. In some cases malaria may simulate tuberculosis, but the presence of the Plasmodium as deter- mined by a blood examination and the response to the treatment with quinine serve to separate this disease from tuberculosis. Prognosis. — The course of this type of the disease is short and the result invariably fatal. (2) Acute Miliary Tuberculosis Simulating" Infantile Atrophy. — Symptoms. — I have frequently had patients brought into the Infants' Hospital in whom it was impossible to differentiate in the beginning, and perhaps for weeks, what eventually proved to be miliary tuberculosis. The symp- toms in these cases are simply progressive emaciation, with occasionally a temperature moderately raised, but in no way differing from what is fre- quently found in the atrophic condition in which a slight disturbance of digestion may cause a similar rise in temperature. These tubercular cases simply die of exhaustion, with no physical signs developing during life, the disease being completely masked and only recognized at the autopsy. In some cases, however, after a variable period, physical signs can be detected in the lungs, the temperature rises more and more, and there may be cough and accelerated respirations. In these cases, also, there are at times diarrhoea and general gastro-enteric disturbance, but these conditions depend entirely on the reduced condition of the infant and not upon tubercular lesions of the intestine. The temperature in these cases varies from 37.2° to 38.8° C. (99° to 102° F.). It must be remembered that infants with simple infantile atrophy at times develop non-tubercular broncho-pneumonia and die of it, so that a diagnosis made by finding physical signs in the lungs in those cases which simulate infantile atrophy is not conclusive, as the signs do not necessarily prove that tuberculosis is present. On the other hand, acute miliary tubercu- losis of the lung usually presents no physical signs whatever, so that the differential diagnosis between many cases of acute miliary tuberculosis and infantile atrophy must be held in abeyance, and, unless the tuber- culin test can be used, cannot be made except at the autopsy. Prognosis. — The prognosis is fatal. Treatment. — The general treatment of acute miliary tuberculosis is essentially symptomatic and by the use of stimulants. When the disease SPECIFIC INFECTIOUS DISEASES. 389 simulates typhoid fever, the treatment should be such as is described in that disease, on the supposition that it may turn out to be typhoid. When it simulates infantile atrophy, however, the CHART 4 treatment should be the same as in that disease, and is essentially dietetic. The following case was one of acute miliary tuberculosis : An infant, one and a half years old, was brought to the Infants' Hospital to be treated for an attack of bronchitis. On entrance it was much emaciated and failed rapidly. No marked signs beyond a subacute bronchitis were found. There was at times a slight cough. The temperature was moderately raised and of an irregular type. The thorax and legs, especially the buttocks, showed numerous subcutaneous abscesses, and there were also a few on the head. Five days before the in- fant died the temperature rose as represented on Chart 4. The post-mortem examination showed that there was chronic tuberculosis of the bron- chial glands, with acute miliary tuberculosis of the pleura, lungs, spleen, kidneys, liver, and meninges. Days of Disease :f. c. 107° 106° 105 M E M E M E M E M E M E 41.6° 41.1° 40.5° 40 0° 103 102° 101 100 Q 39.4° 38.8° 38.3° 37.7° 37.2° 37.0° 36.6° 36. l c 35.5° 35.0° v J \ ) / NORMAL TEMP. 98 97 96° o 95 \y. — CHRONIC GENERAL TUBERCULOSIS. In addition to the lesions which characterize acute miliary tuberculosis, a chronic general form of tuberculosis occurs in certain cases. The symp- toms are more marked than in the acute form, and usually are so closely connected with the bronchial lymph-nodes and the lungs that it is more easily diagnosticated. This chronic general tuberculosis is one of the more common forms of tuberculosis in children. LOCALIZED TUBERCULOSIS.— Although tuberculosis may by a general infection invade all the tissues, thus constituting the general tuber- culosis just described, it is apt to be so pronounced in certain parts, and so much more common in some than in others, that these localized forms can best be described separately. An instance illustrating this is given in the lymph-nodes of the neck in children where the node is very com- monly found to be tuberculous, and yet in many cases no trace of a gen- eral tuberculosis can be found elsewhere. TUBERCULOSIS OF THE LYMPH-NODES. Tuberculosis of the lymph-nodes is an exceedingly common form of tuberculosis in children. In all forms of tuberculosis the lymph-nodes are affected. The tubercle bacilli come in very close relation with the lymph spaces and ducts and are carried by them into the lymph-nodes belonging to the part. There are also cases of tuberculosis of the lymph-nodes in 390 PEDIATRICS. which the disease appears to be primary in these parts. Such cases are found in the lymph-nodes of the neck, of the axillae, and of the mesentery. Tuberculosis of the lymph-nodes appears in two forms: (1) the nodes are enlarged and contain the tubercular tissue in the form of miliary tubercle, which by their increase and coalescence can form large caseous areas ; (2) the nodes are also enlarged in the form of diffuse tubercles, leading to the caseation of large areas, in fact, the entire node may be converted in consequence of this caseation of the diffuse tubercular tis- sue into a large caseous mass. The caseous tissue of the nodes may soften, break down, and even suppurate, leading to the formation of tuber- cular abscesses. The bacilli having entered at some point can be carried from the point of entrance by the lymph-streams into the nearest lymphat- ics and lymph-nodes, without the production of local lesions. In gen- eral, the lymph-nodes play an important part by preventing the tubercle bacilli from entering into the blood, and the disease from extending fur- ther. It is very interesting to note that the lymph-nodes can soften and break down in this way and be discharged, and that no further infection need follow. Tuberculosis of the Cervical Lymph-Nodes (Scrofula). — The most important of the lymph-nodes affected in tuberculosis are the lymph- nodes of the neck. Invasion of the cervical lymph-nodes may occur primarily by infection from the throat. "When this invasion occurs in connection with tuberculosis of the lungs the infection of the cervical nodes is probably primary to the pulmonary lesions. The cervical lymph-nodes are more commonly affected by the tubercle bacillus in the early period of childhood than in infancy, in which the infection of the bronchial nodes are so frequently met with. When the term scrofula was in more general use. tuberculosis of the cervical lymph-nodes was considered as one of its most frequent manifestations ; now the term can be dropped entirely. Symptoms and Diagxosis. — In cases in which the cervical lymph-nodes begin to enlarge in a marked tuberculosis, as of the lung, the symptoms are those of a slow process extending over months, with a tendency to suppuration. The diagnosis in these secondary cases is made by eliminating the causes of glandular enlargement which could produce a similar hyper- plasia by reflex action, or which could be produced by some other organ- ism. The diagnosis, however, is chiefly made by the tubercular history of the case, as in the majority of cases the nodes under these circum- stances are tubercular. Primary tuberculosis of the cervical lymph-nodes is to be distinguished from other forms of infection by its slow progress, by its greater tendency to suppuration, and also by the fact that the suppuration as a whole takes place later than the simple form. The enlarged cervical nodes due to syphi- SPECIFIC INFECTIOUS DISEASES. 391 lis, Hodgkin's disease, or malignant growths should be differentiated from tuberculosis of the cervical lymph-nodes, as described in these diseases. Prognosis. — The prognosis of tuberculosis of the cervical lymph-nodes is good, the exception being for the child to develop tubercular disease elsewhere. The prognosis when the tuberculosis is secondary to tuber- culosis elsewhere varies according to the tubercular lesions from which it originates. Treatment. — When the tubercular disease has extended to other organs there is seldom much benefit to be derived from the treatment of these nodes. Although it is conceded that general tuberculosis following tubercular cervical adenitis is exceedingly rare, yet there have been Fig. Chronic pulmonary tuberculosis, with involvement of the cervical lymph-nodes. cases reported in which such infection has taken place, and the glands should be removed unless they have grown smaller in a number of months, at any rate if they show signs of softening. A change of climate is indicated, and if the child has a tubercular inheritance especial care should be taken to keep the naso-pharynx and throat in a healthy condi- tion. Adenoid growths and enlarged tonsils should be removed. Any lesion of the face and head which may cause irritation should be treated, as, by their reflex action, they may cause increased activity of the tubercle bacilli. Medicines, except for special conditions, such as anaemia, are useless. 392 PEDIATRICS. External applications of an irritating nature are contra-indicated. Pre- venting the head from rolling from side to side, and thus pressing on the inflamed glands, can sometimes be accomplished by various mechanical devices in the shape of collars. The operative treatment includes not only the removal of the gland, but the removal of it at such a time that the smallest scar will be left, as in many cases following a suppuration of these glands unsightly scars are left which disfigure the child for life. These cases should, therefore, be placed in the hands of a skilful surgeon. Fig. 99 represents a child with tuberculosis of the cervical lymph- nodes in a case of marked chronic tuberculosis of the lungs. Tuberculosis of the Bronchial Lymph-Nodes. — Of all the lymph- nodes in the body, the bronchial lymph-nodes are probably the most fre- quently infected, due to the fact that the primary focus of infection is so commonly found in the lungs, and, as the lymph flows from the lung towards the nodes, the nodes may be infected in this way by the lung. Thus, the bronchial lymph-nodes protect the body from general infection, but do not protect the lungs, and such tubercular lymph-nodes can be- come, moreover, a starting-point for further extension of the disease after the primary lesions by which the lymph-nodes themselves became infected have been recovered from. Tuberculosis of the bronchial lymph-nodes, if it is extensive, may in- volve the pneumogastric nerve. The nodes may possibly suppurate into a bronchus, and the infection can in this way also extend into the lungs. Symptoms. — Various symptoms may arise from the breaking down and ulceration of the bronchial lymph-nodes, or by their pressure they may cause irritation of the neighboring parts. Thus, an annoying cough may be produced by local irritation. Loeb has reported cases in which the previous symptoms had been only cough, and in which an attack of suffo- cation caused death. Adelbert and Vogel have reported cases in which ulceration originating from these points has resulted in death. The physical signs are indefinite and unreliable, and we must depend upon the general symptoms of spasmodic cough and dyspnoea, without an ade- quate explanation of these symptoms being found elsewhere. Tuberculosis of the Mesenteric Lymph-Nodes. — Tuberculosis of the mesenteric lymph-nodes may be seen without any evidence of tuber- culosis elsewhere in the body, or it may be found in connection with intestinal tuberculosis. In all cases the infection is by means of the intestine, although there may be no lesions at the point of invasion. When the nodes can be reached or definitely localized, they should be removed, even if laparotomy has to be performed : for there is always danger not only of their breaking down and becoming a source of general tubercular infection, but also a peritonitis may arise suddenly at any time from acute inflammation of the peritoneum originating from a disintegrated node and ending fatally in perhaps a few days. A case of this kind is described on page 843. SPECIFIC INFECTIOUS DISEASES. 393 TUBERCULOSIS OF THE LARYNX AND TRACHEA. Tuberculosis of the larynx and trachea is very rare in infants and rare in young children. When it is present it is invariably secondary to tuber- culosis of the lungs. The symptoms are the same as those of non-tubercu- lar disease of these organs, and the diagnosis can only be made definitely by finding the tubercle bacillus in the sputum. Treatment. — The treatment does not differ from that of the non- tubercular cases. TUBERCULOSIS OF THE LUNGS. — The tubercle bacillus may be brought to the lungs by means of the blood or by the respiratory passages, the latter, according to Northrup, being the most frequent in children, the bacillus entering with the inspired air and lodging in the mucous lining of the bronchi or in the alveoli. When carried by the blood they are generally scattered throughout the tissue and give rise to miliary tubercles. In some cases the infection may arise from the throat with or without the production of a local lesion, the bacilli being carried through the lymph-nodes into the blood and from the right side of the heart to the lung. Rarely a very few bacilli may be brought to the lungs by the blood. They may affect only a certain definite portion of the lung and give rise to lesions which are scarcely distinguishable from the lesions produced by the entry of the bacilli through the respiratory passages. Tuberculosis of the lungs may occur in three forms : (1) acute miliary tuberculosis, (2) the more diffuse tubercular pneumonia, and (3) chronic tuberculosis of the lungs. Ordinarily the distinction made between acute miliary tuberculosis and tubercular pneumonia lies in the preponderance of the exudative lesions in the latter. In the lungs of children there is a much greater tendency to exudation than in adults, and even in acute miliary tubercu- losis the essential proliferative changes are, as a rule, accompanied by exudation. There is a further difference between children and adults in that the chronic forms of tuberculosis which are accompanied by exces- sive destruction of tissue, with inflammation leading to a formation of fibrous tissue, and producing the condition known as fibroiditis, are seen to a much less degree in children than in adults. (1) ACUTE MILIARY TUBERCULOSIS OF THE LUNG. Acute miliary tuberculosis of the lung has been described on page 387 as a part of acute general miliary tuberculosis. It presents no other symptoms, when the acute process is limited to the lung, than those which have been already mentioned as occurring in the acute general miliary tuberculosis. There may, however, be a formation of miliary tubercles in the lung in combination with other forms of tuberculosis of this organ, the formation of tubercles being a more chronic process than in the acute disease. 394 PEDIATRICS. (2) ACUTE TUBERCULAR BRONCHO-PNEUMONIA. Etiology. — Acute tubercular broncho-pneumonia is common in chil- dren from the sixth month to the fifth year, a large proportion of the cases, however, occurring after the second year. It may begin in the lungs, or may be secondary to any other of the .lesions of general tubercu- losis, or it may follow any non-tubercular lesion of the lungs, such as bronchitis or broncho-pneumonia. It is common in children who have been debilitated by previous illness, and occurs especially after measles, pertussis, scarlet fever, and diphtheria, being most frequent in the first two. It may, however, develop in perfectly healthy, well-nourished chil- dren, and, as Osier has expressed it, may be a terminal process in cases in which a local tubercular disease exists in other parts, such as the skin, bones, lymph-nodes, or the uro-genital tract. Pathology. — The infection extends by means of the bronchi, and the lesions extend through the bronchi and the alveoli into the surrounding tissue. This is a true pneumonia. There is an exudation into the alveoli of the lungs, which consists chiefly of fibrin and leucocytes. In addition to this, there are numbers of large cells, which probably arise from pro- liferation of the epithelium lining the alveoli. Both the exudative and the proliferative cells undergo caseation, and the tubercular pneumonia may occur in the form of discreet nodules similar to ordinary forms of broncho-pneumonia, or in the form of larger areas, which may arise either by confluence of the smaller foci or by the simultaneous affection of a large area of the tissue. As in the other forms of broncho-pneumonia, the initial lesion is a bronchitis and peri-bronchitis, the distinguishing tubercular features being caseation and necrosis of the consolidation with the presence of the tubercle bacilli. The accompanying phenomena of atelectasis and emphy- sema occur as they do in non-tubercular broncho-pneumonia. In some cases the non-tubercular broncho-pneumonia precedes the tubercular dis- ease, this occurring particularly after measles, scarlet fever, diphtheria, and pertussis. When the tubercular broncho-pneumonia follows the non- tubercular form, in addition to the lesions of the latter disease, there are found true tubercular processes, such as peri-bronchial nodules, tubercular infiltration, and caseous areas. It is rare for the tubercular process in children to begin at the apices of the lungs and gradually extend downward, as is common in adults. When this occurs it is usually in the later years of childhood, when the conditions are beginning to approximate those of later life. Tubercular broncho-pneumonia may be acute or chronic, but it is rarely very chronic. It may occur in very small foci apparently following the bronchi, or it may invade a much larger area and even an entire lobe of the lung. Symptoms. — The symptoms of acute tubercular broncho-pneumonia SPECIFIC INFECTIOUS DISEASES. 395 are very similar to those of non-tubercular broncho-pneumonia. Ac- cording to Osier, in most cases the onset of the disease simulates that of the ordinary non-tubercular broncho-pneumonia so closely that a differ- ential diagnosis between the two diseases cannot be made until after death, and even then the post-mortem appearances may not be those distinctive of tubercular disease, and the pathological diagnosis can be determined only by finding the tubercle bacillus. Children may be at- tacked with cough, a heightened temperature, and the physical signs of broncho-pneumonia. These signs, as would naturally be expected, are usually found in the back and lower portion of the lung rather than at the apices, as in adults, on account of the usual nidus of the tubercular lesions, — namely, the bronchial lymph-nodes. In some cases the onset of the disease is not so acute, and its course not so rapid. The child emaciates and has only a moderate temperature, but later the develop- ment of such symptoms as sweating, chills, and hectic fever, together with the signs of softening and breaking down of the lung-tissue, leads us to suspect that we are dealing with tuberculosis of the lung. Diagnosis. — The diagnosis, as a rule, is to be made by taking into consideration the family history of the child, as the tissues of children whose parents are tubercular show an especial liability to infection by the tubercle bacillus. Careful investigation should be made as to whether the child has been exposed to tuberculosis in any form ; whether it has itself shown signs of any localized form of tuberculosis ; and especially whether it has recently had an attack of measles or pertussis. The physical signs are in no way characteristic, as they may not only be simi- lar to those of the non-tubercular form of broncho-pneumonia, but also we must remember that the various local conditions of chronic interstitial pneumonia and persistent broncho-pneumonia, although simulating tuber- cular disease, may in children be non-tubercular, Continuous fever of a rather high grade in comparison with the non-tubercular pneumonia, the greater intensity of the anaemia, and emaciation mark the tubercular inva- sion. When the symptoms develop insidiously, especially following measles and pertussis, instead of beginning during the course of these diseases, tuberculosis is probable. It must, however, be remembered that simple non-tubercular processes may last for many months, and the children finally recover. The diagnosis can be made positively only jn those cases in which a specimen of the sputum can be obtained and examined for the tubercle bacillus. Prognosis. — The prognosis is invariably unfavorable. Treatment. — The treatment of tubercular broncho-pneumonia is the same as that of the non-tubercular forms (page 701). (3) CHRONIC TUBERCULOSIS OF THE LUNGS. Chronic Diffuse Tuberculosis. — Chronic tuberculosis of the lungs as it is ordinarily met with in adults is rarely seen in young children. 396 PEDIATRICS. During the first three months of life tubercular disease of any form is very rare, but in the latter part of the first year it becomes very common. The tubercular lesions which are found in the lungs in later life also occur in early life. Although cavities are not so commonly found in young children as in adults, it is not so much that they do not exist, but because they are located at the root and central portions of the lung, and are, therefore, more difficult to detect on physical examination. It has been noticed that large cavities at the apex of the lung are rare in early life, but become more common as the child grows older. Tubercular disease of the lung is very irregular in the extension of its lesions in young chil- dren. Much more advanced lesions are usually found at the post-mortem examination than are detected during life. The primary lesion of chronic tuberculosis of the lungs is commonly a tubercular broncho-pneumonia. Chronic Localized Tuberculosis. — In this form, from a single tuber- cular focus, there is an extension of the disease by continuity. The bacilli find their way into the surrounding lung-tissue by means of the lymphatics, or by means of the infection of the adjoining alveoli. Nodules varying in size may be produced. In this form of localized tuberculosis there seems to be a high resistance of the tissue to the tubercle bacillus, and there is not the same tendency to an extension of the infection as in the other forms. After undergoing caseation the tissues seldom remain in this condition, for the caseous material tends to soften, and is discharged by means of the bronchi, or it may be partly absorbed, leaving a cavity in its place. Symptoms. — The symptoms of chronic tuberculosis of the lungs differ but little in the child from those seen in the adult, and are marked by the same irregularities in their course. This is due to the varied forms of the lesions. In young infants the symptoms are so often obscure and the physical signs of the serious pathological conditions which exist in the lungs are so frequently masked that the diagnosis is apt to be very doubt- ful. There is often a history of tuberculosis in the parents. The more common symptoms of chronic tuberculosis of the lungs are gradual loss in weight, strength, and appetite, irregular and moderate hectic fever, and sweating. The physical signs are slowly increasing dulness in certain areas of the lung, especially in the back, accompanied by rales and the other signs of solidification. Later in the disease the characteristic signs of cavities may develop. Cough is usually present, although it is sometimes so slight in the beginning as not to be especially noticed by the parents. Haemoptysis is rare in infants and in young children, but may be present in older children as they approach the age of puberty. As the disease progresses there is dyspnoea, usually of a moderate grade, with cyanosis, but in some cases considerable destruction may have taken place in the lung-tissue without the presence of any especial dyspnoea. The course of chronic tuberculosis of the lungs is rather more rapid in children than in adults, and it is seldom that the long-protracted course SPECIFIC INFECTIOUS DISEASES. 397 of the disease so frequent in adults is met with in children. Sometimes, however, the child improves in its general health and may live for many years. In these cases the terminal phalanges of the fingers may become clubbed, and there is usually dyspnoea on exertion. Diagnosis. — The diagnosis is to be made from chronic empyema and from chronic non-tubercular broncho-pneumonia. The former disease can be readily eliminated by making an exploratory aspiration, but the latter can often be distinguished only by means of a bacteriological exam- ination. In older children, from whom a specimen of the sputum can be obtained, the diagnosis is readily made by the detection of the tubercle bacillus. In younger children, in whom expectoration does not take place, the diagnosis is much more difficult, but if the children are care- fully watched it is often possible to obtain a specimen of the sputum if the child happens to vomit, in which case particles of sputum may be coughed up with the vomitus and can be separated from it and examined. Prognosis. — The prognosis of chronic tuberculosis of the lungs when the symptoms are at all advanced is very unfavorable, but the post-mortem examinations of so many individuals who have died of non-tubercular diseases show the presence of old tubercular lesions which have ap- parently ceased to be of grave import, that we must acknowledge that it is possible for many cases to survive the invasion of the disease. Treatment. — The treatment of chronic tuberculosis of the lungs is essentially climatic, and the children should be removed at once, if possi- ble, from a climate where the altitude is low and the atmosphere damp and subject to great variations. Too high altitudes are also to be avoided. When the child cannot be removed to a more favorable locality, strict attention to its general hygiene and to its food will in some cases be fol- lowed by an apparent arrest of the tubercular process. The treatment of chronic pulmonary tuberculosis especially calls for fresh air and sunshine. The food should be given at regular intervals five or six times in the twenty-four hours, and should be adapted to the di- gestion of the especial case. There are -no drugs which are of much value in this disease. Cod-liver oil is commonly given, and in many cases seems to be tolerated by the stomach, and to be even agreeable to the child. In my experience, however, pasteurized twenty-four per cent cream with five per cent, lime-water is equally efficacious, and to most children much less distasteful. When the appetite is poor a nerve tonic, such as tincture of nux vomica, is often found to be beneficial, and when there is considerable anaemia the tartrate of iron and potash is indicated. The following case (Fig. 100, p. 398) illustrates chronic tuberculosis of the lung following an acute infectious disease : A girl, eight years old, had a history of tuberculosis in her family. She had an attack of pertussis when she was six years old, and some months later an attack of measles. Following the attack of measles she began to have headache, cough, and 398 PEDIATRICS. expectoration. She complained of pain in her chest and abdomen, and of chilly sen- sations, and progressively lost in weight and strength. A physical examination Fio. 100. Chronic tuberculosis of the lung. Female, 8 years old. showed the skin to be dry and harsh and the heart normal. The left lung in front appeared to be normal. Behind over a small area at the upper part of the lung there CHAKT 5. Days of Disease w. c. 107° 106° 105° 104° 103° 102° o 101 100° o 99 NORMAL TEMP. 98 97° 96° 95° M.E ME ME ME ME ME ME ME ME ME ME ME ME ME ME M E M E ME ME ME ME 41.6° o 41.1' 40.5° 40.0° 39.4° ■38.8° 38.3° 37.7° 37.2° 37.0° 36.6° 36.1° 35.5° 35.0° _j / , / 1 } } 1 / / [/ / j\ / / / 7 / / / / 1 / A / / / / / / / / / AJ V 1 / / ! 1 / / / / V / / V 1 ' If 1 Chronic tuberculosis of the lung. were dulness, broncho-vesicular breathing, and some fine moist rales. Over the right upper lobe in front and behind there was dulness, and the expiration was prolonged SPECIFIC INFECTIOUS DISEASES. 399 and high-pitched. Over the dull region were heard medium and fine moist rales. The borders of the areas of dulness are indicated by black lines, and the rales by black spots. The area of cardiac dulness, the lower part of the sternum, and the lower border of the ribs are indicated by dark lines, and the edge of the liver, which seemed to be somewhat enlarged, by an interrupted line. The chart shows the irregular temperature which is commonly seen in cases of chronic tuberculosis of the lungs, and is of the remittent type. The child was gradually failing and the signs of disorganization of the lung were slowly progressing. TUBERCULOSIS OP THE PLEURA. Tuberculosis of the pleura is a common affection in general tubercu- losis and in tuberculosis of the lungs. The symptoms and treatment do not differ from non-tubercular pleuritis, but hemorrhagic exudations are rare in early childhood. TUBERCULOSIS OP THE GASTRO-ENTERIC TRACT.— Tuber- culosis of the gastro-enteric tract occurs most often in connection with and following tuberculosis of the lungs, the infection being due to the swallowing of sputum containing the tubercle bacillus. In rare cases the bacilli may find their entrance in milk or through food. Tuberculosis of the oesophagus, stomach, and duodenum is exceedingly rare. The oesoph- agus probably escapes infection owing to the fact that the sputum con- taining the bacilli remains for so short a time in contact with its walls, which are also protected by their many layers of epithelium. The stomach probably owes its protection to the presence of the gastric juice. TUBERCULAR LLEO-COLITIS. Etiology. — Tuberculosis of the intestine is not so common in infancy as in older children. In the latter, however, it is met with quite com- monly, especially in the middle period of childhood. The disease may be primary in the intestine, but this is very rare. At the Boston Children's Hospital I have had one case in which the tubercular lesions were confined to the intestine and to the mesenteric nodes. In this case Professor Coun- cilman considered that the evidence was in favor of the intestinal tubercle antedating the tubercle of the nodes. In the great majority of cases tubercular ileo-colitis is secondary to tuberculosis elsewhere, and in such cases is followed by tuberculosis of the mesenteric glands. The most common source of infection, however, in all parts of the gastro-enteric tract, is from the lung, by means of the sputum which has been swal- lowed. Pathology. — The tubercular lesions are most common at the lower end of the ileum, next in the rectum, and then in the colon. In tubercu- losis of the intestine the corresponding lymph-nodes are always affected. The tubercular lesions almost invariably occur in the form of ulcerations. These ulcers begin both in the solitary follicles and in Peyer's patches. The ulcers in the solitary follicles are small. In Peyer's patches they may be large, involving the entire extent of the patch. They also show 400 PEDIATRICS. a tendency to grow in the direction of the lymphatics, so that an ulcer may extend around the entire circumference of the intestine. The tuber- cular ulcer has the following characteristics : in contradistinction to the typhoidal ulcer, the long diameter of which coincides with the long axis of the intestine, the tubercular ulcer is transverse to the long axis, rarely ovoid, and often irregular in outline. The edges overhang and the base is infiltrated, and in many instances small tubercles may be visible to the unaided eye on the peritoneal surface at the base of the ulcer. Fig. 101 represents a specimen of tubercular disease of the intestine which occurred in the practice of Dr. jNorthrup. A girl eight and a half years old was attacked two months before her death with chills, fever, and prostration. The temperature at first varied from 38.8° to 39.4° C, (102° to 103° F.), but as the disease progressed the temperature gradually fell. There was rapid emaciation, the abdomen was sunken at first, but later became tense. There were pain, tenderness, and resistance in the right inguinal region. The sub- maxillary, cervical, and inguinal lymph-nodes were enlarged. The urine contained albumin and hyaline casts. There was diarrhoea. The autopsy showed the lungs to be normal. The bronchial and retro-peritoneal lymph-glands were enlarged and cheesy. The colon showed two large sloughing ulcers, one in the region of the caecum and the other in the ascending portion. They were transverse to the axis of the colon. and their edges were overhanging. The entire membrane was thickened, and there was some follicular ulceration. Fig. 102, I. and II., represent portions of intestine taken from a girl two years and eight months old. She had had diarrhoea occasionally for a year and also convulsions. She died soon after entering the hospital. The autopsy showed extensive ulcerations in the small intestine (I.), and a large ulcer in the ctecum (II. ). There were tubercular ulcers in the middle third of the colon. The peritoneal surface showed miliary tuber- cles. The mesenteric and bronchial lymph-glands were markedly enlarged and cheesy. Symptoms. — The symptoms of tubercular ileo-colitis are varied and in- definite. The most common symptom is a persistent diarrhoea. The diarrhoea, however, does not correspond to the extent of the lesions, as large ulcers may exist and constipation be present, especially if they are in the ileum. Diagnosis. — In cases of primary tuberculosis of the intestine, the only certain means of determining the tubercular character of the disease is to find the tubercle bacillus in the discharges. When the disease is second- ary to tuberculosis elsewhere, the tubercular involvement of the intestine may be suspected, when at any time during the course of the disease the infant is attacked with diarrhoea of an obstinate nature. In these cases the disease can only be established by finding the tubercle bacillus in the dis- charges. It is exceedingly difficult to do this when the stools are watery. It has been suggested that in order to simplify the search for the specific organism, sufficient opium should be given to produce a constipated move- ment, so that the smears may be taken from the mucus which is scraped from the tubercular ulcers and clings to the hard faecal masses as they pass downward along the course of the intestine. Ftg. 101 Tubercular ulcers of colon. Female, 8% years old. Museum of the College of Physicians and Sur- geons, New York. Tubercular ulcers of small intestine. Female 2% years old. Museum of the College of Physi- cians and Surgeons, New York. Large tubercular ulcer of caecum. SPECIFIC INFECTIOUS DISEASES. 401 The differential diagnosis is to be made from chronic non-tnbercular ileo-colitis. In the latter condition the history usually shows that the dis- ease has begun with an acute attack, while in tuberculosis the onset has been insidious. Markedly enlarged mesenteric nodes and the evidence of tuberculosis elsewhere are important as indicating a tubercular cause for the intestinal symptoms. Prognosis. — The prognosis is very unfavorable, and death may occur either from the severity of the intestinal symptoms, or, more rarely, by perforation or hemorrhage. The prognosis, however, largely depends on that of the tubercular disease to which the intestinal tuberculosis is sec- ondary. Treatment. — The treatment is the same as that described for non- tubercular ileo-colitis on page 823. TUBERCULOSIS OF THE PERITONEUM. Tuberculosis of the peritoneum may occur in both infants and chil- dren, but a marked inflammatory condition, either with or without ascites, is more common in children than in infants. In infants it is more com- mon to have a miliary tuberculosis of the peritoneum in the course of a general tuberculosis which does not, as a rule, show abdominal symptoms. In children the peritoneal inflammation may be so markedly localized as to constitute a disease of itself, tubercular peritonitis. Etiology. — The original source of the tubercular process is often ob- scure. It may be a primary infection of the peritoneum, but most com- monly is secondary to tuberculosis of the mesenteric nodes. It may also be secondary to tuberculosis of the intestine, lungs, lymph-nodes in vari- ous parts of the body, and other organs. It may arise in the course of the various infectious diseases, especially the exanthemata. Tubercular peritonitis may be acute or chronic, but the most common form met with in children, and the one which usually represents the disease clinically is the chronic. Pathology. — The process consists in the formation of miliary tuber- cles on the peritoneal surface, which give rise to opaque cheesy thicken- ings, often nodular, with firm adhesions of the adjacent surfaces. An exudation into the peritoneal cavity is usually present, the quantity gen- erally being considerable and sero-purulent in character. The ascites may, however, be serous, or merely purulent. The disease may occur in three forms. (1) A miliary tuberculosis with ascites acute or subacute in its course. (2) A fibrous form in which ascites may be, but is not usually, present. This form is essentially chronic. There is a formation of a fibrous tissue with matting of the intestine, of the omentum and mesentery, and not much tendency to caseation or breaking down. (3) An ulcerative form, which is a later stage of the two forms just described, and in which occur large tubercular deposits with caseation and softening. The lungs in this form are affected. 26 402 PEDIATRICS. It is not so chronic as the fibrous form (2), but it is characterized by more fever and more severe symptoms. Symptoms. — The symptoms of tubercular peritonitis vary according to the extent and character of the lesions. When they consist of a miliary tuberculosis of the peritoneum, with only a slight inflammatory condition, they are usually secondary to a general tuberculosis, and the abdominal symptoms are insignificant. When this form occurs in young infants the later manifestations of abdominal disease are seldom seen, as the infant usually succumbs to the infection before the symptoms have had time to develop. When the disease is acute, the symptoms, as a rule, develop in connection with, or most often following, the symptoms of tuberculosis elsewhere, especially in the lung, and do not differ materially from those of acute non-tubercular peritonitis. When the disease is of the subacute and chronic form the symptoms vary according to the presence or ab- sence of ascites as a prominent condition-. Here, again, the symptoms correspond to the character of the lesions. In either case a tubercular process is going on, but in one it results in a large effusion of fluid, while in the other the more advanced tubercular lesions develop with no fluid at all, or with only a small amount. The initial symptoms of tubercular peritonitis, with gradual develop- ment of ascites, are usually ill defined. There is a gradual loss of appe- tite and flesh, with occasional abdominal pain, which, as a rule, is not severe in character. There is seldom any tenderness of the abdomen. Vomiting is not a marked symptom. Attacks of diarrhoea are common and are apt to be paroxysmal. There may be constipation. The tem- perature is at times raised, especially in the latter part of the day, but, as a rule, is moderate,— 37.2° to 38.8° C. (99° to 102° F.),— and may be so nearly normal as to simulate ascites due to obstruction. After these gen- eral symptoms have lasted for a number of weeks, the abdomen is noticed to be distended. A physical examination may show that there is nothing abnormal in the thorax, and that the morbid condition is confined entirely to the abdomen. At first the abdomen is resonant on percus- sion, but later fluctuation is detected. While for a time there is reso- nance in the region of the umbilicus when the child is lying on its back, and a change in the area of resonance with a change of position, this area of resonance gradually grows less. The fluid, however, may be encapsu- lated by adhesions and thus the area of dulness and resonance be less distinctly followed. As the disease progresses and the fluid increases, the whole abdomen becomes much distended and tense, the abdominal veins prominent, and the dulness and fluctuation diminished. In this higher grade of ascites the umbilicus is at times found to be pushed out by the fluid. Clinically separated from the class of cases with ascites as the promi- nent symptom, are the still more chronic cases in which ascites is not prominent, but in which there are tubercular processes which, because of SPECIFIC INFECTIOUS DISEASES. 403 certain mechanical conditions, result in a set of symptoms induced by pressure, such as oedema, digestive disturbance, and renal congestion. The general symptoms are about the same as in the ascitic form just de- scribed, the difference being in the conditions found on examining the abdomen. Possibly the onset is still more insidious than in the other form, and the temperature more likely to be normal. The abdomen may be distended and tympanitic, or, again, varying areas of dulness may be detected, depending usually on tuberculous masses or tubercu- lous thickening of the greater omentum. There may at times be a cer- tain amount of fluid which can be detected by fluctuation and change of position. Although there may be abdominal pain and tenderness, yet usually these symptoms are absent, and sometimes markedly so, even when the process has gone on to a purulent ascites. The cases in which the more advanced tubercular lesions, such as ulceration and breaking down of the tubercular growths, have taken place are usually secondary to advanced lesions elsewhere, as in the lung, and do not properly constitute a localized tubercular disease. In these cases, however, the temperature is raised, a hectic condition is commonly present, the wasting is extreme, and all the symptoms irregular, so that when these symptoms become marked in the other forms of tubercular peritonitis just described, the presence of a general tuberculosis should at once be thought of. Diagnosis. — In a case in which the symptoms which have just been mentioned are present the diagnosis is not difficult. Occasionally, how- ever, there are no definite signs by which a diagnosis can be made, the only tangible sign being a seeming abdominal tumor, the resemblance of which to other abdominal tumors is so close that the diagnosis can only be made by laparotomy. We should remember, however, that most cases of doubtful abdominal tumors in children are tuberculous. In a case in which there is considerable ascites, it should be recognized that while the most frequent form of ascites in adults is obstruction of the portal circulation, as in cirrhosis, in young children, on the contrary, portal ob- struction is rare, while ascites from tubercular peritonitis is exceedingly common, and is the disease which should at first be thought of. The greatest difficulty arises in differentiating simple non-tubercular peritonitis with ascites from the tubercular form. It is often impossible to do this without an exploratory paracentesis. If, however, there is evidence of tuberculosis elsewhere, or if the fluid is encapsulated, or if there is con- siderable fever, the process is most likely to be tubercular. In the cases of tubercular peritonitis where there are tubercular lymph-nodes without ascites, the diagnosis can only be made if irregular masses can be detected in the abdomen, accompanied by fever, wasting, and possibly some ab- dominal tenderness not accounted for by disease elsewhere. If tubercular disease is detected in the lungs, the diagnosis is still more assured. In many cases, however, the diagnosis can only be made by abdominal para- 404 PEDIATRICS. centesis. The diagnosis of the advanced cases, in which ulceration has taken place, is usually to be made as part of a tubercular condition of other organs, especially the lung. Prognosis. — When tubercular lesions of other organs are present the prognosis is bad. In those cases in which the tuberculosis is apparently confined to the abdomen, the prognosis has been much improved since the employment of laparotomy for treatment. Any of these cases may, however, eventually die from a later infection, as of the brain or lung. When untreated the prognosis of tubercular peritonitis is very variable. In some cases the disease after a number of months retrogrades and the patient recovers. In most instances the child becomes more and more wasted, the fever becomes more pronounced, the diarrhoea continues, the emaciation becomes extreme, and the child dies usually of exhaustion. The surgical treatment of the disease has made the prognosis much more favorable. Treatment. — The general treatment of tubercular peritonitis does not differ from that of the non-tubercular form (see page 843). The essential treatment, however, in the cases which are supposed to be localized is surgical, especially when there is ascites of any amount. In some cases opening the abdomen and evacuating the fluid will not only give relief, but will produce a permanent cure. In my experience at the Boston Children's Hospital this procedure has been in a large number of cases followed by a complete arrest of the disease. Cases of marked tuber- cular peritonitis in which laparotomy had been performed, have been re- ported as perfectly well some years after the operation. Fig. 103 represents a colored boy, nine years old, with tubercular peritonitis. His father died of phthisis. The boy had never been strong, but had suffered no acute Fig. 103. Tubercular peritonitis. Male, 9 years old. illness. Three weeks previous to my seeing him, he began to have diarrhoea, and soon after, enlargement of the abdomen. There was no pain, vomiting, nor cough. He had lost greatly in weight and was much emaciated. His temperature was 38.3° C. (101° F.). The abdomen was much distended and gave a distinct wave of fluctua- tion. Physical examination showed nothing else abnormal. Laparotomy was performed and the fluid evacuated. Tubercle bacilli were found in the peritoneal tissue. When seen six months later the wound had healed perfectly, and he was strong and well. Another case was that of a boy, two years old, and is especially interesting in regard to the diagnosis. He had not had general symptoms of serious import, but had lost slightly in weight, appetite, and strength. From time to time for six months he complained of abdominal SPECIFIC INFECTIOUS DISEASES. 405 pain and tenderness. An examination of the abdomen showed a hardened, slightly irregular mass extending directly across the abdomen from one side to the other, 5 cm. {'2 inches) above and the same distance below the umbilicus. It was not especially tender on pressure. Nothing else abnormal was detected about the child. The line of percussion did not change when he was lying on his back. There was no evidence of ascites. Laparotomy was performed and a mass of cheesy nodules matting together the intestine was found. An examination of a portion of this mass showed the pres- ence of the tubercle bacillus. No fluid was present. The child recovered. The next case was that of a boy, four years old, brought to the hospital with the extreme distention of the abdomen which is represented in Fig. 104. A physical ex- amination showed nothing abnormal except in the abdomen, which was dull on per- Fig. 104. Tubercular peritonitis. Male, 4 years old. cussion and showed fluctuation in every part. The child had gradually lost in weight, appetite, and strength. Laparotomy was performed and a large amount' of ascitic fluid evacuated. Tubercle bacilli were present in the diseased peritoneum. The wound healed, but in the course of a few weeks the fluid re-accumulated, and laparotomy was again performed. Some weeks after the second operation no fluid could be detected. There was no recurrence of the ascites, and the child recovered completely. The next case is that of a boy, eleven years old. He had been perfectly well until four months before coming to the hospital, when he began to lose in weight and appe- tite and to show an increase in the size of his abdomen. Although he was not espe- cially emaciated, he had lost in flesh and was pale. The circumference of the abdomen was 76.4 cm. (30 inches). On physical examination, nothing abnormal was detected in any of the other organs. For some months before the boy showed peritoneal symp- toms, he had been drinking the milk of a tubercular cow. Laparotomy was per- formed and a large amount of serous fluid of a dark yellow color was removed. The peritoneum was found to be thickly studded with minute tubercles, and tubercle bacilli were demonstrated. The peritoneal cavity was irrigated and drained. He recovered completely from the operation, and when examined four years later, was found to be well and strong, and to show no signs of tubercular disease. TUBERCULOSIS OF THE CEREBRO-SPINAL SYSTEM.— Tuberculosis of the cerebro-spinal system usually takes the form of an infection of the meninges (tubercular meningitis), and is found most com- monly in the meninges at the base of the brain. As a rule, the disease is never so extensive in the spinal as in the cerebral meninges. Some- times, though very rarely, a growth of miliary tubercles in the meninges extends into the tissues of the brain. The tubercle bacilli themselves are usually confined to the brain, but they may extend to the lungs and pro- duce definite foci of embolic pneumonia. 406 PEDIATRICS. TUBERCULOSIS OF THE BRAIN. Pathology. — Tuberculosis of the brain may occur in the form of scattered miliary tubercles, or these tubercles may occur as nodular masses of various sizes formed by aggregations of miliary tubercles. These nodular masses may be single, but are more commonly multiple, and are found in both the cerebrum and cerebellum, but most frequently in the latter. They are occasionally found in the cms. . Symptoms. — Tubercular lesions of the brain are always terminal. The scattered miliary tubercles are usually a part of a general miliary tubercu- losis, and usually do not produce any special cerebral symptoms. When, however, masses of tubercles large enough to be considered tumors are present, they present the symptoms of cerebral tumor as described on page 978. In some cases tubercular tumors of considerable size have been found at the autopsy, when during life no symptoms have been noted. Such a case is described on page 980. Prognosis. — Although these tubercular lesions of the brain may remain latent during long periods, as a rule they result fatally, so that the prog- nosis is very bad. Treatment. — The use of drugs in these cases is not of very much benefit. Surgical interference has proved of value when we are assured that a tubercular condition is present. TUBERCULAR MENINGITIS. Etiology. — Tubercular meningitis is a tubercular infection resulting in an inflammation of the pia mater. It is not a primary disease of the meninges, but is always a terminal lesion produced by the tubercle bacillus, which, originating elsewhere, is carried to the brain by the lymphatics or the blood-vessels. In infants the tubercular meningitis is usually second- ary to a general tuberculosis or to tubercular lesions in the lungs. In older children it is apt to be secondary to tuberculosis of the lymph- nodes, bones, or joints. The tubercular form of otitis is not uncommon, and may be the starting-point of a meningeal infection. Tubercular meningitis is the most common form of meningeal disease in children. It occurs most commonly in early life, runs a subacute course, and is invari- ably fatal. It occurs more commonly between the ages of two and seven, than at any other period of life. It is rare in the first year of life, espe- cially in the early months ; the number of cases increases rapidly in the second year and decreases as rapidly after the eighth year. It is com- paratively so rare in adult life that out of a large number of adult pa- tients that I met in my service at the City Hospital only a few cases of tubercular meningitis came under my care during a service of ten years. In a large number of cases there is a tubercular history of one or both parents. Pathology. — A knowledge of the general pathology of tubercular meningitis is of great practical importance in acquiring a clear picture of . SPECIFIC INFECTIOUS DISEASES. 407 the disease. Although the nidus of the tubercle bacillus which produces the pathological lesions of tubercular meningitis is in some other part of the body, and the lesions of the brain and its meninges are always second- ary, yet. as the clinical characteristics of the disease are those of a pri- mary cerebral nature, only the morbid lesions which occur in the brain will be described. The macroscopic pathological condition which is seen in the brain as a result of the action of the tubercle bacillus is a growth of miliary tuber- cle in the meninges. This growth is especially marked in the meshes of the pia mater along the course of the blood-vessels at the base of the brain. These small granulations are conspicuously numerous in the choroid plexus, and cause great irritation in the neighboring parts. The irritation is followed by an exudation of greater or less extent into the ventricles. Accompanying this there is also a fibrino-purulent exudation between the pia mater and the cerebral convolutions at the base of the brain, notably in the fissures of Sylvius, but at times covering the whole convexity. This inflammatory exudation is usually confined to the meninges, but it may extend into the tissue of both brain and cord and over the upper surface of the cerebellum. A marked characteristic of the disease, and one which tends to distinguish it from other forms of meningitis, is the extension of the exudation from the meninges around the sheaths of the cranial nerves. The nerves apt to be affected are the auditory, optic, and the fifth nerve. The amount of exudation is not proportionate to the number of tubercles. The ventricles are sometimes so distended as to burst the septum. Pressure is thus brought upon the central portions of the brain, involving especially the optic thalamus, the corpus striatum, and the corpus callosum. While the symptoms vary in different indi- viduals and at different ages, the pathological lesions, on the other hand, with the exception of their location, are comparatively stable. What is of especial interest to us clinically, however, is that, although in a typical case of tubercular meningitis in middle childhood the symptoms, as a rule, correspond to the pathological lesions, yet in some cases we find an entire lack of such symptoms as would naturally result from the wide- spread and prominent lesions. The spinal meninges are occasionally involved in tubercular spondylitis (Pott's disease). Symptoms. — Tubercular meningitis presents many irregularities in its manifestations, and its typical symptoms vary according to the age of the patient. By careful study of the pathology of tubercular meningitis we can almost deduce the sequence of symptoms which we should expect to meet with in the middle period of childhood, a period when the disease is seen in its most typical form. In fact, in the great majority of cases oc- curring between the ages of two and eight years this sequence is very striking. As we are dealing with a symptom of general tuberculosis, we should expect to find in the early stages of the disease that the nutrition is affected, that there are a lessened appetite, loss in weight, anaemia, and. 408 PEDIATRICS. ir fact, symptoms which warn us that something is affecting the child's general health. This condition may last for many weeks, or even months, varying as to the time when the tubercle bacillus has left its original nidus and migrated to the cerebral meninges. Only after this has occurred do we begin to get symptoms of cerebral irritation. The child then be- comes peevish and capricious, and is in some cases easily frightened. As the tubercular growth increases and causes further congestion of the blood-vessels, the sleep is disturbed ; the child complains of dizziness and slight evanescent pains in the head ; it staggers slightly in its walk (static ataxia) ; sometimes it cries out sharply, especially at night (hydrocephalic cry). Vomiting, apparently not connected with the food, and usually without nausea, is a common symptom. It may occur only once or several times, or it may last for a number of days. These are symptoms of irritation of the nervous centres, and may last for a week or two, ac- cording to the development of the pathological lesions. Progressive emaciation becomes prominent, and the increasing apathy is very notice- able. The temperature is usually moderately raised, 37.2 -37.7°-38.3° C. (99°-100°-101° F.), but on some days it rises a degree or so higher, and just before death a considerable elevation may occur. Chart 6 shows the CHART 6. Days of Disease. F. 1 1 | 2 3 4 5 6 | 7 | 8 1 9 10 11 12 13 14 15 1 16 | 17 18 19 c. 107° 106 c 105° 104° 103° 102° 101 c 100 c 99° NORM'L TEMP. 98° 97° 96° 95° Mfl ME ME ME ME ME ME ME M E ME ME ME ME ME ME M E ME' ME ME 41.6' 41.1' 40.5' 40.0' 39.4' 38.8' 38.3' 37.7' 37.2" 37.0" 36.6' 36.1° 35.5° 35.0" J / <^ / « / / / ^ J A - / A/ w Ir V V — — 7 V (\ H' /_.. --- ... i i Tubercular meningitis. Male, 4 years old. temperature of a child four years old. It represents very well what will usually be met with in uncomplicated cases of tubercular meningitis. It is impossible to determine the exact day of the beginning of the disease in such an affection as tubercular meningitis, so that the first day marked on the chart is merely approximate and serves as a starting-point to show SPECIFIC INFECTIOUS DISEASES, 409 the character of the temperature. The pulse at first is somewhat accel- erated, but soon becomes slower than normal, and is apt to intermit. In determining whether the pulse is slow, the age of the child must be taken into consideration. (See page 71.) The respirations may in the early part of the disease be quickened, and at times are of a sighing character. Obstinate constipation is a common symptom. The urine is scanty. Hyperesthesia of the skin, with occasional waves of congestion, especially of the cheeks, is sometimes met with. The pain in the head increases, and the child is apt to hold its hand to its head. Drowsiness, at first slight, soon becomes very marked, and gradually changes to stupor, diffi- culty in arousing the child becoming greater and greater. The child is apathetic and lies in bed, refusing to eat. There is photophobia, and the pupils may, early in the disease, be contracted. Tubercles in the fundus of the eye are rarely seen during life. The eyes have a fixed, expression- less look. Abdominal pains are quite frequent, and depression of the abdomen (boat-shaped) is noticed in a certain number of cases. Drawing the finger over the skin usually produces a bright red line, which be- comes in a few minutes quite intense, and lasts perhaps ten or fifteen minutes, which is much longer than would be the case in a healthy child. This phenomenon is called the tache cerebrate, and is quite frequently met with in tubercular meningitis, although it may be absent. This sign is, however, in no sense typical, and is seen in a number of other diseases. Kernig's sign may or may not be present. The child at this stage of the disease is apt to roll its head on the pillow almost continuously. If diarrhoea appears, we should suspect tuberculosis of the intestine. When the pathological irritation has gone on to exudation, we begin to get symptoms of pressure. Sopor comes on rapidly, and the child can no longer be aroused. Strabismus, nystagmus, and ptosis may appear. The pupils are dilated and irregular, respond slowly to light and later not at all. The cornea becomes clouded. The Meibomian secretion is some- times markedly increased. Muscular twitching may occur. Convulsions, generally partial, and of a rather mild type, set in. Rigidity of the neck and, at times, opisthotonos develop. Movement of the head and trunk and pressure over the spinous processes may cause pain. At times paralysis of the arm, or of the arm and leg (hemiplegia), and interference with sight (optic neuritis), may be noticed. The cutaneous reflexes are dimin- ished and the deep reflexes of the arms and legs are, as a rule, increased. The paralysis which in some cases occurs early in the disease is not necessarily permanent. At this stage the pulse becomes markedly slow and irregular, 50-60-70, and it is very common to find an intermis- sion in the pulse, although this must not be considered as diagnostic of tubercular meningitis. The respirations are not perceptibly diminished at first, but soon become slow, 10 to 15 in a minute. A peculiar form of respiration, called Cheyne-Stokes, is usually seen at this stage of the disease. The type of respiration is characterized by complete or 410 PEDIATRICS. almost complete cessation of the respiratory mo Yemenis for a number of seconds. This is followed by a faint return of the respiratory move- ments, which gradually increase in depth, rising for five or six inspirations and then fading away again so as to be imperceptible. Chart 7 repre- CHAKT 7. MWw. Pause. Cheyne-Stokes respiration. Tubercular meningitis. Child, 4 years old. sents this type of respirations occurring in the third week of the illness of a child four years old who died of tubercular meningitis. A heightened temperature in tubercular meningitis indicates a compli- cation of some kind, such as pulmonary tuberculosis, pneumonia, or tuber- culosis of the intestine. At the end of the disease, however, the temper- ature rises rapidly, as do the pulse and respirations. Hearing, taste, and smell seem to be unimpaired for some time. The position which children with tubercular meningitis often take is somewhat characteristic. In all forms of meningitis they are apt to bury their heads in the bedclothes,- and there is often spasmodic retraction of the head. They are inclined to lie with their knees drawn up, and there may be spasmodic opisthot- onos. A striking feature which not infrequently occurs in the course of these general symptoms is a partial return to consciousness after the child has been lying in a stupor for several days. This phenomenon often in- duces the parents, and sometimes even the physician, to entertain hopes of improvement. It is, however, always delusive, for it has no favorable significance, and is soon followed by a more profound state of uncon- sciousness. These symptoms which been have mentioned do not, of course, always appear together, but may be present in different groups, varying with the individual. All the symptoms may disappear temporarily. The duration of the disease varies. It is usually from three to six weeks, but may last only one week, and again eight or even twelve weeks. The cases of shorter duration usually present more active and severe symptoms, and ones more difficult to differentiate from simple acute meningitis. Death may be preceded by continued convulsions for several hours, but usually the pulse becomes weaker, the temperature rises, the child can no longer be made to swallow, and, according to Sachs, dies from paralysis of the cardiac and respiratory centres. Infantile Tubercular Meningitis. — Symptoms. — According to some extended observations made at the hospital in Stockholm, infantile tuber- cular meningitis is characterized in the first year by an absence of prodro- mata, the sudden development of acute symptoms, a short course, and a fatal issue. The temperature is high,— 38.8 °-39.4°-40° C. (102°-103°- SPECIFIC INFECTIOUS DISEASES. 411 104° F.) The respirations are quickened and comparatively regular, — 30-40-50. The pulse is high, — 130-140-150. Clonic spasms and strabismus often occur. Paralysis is quite frequent, and diarrhoea is present rather than constipation. Bulging of the fontanelles is usual. Sinking of the abdomen is rare. Vomiting may occur, but is not espe- cially common. Sharp cries are occasionally met with. The differential diagnosis from non-tubercular meningitis is difficult. Sopor and coma at the end are frequent in both diseases. The duration is seldom more than a week. It may be only two days, yet in rare cases the infant, like the child, may live for a month. During the second year the symptoms of tubercular meningitis become of an irregular type, sometimes assuming the character of those which are seen in the first year, but soon corresponding more nearly to those which are met with in the middle period of childhood. Diagnosis. — The diagnosis of tubercular meningitis in the middle period of childhood, and with the sequence of symptoms just described, is not difficult, but in the early days, or even in the first week of the disease, must necessarily be very obscure. When the process occurs in young infants the difficulty is still greater. It is by watching the course of the disease and the general grouping of symptoms, rather than by the consideration of any one symptom, or even one group of symptoms, that we are justified in making a definite diagnosis. The diagnosis, then, must, as a rule, be held in abeyance for many days. Reflex vomiting with a moderate temperature, irregularity and intermission of the pulse, apathy, and many other symptoms of tubercular meningitis I have seen in cases in which there were no serious cerebral lesions. The active development and sensitive condition of the nervous system in children are so exagger- ated in comparison with those of adults, that whatever condition may be present, it is liable to produce so profound an impression on the child's nervous centres that actual disease of these centres is readily simulated. Thus, for days symptoms apparently cerebral may mask by their undue prominence the presence of the real disease. As a rule, in most cases the distinctive picture of a beginning tuber- cular meningitis after the first year of life closely simulates that of a simple digestive attack. Reflex vomiting, continued for some time without ade- quate explanation, and progressive loss in weight and strength, with change in temperament, should awaken suspicion of the more serious disease. Marked constipation, apathy, and drowsiness, slowly increasing stupor, and slow, irregular pulse and respiration, with a moderate tem- perature, will strengthen the diagnosis. Confirmatory evidence of the presence of tubercular meningitis can be obtained in many cases by means of lumbar puncture. The differential diagnosis from other diseases and the presence of some form of meningitis can readily be made by the cerebro-spinal fluid, which contains some form of pathogenic organism and is usually cloudy. The cerebro-spinal fluid in tubercular meningitis 412 PEDIATRICS. contains cells which are essentially lymphoid in character, the polymor- phonuclear leucocytes being much less numerous. In addition to this, the fluid is less turbid than in the other forms of meningitis. Cover-glass preparations may show the tubercle bacillus, and inoculation of the fluid will often produce tuberculosis in guinea-pigs. In the other forms of meningitis, including the epidemic cerebro-spinal form, the cells are mostly of the polymorphonuclear variety, while the lymphoid cells are less numerous. The fluid is also more cloudy than in the tubercular form. In addition to this, some special organism may be found, such as the pneumococcus in cases of pneumonia, and the diplo- coccus intracellularis in the epidemic form. Differential Diagnosis. — The differential diagnosis must be made be- tween meningitis in general and other diseases, such as (1) diseases of the stomach, (2) anterior poliomyelitis, (3) pneumonia, (4) malaria, (5) typhoid fever, (6) syphilis, (7) nephritis, (8) epidemic cerebro-spinal meningitis, and (9) acute meningitis. (1) From Diseases of the Stomach. — Unless the child is very young, symptoms due to acute gastric disturbance are, as a rule, not difficult to recognize after the first few days. We may at times, however, be sus- picious of cerebral disease when in an infant there is continual vomiting and an elevated temperature, in whom there is no discoverable source of reflex irritation to account for the symptoms. This is especially the case if there is some irregularity of respiration and the pulse is slow. These may prove to be cases of tubercular meningitis in the first year of life. Again, however, they may be simply cases of reflex vomiting. As an illus- tration of this class of reflex gastric disturbance the following case may be cited : A male infant, eight months old, was attacked with vomiting which lasted with short intervals for two days. There was apathy, and the pulse was slow and intermit- tent. The temperature was 37.2° C. (99° F.). There were irregular respiration and rapid emaciation. The patient made a perfect recovery in four or five days, and the case proved to be one of cyclic vomiting. The slow, intermittent pulse, and the moderate temperature, which would have been so alarming in an older child, led me in this case, as in others in the first year of life, to eliminate tubercular meningitis. In my experience this interpretation of symptoms has proved to be correct. (2) From Anterior Poliomyelitis. — The following case of anterior polio- myelitis resembled tubercular meningitis : A boy, eighteen months old, showed for over a week symptoms closely simulating those of tubercular meningitis. Obstinate constipation and apathy were present, fol- lowed by unconsciousness : there were also a marked tache cerebrate, distended fonta- nelle, irregular pulse, contracted pupils, eyes turned upward, and convulsive attacks. Finally, paralysis of the arms appeared, the general symptoms passed off, and the diag- nosis of anterior poliomyelitis was readily made. (3) From Pneumonia. — A certain number of both primary and secondary cases of meningitis have been proved to have been caused SPECIFIC INFECTIOUS DISEASES. 413 by the pneumococcus lanceolatus, but the number as yet has been too few to formulate a symptomatology separate from that of the other forms of meningitis. The cases of pneumonia reported on page 682 warn us that Ave should hold our diagnosis in abeyance sometimes even for a week, and that the nervous symptoms arising in the course of a pneu- monia may closely simulate those arising from meningitis. (4) From Malaria. — Although we must admit that malaria closely sim- ulates almost any disease, it is not usual to mistake the malaria of older children for tubercular meningitis. An examination of the blood for the presence of the plasmodium will generally make the diagnosis clear. In the first two years of life, however, malaria may affect so insidiously the general nutrition before its characteristic symptoms appear that some doubt as to the differential diagnosis may arise, as illustrated in the fol- lowing case : A male infant, twenty months old, with a history of tuberculosis on the mother's side, began to show symptoms of anaemia and malnutrition with no perceptible cause, such as improper food or bad general hygiene, to account for it. After two or three weeks it had attacks of unconsciousness lasting for hours ; at other times drowsiness, with irregular pulse and respirations, was noticed. The temperature was 39.5° to 40° C. (103° to 104° F.). There were slight convulsions, and the fontanelles were dis- tended. At first there was no periodicity of the symptoms, but a week later the attacks were evidently more pronounced every other day, while on the intervening days the infant was brighter. It lived in a malarial district. On the administration of quinine and on removing the infant to a non-malarial region, these symptoms entirely disappeared. The detection of the plasmodium would, of course, have determined the diagnosis in this case, but it could not be obtained. Another case, which I saw in consultation, is also very instructive in warning us to be careful in making a diagnosis of tubercular meningitis in cases in which there is a possibility of malaria being the cause of the symptoms. A male infant, fourteen months old, had always been well until fourteen days pre- vious to the time when I first saw it. It then began to be fretful and to have diarrhcea. This condition continued for about a week, when it fell into a stupor, became very anaemic, and it was necessary to feed it by means of a dropper. At times it would cry out sharply. The temperature varied from 37.2° to 38.7° C. (99° to 102° F.). The respirations were usually regular, but at times were of the Cheyne-Stokes type. The pulse was about 120, sometimes regular, but at times intermitting. The pupils were sometimes contracted, but showed no irregularity. No other abnormal conditions were detected, but the abdomen was depressed. The tache cerebrate was very distinct. On close inquiry I found that there was a slight periodicity in the symptoms, shown by a rise of temperature on each afternoon and followed by the stupor becoming some- what less. Although the infant had been unconscious for a week, and was becoming weaker and taking less nourishment every day, yet, on the supposition that it might possibly be an obscure case of malaria, I decided that quinine should be administered in suppositories. On the next day a slight improvement was noticed during the after- noon. The infant appeared less comatose, but its temperature and pulse remained as on the previous days. On the following day, which was the second from the time that 414 PEDIATRICS. it had begun to receive the quinine, it rapidly became conscious and began to drink milk. On the following day it was reported to have had a restless night and two slight convulsions. Its temperature in the morning was 38.2° C. (100.9° F.), and the pulse was 115 and not intermittent. On the next day there was marked improvement in every way, and this continued without interruption for the following four days. The infant then continued to improve rapidly, the temperature and pulse becoming normal, and later it was reported to be perfectly well. * (5) Fro ni Typhoid Fever. — In my experience in cases in which positive results are not obtained from the Widal reaction and from lumbar punc- ture, typhoid fever in young children is the disease which, next to the non-tubercular forms of meningitis, is most likely to simulate and be mis- taken for tubercular meningitis. The differential diagnosis is given on page 453. We may also have considerable difficulty in differentiating tu- bercular meningitis from the non-tubercular meningitis which may occur in the course of typhoid fever ; this form of meningitis, though exceedingly rare, may occur, as has been proved by finding the typhoid bacillus in the cerebro-spinal fluid by lumbar puncture. The extreme cerebral con- gestion which at times arises as a symptom of typhoid fever may also add fresh difficulties to the differential diagnosis. (6) From Syphilis. — The history and general symptoms of syphilis are to be sought for where a syphilitic meningitis is suspected. The temper- ature is not especially high, and the symptoms are seldom acute. The pathology is said to be usually that of a chronic basic meningitis. (7) From Nephritis. — In addition to the other diseases which may simulate tubercular meningitis should be mentioned nephritis, in which the symptoms of uraemia simulate, to a certain extent, those of tubercular meningitis. The urine should always be examined in doubtful cases of this kind. When uraemic symptoms resulting from nephritis are present the disease will be shown by such examination, and we are thus able to differentiate it from tubercular meningitis. (8) From Epidemic Cerebro-Spinal Meningitis. — It is often quite difficult to differentiate the early stages of tubercular meningitis from those of cerebro-spinal meningitis. In typical cases, however, the diagnosis is not difficult, as the long prodromal period of tubercular meningitis, as a rule, does not occur in cerebro-spinal meningitis. The temperature in the latter disease is high in comparison with the former, in Avhich it is moderate. In fact, all the symptoms of cerebro-spinal meningitis are markedly acute in comparison with those of tubercular meningitis, which is essentially a dis- ease of a subacute character. The sudden onset, extreme hyperesthesia and sensitiveness to sound, intense headache, and marked tenderness on pressure over the spine, so common in cerebro-spinal meningitis, are seldom met with in the tubercular form. The absence Of leucocytosis points strongly to tubercular meningitis ; if leucocytosis is present, it is of little value in the differential diagnosis. (9) From Acute Meningitis. — The symptoms of meningitis in general SPECIFIC INFECTIOUS DISEASES. 415 can, in the great majority of cases, be differentiated from other diseases, provided that we do not attempt to make the diagnosis too early. Having determined that the disease is of cerebral origin, we must next differentiate between the tubercular and the other forms of menin- gitis by means of the broad rules of which I have just spoken, and which I have condensed and simplified by means of the following table : TABLE 61. Cerebral Meningitis. Acute Form. Tubercular Form. Usually secondary (possibly primary). Secondary. Not hereditary. Hereditary. Acute. Subacute. Prodromata short, if any. Prodromata long, decided. Headache seyere at once, with delirium early, Headache less severe at first, but gradually and soon followed by somnolence. increasing ; delirium less common and milder. Photophobia extreme. Photophobia not so marked. Convulsions violent. Convulsions less violent. Temperature high. Temperature moderate. Pulse and respiration rapid. Pulse and respiration slow and irregular. Duration short. Duration long. Cerebro-spinal fluid turbid, with preponder- Cerebro-spinal fluid less turbid, with pre- ance of polymorphonuclear cells. ponderance of lymphoid cells. Leucocytosis present. Leucocytosis sometimes present, often absent. Presence of specific organism in the cerebro- Presence of tubercle bacillus in cerebro-spinal spinal fluid. fluid. Transudation into the ventricles may occur in either form. The younger the infant the nearer the two forms approach each other in the similarity of their symptoms. Prognosis. — When we are sure of our diagnosis, I believe that in our prognosis we should give no hope of recovery whatever, except that in extremely rare cases a temporary remission may take place. The reported cases of absolute recovery from tubercular meningitis cannot but be looked upon with scepticism. Indeed, the acute forms of meningitis simulate the tubercular so closely that without post-mortem verification recoveries can be supposed to be possible, but can hardly be accepted as proved. Treatment. — The treatment of tubercular meningitis up to the time when the diagnosis is established should be purely symptomatic ; later we should make the child comfortable by every means in our power. As no case of tubercular meningitis has ever been proved to be cured by iodide of potassium or any other drug, it is useless and unwise to encourage ourselves and the parents by false hopes of good results arising from the administration of any drug whatever. Up to the present time our knowl- edge of the disease justifies us only in using drugs as palliatives for the child's suffering. The following cases illustrate the different phases of tubercular menin- gitis. The first case illustrates a type of disease such as may occur in the first year of life : 416 PEDIATRICS. A male infant, ten months old, had always been well and strong. For a few days before he was seen he had been rather dull and feverish, but had shown nc other ab- normal symptoms. He was evidently cutting some teeth at that time. On the day I saw him, except that he was somewhat fretful and put his hands to his mouth as though his gums were disturbing him, he seemed very well, and careful physical exam- ination revealed nothing abnormal in the ear. throat, chest, or abdomen. On the day following my visit the slight symptoms of indisposition which he had previously shown disappeared, and he played with a toy whistle, blowing it himself, and seemed to be very well. This condition lasted for two or three days, when he became stupid and un- conscious, and about the tenth day from the time he first came under my observation he died in convulsions. This case should impress upon us the difficulty of making a diagnosis in the early period of a tubercular meningitis, and how guarded we should be in giving a prognosis in young infants, even when the character of the disturbance is very slight. The next case illustrates a tubercular meningitis occurring in a child two and a half years of age : The history of the case showed that the father's mother and the mother's mother and brother had died of consumption. When the patient was one' year old he had measles ; otherwise he had always been well. About two or three weeks before he was first seen it was noticed that the child slept more than usual. At that time he appeared to be feverish, his tongue was coated, but there was no nausea nor vomiting. A few days later he vomited once or twice during the day. The bowels were constipated. Eight days before entering the hospital he had a slight convulsion, and three days later he cried a great deal, as if in pain. Two days before entering the hospital he had a number of convulsions during the night, each lasting about ten minutes. On the fol- lowing day the convulsions recurred. On the day he entered the hospital he began to have convulsions at three o'clock, which lasted about two and a half hours. At that time he was noticed to have marked internal strabismus of the left eye and slight strabismus of the right eye. The muscles of the neck were somewhat contracted. There was no paralysis of the extremities. The pupils were equal, reacted to light, and were somewhat dilated. The con- junctivae were injected, the left one especially so. Sensation was not impaired. The knee-jerks and ankle-clonus were absent. There was a marked tache cerebrate. The respirations were irregular and sometimes of the Cheyne-Stokes type. The child was unconscious and very pale. The heart's action was very rapid, sometimes as high as 200 beats in a minute. Xo souffles were detected. The temperature was 38.3° C. (101° F.). During the next day the child lay in a state of stupor. He continually moved the left forefinger and thumb, kept drawing the head to the left, and was very restless. He was reported to have cried all night and to have put his hand to his left ear. He lay with his eyes wide open, took nourishment well, and had less strabismus than when he entered the hospital. On the following day (about the thirteenth day of the disease) he became very restless, had sordes on the teeth, and his tongue was very dry. Examina- tion of the ears showed nothing abnormal. The abdomen was somewhat retracted. The bowels were moved regularly, and the movements appeared to be well digested. He took about 90 c.c. (3 ounces) of milk every two hours. On the following day there was no especial change, except that the muscles of the neck were firmly contracted and the tache cerebrate came out more slowly than on the previous day. A slight paralysis of the left side of the face appeared on this day. The left eyelid moved rather slowly. and the left corner of the mouth seemed to drop a little. The pulse was irregular, of fair strength, and intermittent. He did not take his nourishment so well. The comatose condition and other signs continued without improvement. The face SPECIFIC INFECTIOUS DISEASES. 417 became cyanotic, the respirations Cheyne-Stokes in character, the pulse irregular and intermittent. The temperature gradually fell until it was 37.2° C. (99° F.) in the CHART 8. Days of Disease F. 10 | 11 12 J3 14 15 16 17 h < o: ai a s h 3 D a CO z. O h < K LU en 107 106 105 104 108 102 101 100° 98 97 96 95 160 140 130 120 110 100 90 P0 70 60 5 45 40 35 30 25 20 15 f / \J \ / V : c o 1 1 i / 1 J 1 ' h J i I » III II Tubercular meningitis. Age, 3 years. Tubercular meningitis. Age, 2 years. The physical examination showed the child to be well developed and fairly nour- ished, but anaemic. She lay in a stupor most of the time, but could be aroused. The pupils were equal and reacted sluggishly. The tongue was coated, the throat, heart, and lungs showed nothing. The head was slightly retracted, and the posterior muscles of the neck were rigid. The abdomen was not retracted, and nothing abnormal was de- tected. A tache cerebrate was present. The knee-jerks were normal. Babinsky's sign was present in both feet, and Kernig's sign was also obtained. 426 PEDIATRICS. On September 14 there were some convulsive movements of the right extremities, and breathing was somewhat labored. On September 15 the child took her food very poorly, and could not swallow well. There were convulsive movements, but no general convulsion. On September 16 the legs were rigid and held in extreme extension most of the time. The pupils were unequal and dilated, and did not react to light. On September 17 strabismus of left eye developed, but was not constant. There was convulsive twitching of the limbs, with rigidity most of the time. The face was flushed, perspiration was very free, and the abdomen was somewhat distended. On September 18 the condition remained the same, except for the additional symp- tom of Cheyne-Stokes respiration. The rectal feedings were not retained, and it was impossible to insert a catheter for nasal feedings, owing to the swollen condition of the mucous membrane of the nares and the difficult breathing. On September 21 the respiration had become more sighing in character. The child perspired very freely. The white blood count was 8000. On September 22 the condition, which had remained practically the same, except for the rising temperature and accelerated pulse, became worse. The child seemed to grow weak rapidly, and the respirations and pulse became irregular and the child finally died. Chart 9. page 425, shows the course of the temperature. Lumbar puncture was performed immediately after death, and a slightly cloudy fluid with flecks of fibrin was obtained. The autopsy showed the original focus to be in a bronchial lymph-gland, which was enlarged and caseous, with a cavity at the centre. There were found miliary tuber- culosis of the lungs, liver, spleen, and kidneys, tubercular meningitis, and tubercular bronchial glands. The brain weighed 1080 grammes. At the base, around the pons, and in the fissure of Sylvius there was a yellow, gelatinous material, while along the blood-vessels of the pia were scattered numerous miliary tubercles, sometimes single and again confluent. The following was a case of tubercular meningitis with symptoms of comparatively short duration and associated with a general miliary tuber- culosis. It is especially interesting in that the tubercular process, as shown by the autopsy, and as represented in Plate L, frontispiece, was most highly and typically developed on the convexity of the brain instead of at the base, as is generally the rule. The child was two years old. She had been losing flesh and strength for about two months. Two weeks before entering my hospital wards she was taken with vomiting without special reference to the taking of food. This was the only symptom the parents noticed until three days before entrance, when convulsions and fever de- veloped. Nothing more definitf could be learned from the parents. The physical examination showed a child who was fairly developed and nourished, pale, pupils widely dilated, the right reacting sluggishly, and the left not at all, The eyes were rolled up. but there was no strabismus. The head was retracted, there was no tenderness along the spine. The tongue was slightly coated. There was a slight rosary. The throat, heart, lungs, and abdomen presented nothing abnormal so far as could be determined. There were no petechiae. A tache cerebrate was present. The knee-jerks were slightly, exaggerated on both sides. The plantar reflexes were normal. Babinsky's sign was present in both feet. Kernig's sign was absent. The child lay in a stupor. The white blood count was 6000. On the following day there were convulsive twitchings of the right arm and right side of the face. On the third day after entrance these signs became more marked, SPECIFIC INFECTIOUS DISEASES. 427 the respirations Cheyne-Stokes in character, the pulse rapid, irregular, and small. There were no convulsions of the entire body, but the right arm was flexed at the elbow. These symptoms continued until the fourth day, when the child died. The course of the temperature is shown in Chart 10, page 425. Lumbar puncture, done immediately after death, gave a slightly turbid fluid, and flecks of fibrin separated out. No tubercle bacilli were discovered in the sediment from lumbar puncture. At the autopsy the following condition of the brain was found : The dura was tense and bulging ; the superior longitudinal sinus was normal ; the gyri were flattened ; the sulci were partly obliterated ; the vessels of the pi- arachnoid over the vertex were markedly injected, and the cerebro-spinal fluid consid- erably increased. In the pia mater over the superior surface of the right frontal lobe, and extending to the mesial surface, was an area 5 by 3 cm., with opaque, grayish- yellow, single and conglomerate tubercles ; the single tubercles averaging one mm. in size. Tubercles were present in great numbers in the sulci, adjacent to the blood-vessels, but were also distributed upon the gyri over both hemispheres, but especially over the lateral surfaces of the parietal lobes. About the optic chiasm and interpeduncular spaces was a mass of semi-opaque gelatinous material beneath the turbid pia. Around the branches of the middle meningeal artery, and especially in the Sylvian fissure, was an abundant diffuse fibrino-purulent exudation. Scattered tubercles were found over the base, but in less numbers than over the vertex. Many were scarcely visible, being nearly transparent and less than a millimetre in diameter. The anatomical diagnosis was : tubercular meningitis, acute miliary tuberculosis of the lungs, tubercular ulceration of the intestines, tuberculosis of the mesenteric lymph-nodes, and a mild degree of rhachitis. TUBERCULOSIS OF THE JOINTS. Tubercular disease of the joints is essentially a disease of childhood; it is rarely congenital, and under one year is not common. In 1344 cases of hip disease, 1000 occurred under fifteen years of age. (Bradford and Lovett.) In hip disease, for example, a series of cases from the New York Dispensary showed that 115 occurred under three, 316 from three to five, 509 from five to ten, 140 from ten to fifteen, and 98 over fifteen years. This may be taken as fairly representative of the general liability to the diseases at different ages. At the Children's Hospital, Boston, from 1869 to 1893, 3820 cases of tuberculosis of the joints were as follows : TABLE 62. Spine 1964 Hip 1402 Ankle 300 Knee 104 Wrist 20 Shoulder 15 Elbow lo These figures are similar to those reported by other American authors. With regard to the causation of tubercular disease of the joint, it may be stated that 'the element of heredity is to be found in a large proportion of cases, which is variously estimated, the percentage, according to differ- 428 PEDIATRICS. ent authors, varying from twenty-four (Croft) to sixty-eight (Gibney) ; an average estimate would perhaps be forty per cent. (Nichols). Traumatism is accepted as being the cause of chronic disease of the joints in certain cases (Konig) ; this percentage, also, is variously estimated from thirty-five to fifty per cent. Chronic tubercular disease of the joints follows in certain cases after the exanthemata, especially measles and scarlet fever. Pathology. — Tuberculosis of the joints in children, as well as in adults, is now much more uniformly regarded as being of bony origin than was formerly supposed. The existence of a primary synovial tuberculosis in children must be regarded as extremely rare, and only to be demonstrated by the examina- tion of all parts of the bones entering into the formation of the joint. Finding a tuberculosis of the synovial membrane at operation, with an ob- vious bony lesion, cannot be accepted as proof of primary synovial disease. The original statement of Volkmann is. " The fungous inflammation of the joints in children and adults begins generally not at all as an arthrop- athy, but as a pure osteopathy, with a very circumscribed condition of tubercular osteitis. " Nichols, in the examination of one hundred and twenty tubercular joints from children and adults, did not find one joint where, if all the bones entering into the joints were sawed open in thin layers, one or more old bone foci were not found. The process by which joints become affected by tubercular disease is as follows : A tubercular focus develops in the spongy tissue of the bone near the epiphysis, and by an extension of this process the bone is de- stroyed in the line of least resistance, which is usually towards the sur- face of the joint. When perforation of the joint by this focus occurs, the tubercle bacilli obtain access to the joint cavity and a tubercular syno- vitis begins. From this point destruction in any direction is, of course, possible. Under favorable conditions of rest and separation of the surfaces of the joint by traction, in certain cases, nature tends to limit the process by repairing and replacing the tubercular tissue by the formation of fibrous tissue which grows into and replaces the tubercular material. The soft parts around the joint are, of course, secondarily affected, and abscesses are a frequent complication. The contents of a tubercular abscess may be sterile so far as pyogenic organisms are concerned, or they may contain, especially in their later stages, pyogenic organisms. Tubercle bacilli are to be found in these abscesses in only about one-third of the cases, and. as a rule, only after prolonged search. Inoculation experiments must be relied upon in the majority of cases to establish their presence. The presence of leucocy- tosis in a child with disease of a joint does not establish the presence of pyogenic organisms Symptoms. — Hip. — Chronic tubercular disease of the hip-joint, com- SPECIFIC INFECTIOUS DISEASES. 429 monly known as hip disease, most often begins with lameness, paroxysmal cries at night, and a stiffness in the joint which is more noticeable in the morning than at night. The pain is more often referred to the knee than to the hip. and may be very severe or may be slight. On examination in the early stages, the joint is found to be somewhat limited in its motions, the trochanter is slightly thicker than the one in the well limb, and wasting of the muscles occurs in the thigh and the calf. The prognosis in early cases is excellent for the restoration of a useful limb, and even in the late cases the adoption of treatment by traction gen- erally brings about good results. It must, however, be remembered that these children are tubercular, and that a certain number of them develop tubercular meningitis in the course of the disease. Spine. — Chronic tubercular disease of the spine, or Pott's disease, begins usually with stiffness of the back and pain on exertion, which is in most cases referred to the peripheral end of the nerves, so that the pain may be complained of either in the abdomen or chest. Such chil- dren walk with a guarded gait and stiffly, and when tired support them- selves by leaning on furniture or by resting the hands upon the thighs. In the cervical region torticollis and difficult breathing at night may be the only symptoms. In the lumbar region one symptom generally noticed is an apparent lordosis, in which the child leans far backward. Paralysis, which occurs in a certain proportion of cases due to a pressure from meningitis originating at the seat of the disease, may be the first symp- tom ; it is accompanied by increased reflexes and a loss of power in the legs. Psoas abscess is a common complication in the lower part of the column, and the first symptom noticed in this complication is generally inability to hyperextend the leg upon the affected side. The chief sign to be relied upon in the diagnosis is stiffness in some part of the spine. This is most easily detected by having the child stoop to pick up objects from the floor, and by laying the child on the face and flexing the spine by lifting the body by the legs. The appearance of a knuckle occurs early in the disease, but it is most important that the diagnosis should be made before this knuckle occurs, or while it is still small. The prognosis is perhaps not so favorable as in hip disease, but in early cases the results are usually excellent, and even in late cases much is to be gained from accurate support to the spine. Knee. — Chronic tubercular disease of the knee-joint, or tumor albus, is most often made evident by swelling of the knee of a chronic charac- ter, as a rule accompanied by pain. The child is apt to walk with the knee somewhat bent, and it is often difficult to fully extend it. Motion in the knee-joint is limited and the joint may or may not contain fluid. The character of the swelling is commonly that of a gelatinous mass involving the joint rather than a mass of fluid filling it. The occurrence of bony enlargement is most significant as probably establishing the existence of chronic tuberculosis. 430 PEDIATRICS. Fig. 10" In the diagnosis much difficulty is often experienced in determining between chronic disease and sprains. It may be said in general that chronic sprains in children are not very common, and that it is not wise to make such a diagnosis until after recovery has occurred. As to the prognosis, chronic tuberculosis of the knee-joint apparently runs a much less severe course than that of the hip or spine, and is most favorably affected by efficient treatment. Chronic tubercular disease of the other joints is characterized by swelling, more or less stiffness and pain, and such joints, as a rule, present the same symptoms as those described in speaking of the knee. Tubercular Dactylitis. — Tubercular dactylitis is a tubercular disease of the phalanges of the hand and foot. Usually, the cartilaginous ends of the bones are not affected ; the bone appears larger in diameter than is normal and is pyriform in shape. This enlargement is due to the increased size of the periosteum which forms a new layer of bone, and this new layer of bone may be very thin. Fre- quently the tubercular centre -=■ opens to the surface by one or several tubercular sinuses ; heal- ing in such cases may occur spontaneously, but operation in advanced cases is advisable. A permanent deformity may arise from the removal of the diseased phalanx. Fig. 107 represents a tubercular dactylitis of the third finger of the left hand of an infant. TUBERCULOSIS OF THE THYROID GLAND. Although tuberculosis of the thyroid gland may occur as a primary disease, it is exceedingly rare, the disease practically being always second- ary to a general miliary tuberculosis, and not presenting symptoms which, as a rule, can enable us to make a diagnosis during life. Amyloid de- generation of the thyroid gland may occur as the result of a chronic tuberculosis, especially of the joints. TUBERCULOSIS OF THE THYMUS GLAND. Tuberculosis of the thymus gland may occur in general tuberculosis. but is never primary. TUBERCULOSIS OF THE PANCREAS. Tuberculosis of the pancreas may occur in general tuberculosis, but is never a primary disease. Amyloid degeneration of the pancreas may occur as a result of chronic tuberculosis, especially of the joints. Tubercular dactylitis. SPECIFIC INFECTIOUS DISEASES. 431 TUBERCULOSIS OF THE SPLEEN. Tubercular lesions of the spleen are always secondary. They occur only in the form of small miliary tubercles. Amyloid degeneration of the spleen may occur as a result of chronic tuberculosis, especially of the joints. TUBERCULOSIS OF THE LIVER. Tubercular lesions of the liver are always secondary. They appear in the form of small miliary tubercles and cheesy nodules. Amyloid de- generation of the liver occurs in certain cases of tuberculosis, especially where there is wasting. Tuberculosis is not, however, a primary disease of the liver, but a symptom of tuberculosis elsewhere, especially of the bones and joints, and is not so common in children as in adults. Tuber- culosis of the liver occurs in connection with general tubercular disease of other organs, and does not in itself present any especial characteristic clinical manifestations. The rare instances in which large caseous masses cause obstruction and, later, disintegration of the tissues, with hepatic en- largement and abscess, are not usually recognized during life. TUBERCULOSIS OF THE KIDNEY. Tuberculosis of the kidney in children occurs in two forms : (1) As a miliary tuberculosis, the tubercle bacillus being conveyed into the tissues by the blood. This form rarely reaches any clinical importance. (2) As a tuberculosis beginning in the pelvis of the kidney and extending from this into the cortex. This form is by far the most serious in its symptoms and results. The detection of the tubercle bacillus in the urine in these cases is the only positive sign of the disease. The symptoms are those of a pyelonephritis represented by pus in the urine, an irritable bladder, and sometimes the presence of a tumor or abscess in the renal region. The treatment is essentially surgical. Amyloid degeneration of the kidney may occur as a result of chronic tuberculosis, especially of the joints. TUBERCULOSIS OF THE BLADDER. Tuberculosis of the bladder is very rare. TUBERCULOSIS OF THE TESTICLE. As compared with the frequency of its occurrence in adults, tubercu- lar disease of the testicle is rare in infancy and childhood. When the disease is present the gland is considerably swollen and often nodular, but rarely very tender. As the disease progresses adhesions may form with the tissues of the scrotum, and the degenerated material may be dis- charged through a fistulous tract. General treatment is indicated if the disease is just starting, but if it has already destroyed the usefulness of the gland it is safer to operate immediately and remove the foe as of infection. Here, of course, we should be guided by the conditions elsewhere. 432 PEDIATRICS. TUBERCULOSIS OF THE SKIN. The cause of what is now known to be tuberculosis of the skin (lupus or scrofuloderma) was for many years unknown. It was desig- nated by various terms according to the different forms which it assumed on the skin. Thus, in one form it was called lupus, and in another scrofula. We now know that all these forms are caused by the same micro-organism, the tubercle bacillus, and that this bacillus may find its nidus in the skin, as it does in all other organs of the body, — that is, we may have a local tuberculosis of the skin. The disease does not differ in the child in its appearance, its course, and its general symptoms from that met with in the adult. As a rule, it causes, next to syphilis, the greatest destruction of tissue of any known disease of the skin. The time of its appearance varies, but it is more common in adults than in children. Treatment. — The treatment is the same as in adults. The funda- mental object to be obtained is the destruction of the diseased tissue. Where there is a small isolated area which can be easily removed by the knife, this method of treatment should be employed. We must remem- ber, however, that by this method it is almost impossible to avoid re- moving the sound tissue with the diseased, and that such good results as the avoidance of unsightly scars are not obtained so well by this method as by others. Therefore, when the tissues are extensively dis- eased, and areas are involved where it is desirable to avoid scarring, such as the face, a locality which is very frequently attacked by tuberculosis, the actual cautery and electro-cautery may preferably be used. Various caustics, as the solid stick of nitrate of silver, as recommended by the Vienna School, have been found of much value. This disease, under all circumstances, is very intractable to treatment, and often causes great deformity. EPIDEMIC CEREBRO-SPINAL MENINGITIS. Epidemic cerebro-spinal meningitis is a primary acute infectious disease caused by the diplococcus intracellularis, and characterized primarily by lesions of the piarachnoid of the brain and cord. Etiology. — The cases of cerebro-spinal meningitis which have occurred in Boston and its vicinity, including my own cases at the Children's Hospital, reported by me in 1895, have been so exhaustively treated by Councilman, and Mallory and Wright in the Report of the State Board of Health of Massachusetts for 1898. that in my description of the disease I must acknowledge at once my indebtedness to these investigators for the use which I have necessarily made of their work. As, for the first time in the history of the disease, the lesions have been studied from the stand-point of their bacteriology, this work should be taken as the standard by which we are to be guided in the study of the pathology, symptoms, diagnosis, and prognosis of the disease. SPECIFIC INFECTIOUS DISEASES. 433 Cerebrospinal meningitis was first recognized and described by Vieus- seaux in Geneva in 1805. The first case which occurred in America was in 1809. The disease may occur in beasts as well as in man, and has been much more wide-spread and frequent in America than in Europe. It is rare in infancy, but is more common in children than in adults. The contagious nature of the disease is somewhat doubtful. There seems to be a high degree of immunity to a second attack. The incu- bation is unknown. The disease may be epidemic or sporadic. The mode of entrance of the organism is unknown, but may possibly be through the nose. Pathology. — Xervous System; Meninges. — The inflammatory process is characterized by purulent, sero-purulent, and fibrino-purulent exuda- tion, chiefly in the sulci along the vessels of the choroid plexus, and is usually most pronounced at the base, but at times is more marked on the convexity of the brain, especially over the parietal and occipital lobes. The meninges of the cerebellum are always affected. The meninges of the entire brain are rarely involved, although occasionally large areas are included in the inflammatory process. The longer the duration of the disease the more extensive are the lesions. In the very chronic cases oedema and general thickening of the meninges are the characteristic features of the lesions. The inflammation is confined chiefly to the piarachnoid ; the dura is but slightly involved, and the subdural space is increased by the fluid exudate. In the most acute cases, in which the macroscopic changes are very slight, the lesions are shown by microscopic examination to consist chiefly of purulent infiltration of the meninges, with injection of the blood- vessels. The polynuclear leucocytes are massed in some places, scattered in others, and with but little fibrin among them. The absence of eosino- philic cells is notable. There is no evidence of proliferation of tissue. In the more advanced cases, on the other hand, there are large num- bers of cells, chiefly polynuclear leucocytes, lying in the dilated lymph- spaces of the tissue. The presence of red blood-corpuscles is rare. The fibrin is present in considerable amount, often showing hyaline changes, but is never so great as in the meningitis produced by the pneumococcus. Large epithelioid cells, from two to eight times the diameter of a leuco- cyte, and filled with leucocytes, or rarely with lymphoid cells, are often seen, but their origin is obscure. The vessels are dilated, and at times contain thrombi. Proliferative changes within the intima of the arteries, which are common in tubercular or pneumococcus meningitis, are rarely found. In the acute cases the macroscopic and microscopic changes in the meninges of the cord are very similar to those of the brain. The cord is always somewhat affected, and occasionally to a greater degree than the brain. The injection of the dura is especially intense. The fluid in 28 434 PEDIATRICS. the subarachnoid space is greatly increased ; it is cloudy and contains flocculi of fibrin and pus. As a rule, the dorsal and lumbar cords are more extensively involved than the cervical portion. In the chronic- cases the meninges of the cord show the same oedema and thickening as those of the brain. Brain and Cord Tissues. — Lesions of the tissue of the brain and cord, as a rule, cannot be determined without careful microscopic examination. They are more marked in the prolonged or chronic cases. They are represented chiefly by slight dilatation of the ventricles with cloudy fluid, by dilatation of the vessels of the ependyma and choroid plexus, and by an accumulation of pure pus or pus and fibrin in the posterior cornua of the lateral ventricles. The consistency of the brain-substance is gener- ally but little altered, but is softer than usual, owing to the cedema and dilatation of the ventricles. Sometimes areas of softening and punctiform hemorrhages may occur. All the blood-vessels of both the gray and white matter are injected. In the cord the congestion of the vessels and the diminished consistency of its tissue are the chief lesions. The cord is always less affected than the brain. Proliferative changes in the neuroglia are among the most characteristic microscopic lesions in the brain tissue, but are rarely found in the cord. Degenerative lesions in the ganglion cells are usually present, especially in the very chronic cases. Nerves and Ganglia. — All of the cranial nerves are affected, but the second, fifth, seventh, and eighth are most extensively involved. They are reddened, cedematous. and infiltrated with the purulent exudation which often follows the nerves to their foramina. The spinal nerves are also involved, and their roots lie embedded in the exudation. The spinal ganglia are injected and cedematous. Degenerative changes in the nerve- fibres are common. The inflammatory process may extend along the optic nerve and pro- duce a purulent inflammation of the orbit or eye ; by extension along the fifth nerve it may produce a degeneration or destruction of nerve-cells of the Gasserian ganglion, and by extension along the auditory nerve it may cause lesions of the internal ear. with or without acute inflammation of the middle ear. The Lungs. — The lesions in the lungs occurring in the course of an epidemic cerebro-spmal meningitis vary from a simple congestion with oedema to areas of broncho-pneumonia associated with general bronchitis, or there may be a characteristic croupous pneumonia due to the pneumo- coccus. In a certain proportion of cases the pulmonary lesions are due to the diplococcus intracellularis. which enters the lungs and produces a focal pneumonia characterized by especial anatomical conditions. Hemor- rhagic cedema is found in the periphery of the foci, which vary in size from that of a pea to large areas of consolidation, which closely resemble an acute croupous pneumonia, even to the presence of a fibrinous exuda- tion on the pleura. On section of such an area, numbers of irregular SPECIFIC INFECTIOUS DISEASES. 435 grayish foci with softened centres and hemorrhagic and cedematous tissue between them are found. The central areas represent a purulent infil- tration of the tissue with abscess formation. The foci of consolidation are not bronchial in origin. The infection of the lungs by the diplococ- cus is probably by means of the blood rather than of the bronchi, and may occur in almost any period of the disease. In all these cases im- mense numbers of diplococci are found within the pus-cells. Spleen. — The size of the spleen is generally smaller than in most of the acute diseases, although there is considerable variation. The increase in size is due chiefly to hyperemia. There is very little change in the histological appearances of the spleen. Lymphatic Xocles. — There is usually no enlargement of the lymphatic nodes except in the complicated cases, and there are no microscopic changes beyond the injection of the blood-vessels. Liver. — The liver is usually pale and cloudy on section, and in some cases there is slight increase in the fibrous tissue with cellular infiltration. Kidneys. — The kidneys show acute, degenerative lesions in all cases, but a nephritis is rare if the meningitis is uncomplicated. Shin. — Lesions of the skin are rare ; when present, they are in the nature of ecchymoses with intense congestion of the surrounding vessels, and with some infiltration with pus-cells beneath the epithelium. In addition to the parenchymatous degeneration of the heart, liver, and kidneys, there are a certain number of other secondary lesions frequently met with, such as subserous, punctate hemorrhages in the endocardium, hyaline and granular degeneration in the voluntary striated muscles, occa- sionally multiple abscesses in various parts of the body, suppurative in- flammation of the joints, and choroiditis. The lesions are essentially the same in the epidemic and sporadic cases of cerebro -spinal meningitis. Types of the Disease. — There are certain types of epidemic cerebro- spinal meningitis which differ so markedly as to deserve special mention. The cases may be either acute or chronic. The acute cases are those in which active symptoms last for about fifteen days, and two other forms may be recognized, — the mild and the fulminating. Mild Form. — The mild form occurs more frequently in children than in adults. It has an acute onset, short course of one or two days, and rapid subsidence. These cases are sometimes called "abortive," but have not been verified as yet by lumbar puncture. Fulminating Form. — This term is restricted by Councilman to those cases which are fatal within forty-eight hours from the onset of the disease. Chronic Cases. — The chronic cases are those represented by less active onset, by remissions and exacerbations, and long duration. Lntermittent Forms. — These cases are chronic in type, and are seen in those instances in which, with or without abatement of the other symp- toms, there are complete intermissions in the temperature. 436 PEDIATRICS. Symptoms. — The chief symptoms are those connected with the nervous system, such as vomiting, delirium, coma, paralysis, pain, retraction of the neck, opisthotonos, and the mental condition after the attack ; also those symptoms connected with the lung, with the skin, the eye, the ear, the nose, the throat, and the joints ; also the pulse and temperature, and the condition of the blood and spinal fluid. In some cases the onset is not so sudden, and difficulties have arisen in the differentiation from typhoid fever and pneumonia ; but, except in the rather rare meningeal types of these latter diseases, the diagnosis will in a few days become clear. In young infants the symptoms of cerebro-spinal meningitis may be merely a heightened temperature with clonic convulsions, so that the diagnosis cannot be made during life from the various forms of reflex convulsions which may occur at this age, and cerebro-spinal meningitis can only be suspected. General infection by the diplococcus intracellu- laris is unknown. The mild cases may subside in a few days ; the acute cases may last for a number of weeks, and are often fatal. Some cases are so very sudden and violent in their development that they resemble a general toxic infection, and rapidly prove fatal in even a few hours (fou- droyant). Some cases show decided intermissions in intervals of several days, during which the child seems much better, the temperature is nor- mal or slightly raised, and the pain and tenderness are much diminished. The symptoms then return. Marked emaciation occurs in these cases. In some cases after the usual acute onset, an intermission may come, of a much longer interval of Aveeks, as to the severe symptoms and the fever ; but the other symptoms are apt to continue, and the disease may assume a chronic form, lasting three or four months. Vomiting. — Vomiting is a very common symptom, and may from its constancy become a dangerous one. It may occur early or late in the disease, and is due to direct or reflex irritation of the vomiting centre, being regarded as of cerebral origin. Delirium. — Delirium is a common symptom ; it may occur early or late in the disease, may be violent or moderate, continuous or intermit- tent, not more frequently present in the fatal cases than in those which recover, and does not always correspond to an increase of temperature or to an aggravation of the other symptoms. Pain. — Pain, especially in the head, is a very common symptom, and is at times violent. It may be located either in the occipital or frontal regions, and may extend down the back. In some cases, especially in children, there are abdominal pains and also pains in the extremities. An almost constant symptom is hyperesthesia of the skin ; the patients do not like to be touched, and often the least jarring of the bed causes intense pain. According to Councilman, the general pain in the head is due to the inflammation of the meninges. The pain in the cervical region and back may be referred to pressure exerted on or inflammation of the posterior nerve-roots. SPECIFIC INFECTIOUS DISEASES. 437 Coma. — There are great variations in the cerebral symptoms : there may be stupor, drowsiness, or deep coma, varying from day to day or from hour to hour ; insensibility may suddenly change to consciousness. Coma may occur in the beginning, and the comatose condition may con- tinue until death. Neck and Spine. — Symptoms connected with the neck are almost always present, and vary from a simple stiffness to rigidity of various degrees, with or without retraction. Attempts to move the head are usually painful. The retraction of the neck is sometimes accompanied by opisthotonos, and all these symptoms can be referred to the effect of pressure on or inflammation of the spinal nerve-roots. Paralysis. — According to Bullard, these cases, while at times and in certain stages precisely resembling cases of paralysis occurring in anterior poliomyelitis, are to be distinguished clinically from the paralyses of this disease by the following conditions : 1. In cases of paralysis following cerebro-spinal meningitis we find that pain on passive motion of the limbs persists to a degree rarely, if ever, found in anterior poliomyelitis. Such pain and tenderness sometimes exist during the acute stage of anterior poliomyelitis for two or three days, but if they last longer than a week the case is one in which the diag- nosis is to be very carefully considered. It is not uncommon, on the other hand, for great pain on passive motion of the limbs or of certain joints, especially of the ankles, to exist in cerebro-spinal meningitis for one, two, or more months after the acute stage of the disease has ceased. Tender- ness on pressure over the muscles also persists much longer than in an- terior poliomyelitis, where it rarely continues much beyond the acute stage, but does not last as long as the pain on motion, active or passive. 2. The character of the paralysis also differs, at least in the early stages, although later it is often nearly indistinguishable. There is always a tendency to spastic contracture in the early stages of the paralysis of cerebro-spinal meningitis. This is sometimes so marked that it is evident on casual examination. Certain portions of the limbs are flexed, and there is a decided muscular resistance to passive motion due to a perma- nent tonic contraction. More often, and particularly in the later stages, this tonic or spastic condition is not so evident, and shows itself only or principally in the extreme degree of flexion at the ankle-joint, the foot often being in a position of equinus, and its axis almost in direct continu- ance with that of the leg. 3. The knee-jerk is usually less affected than in anterior poliomye- litis. In other words, there seems to be a greater tendency to retain the knee-jerk. This is rather a question of degree than of anything else, and may have been accidental in Bullard's patients ; he lays stress on it only in connection with other symptoms. The knee-jerk is sometimes in this affection, as in anterior poliomyelitis, totally abolished. 4. In addition to these clinical signs we have the history of the initial 438 PEDIATRICS. attack to guide us. While certain cases occur in which it is difficult to determine the character of the initial attack, as a rule, the existence of retraction of the head and of contractures of the muscles of the back or limbs, the continued presence of extreme tenderness or pain on movement, and the duration of the acute stage of the disease, enable us to determine more or less accurately the character of the disease. Any case is suspicious in which the acute stage lasts more than seven days. Lungs. — Although instances of pneumococcus pneumonia are quite often met with in connection with meningitis, and sometimes with diplo- coccus meningitis, yet it will probably be found in the future that the meningitis which accompanies pneumococcus pneumonia is a pneumo- coccus meningitis, while in the epidemic meningitis the complicating pneu- monia is caused by the diplococcus intracellularis. This view is especially upheld by Leichtenstern, who states that while epidemic meningitis is rare in many countries, occurs chiefly in early life, and has no crisis, pneu- monia is common all over the world, at all ages, and has a distinct crisis. The complications of the two diseases are different. Multiple synovitis and affections of the eye, so frequent in epidemic meningitis, are rare in pneumococcus meningitis. The exudation is more fibrinous in the latter disease, and the result usually rapidly fatal, while the epidemic form is frequently recovered from. The remissions and exacerbations, varying course, relapses, and uncertain gait belong exclusively to the epidemic form. Leichtenstern also believes that the cerebral symptoms dependent on a pneumococcus pneumonia subside at the time of the crisis, just as the other symptoms do. The diplococcus intracellularis can enter the lung and produce a focal pneumonia characterized by especial anatomical features, and occurring in both the acute and chronic cases. Skin. — The lesions of the skin gave, in the earlier epidemics, the name of spotted fever to the disease. These lesions vary greatly, and may be represented by petechise, larger hemorrhagic foci, or circumscribed areas of hyperemia ; the most common form of efflorescence is, however, herpes. In numbers of cases there are no lesions of the skin whatever. A tache cerebrate is of common occurrence. Eye. — Symptoms connected with the eye are prominent in epidemics of meningitis, and there is a marked tendency for the infection to extend along the optic nerve, as already described in the pathology. The cause of the lesions (neuritis or degeneration of the nerves of the eye) may be due to their involvement in the exudation at the base of the brain without any extension of the inflammatory process to either the orbit or the eye. Or the optic nerves may also be involved in this exudation. Again, the inflammation from the meninges may extend directly from the brain into the eye by means of the piarachnoid. All of the cases of purulent choroido-iritis and the very rare cases of suppuration in the orbit are probably due to such extension. There is no metastasis in these con- SPECIFIC INFECTIOUS DISEASES 439 ditions. but a direct extension. A third cause of the lesions of the eye, and one to which most of the cases of keratitis are due, is a neuritis of the fifth nerve, with destruction of the Gasserian ganglion and a loss of sensation. The pupils are generally altered. Reaction to light is slow and in- complete, and dilatation is very apt to occur. Paralysis of the ocular muscles with resulting strabismus may develop, but the paralysis is often temporary, and different muscles may be affected at different times. Ear. — As in the eye, so in the ear, the infection may extend along the auditory nerve. There may be pain, tenderness of the mastoid, and deaf- ness with or without otitis media. The lesions in epidemic meningitis are always secondary and are due to extension from the brain, while when the meningitis is secondary to an otitis media the organism of infection is the pneumococcus or streptococcus. These lesions of the ear are the most common complications of epidemic meningitis, and in a large num- ber of cases deafness results. Nose and Throat. — Acute coryza and inflammation of the throat may occur. The lesions may be due to a primary extension from the brain or from a direct secondary infection from the ear. These questions, how- ever, have not yet been satisfactorily determined, and it is possible that the diplococcus intracellularis may be found in the nasal secretion of patients without meningitis. Joints. — Acute inflammation of the joints is frequent in epidemic meningitis. The knees are the joints most commonly affected. Pulse and Temperature. — A marked characteristic of epidemic cerebro- spinal meningitis is the inequality of the pulse and temperature. The pulse may often remain normal while the temperature is heightened, and there is no relation between the height of the temperature and the se- verity of the symptoms. The temperature rarely reaches 40° C. (104° F.), and varies from 39° C. (102.2° F.) to 38° C. (100.4° F.). The type is often remittent. The fever gradually disappears and the temperature curve is interrupted by irregular rises and falls. A terminal rise of tem- perature occurs in some cases. The pulse shows the same irregularity as the temperature, and may range from 70 to 130 in a minute. Relative slowness of the pulse to the temperature is often found in children. Ab- solute slowness of the pulse is not common. Blood. — Leucocytosis is always present. The leucocytes gradually diminish towards the end of the disease in the cases which recover. Spinal Fluid. — In cerebro-spinal meningitis the character of the fluid is more or less turbid, and in severe acute cases a puriform deposit fre- quently settles to the bottom of the test-tube in a short time ; there are numerous polymorphonuclear leucocytes (pus-corpuscles) and occasional smaller mononuclear lymphoid cells and fibrin. Groups of the diplococcus intracellularis are found in varying numbers in the protoplasm of some of the leucocytes. The fluid should be withdrawn at the time when the active 440 PEDIATRICS. symptoms are present, or the growth of the organism may fail to be ob- tained. A microscopic examination is necessary in all cases, as the macro- scopic appearance of the fluid is not to be relied on. Inoculation experi- ments are, as a rule, unsuccessful, as the organism is not pathogenic for guinea-pigs. Goats are susceptible to it. Mental Condition after Recovery. — In some cases after recovery from the acute symptoms a condition of mental impairment remains. Diagnosis. — The differential diagnosis of cerebro-spinal meningitis is essentially from other forms of meningitis, whether tubercular or non- tubercular. The sudden onset, extreme headache, hyperesthesia, opis- thotonos, rigidity and retraction of the neck, pain and tenderness of the neck and spine, herpes, moderate temperature in comparison with the severity of the symptoms, and rapid development of apathy and coma in keeping with the early exudation of pus over the surface of the brain, are in strong contrast to the slow onset and gradual development of the symp- toms in tubercular meningitis, described on page 407. The non-tubercular forms of acute meningitis are more difficult to differentiate, and the only exact means of diagnosis is by lumbar puncture. Epidemic influenza at times simulates epidemic cerebro-spinal meningitis so closely that the dif- erential diagnosis can only be made by spinal puncture. Prognosis. — The prognosis, where the child is young and the onset is violent, with high temperature and continuous convulsions, is very serious, as the disease is one of the most fatal in childhood, and only about one-half recover (Sachs) ; but even in the apparently fatal cases, where coma has intervened, a change may take place and the child recover. The first two weeks are usually the critical period, so far as the acute form of the dis- ease is concerned. According to Sachs, the cases in which the coma de- velops rapidly, and does not show any signs of receding within the first week or two, are almost certain to end fatally. If the coma has been slow to develop, the process is usually less intense and the prognosis is better ; but even in these cases, if the coma remains stationary for a week or more the chances of recovery lessen every hour that the coma continues. The chronic form is apt to prove fatal, both from exhaustion and from the development of more serious central nervous lesions. The cases which recover are often left with permanent lesions, causing deafness, blindness, various paralyses, and mental impairment. Death is very apt to occur quietly. Treatment. — The treatment of cerebro-spinal meningitis varies accord- ing to the severity of the symptoms. In most cases sedatives, such as the bromides, are indicated, and where the pain is severe opium in con- siderable doses is often needed. The ice-bag or Leiter's coil applied to the head, and absolute quiet in a darkened room, are important adjuvants to the treatment. In many cases the pulse becomes so weak and the prostration so marked that stimulants are required until convalescence is established, when they can usually be replaced by tonics. In some cases SPECIFIC INFECTIOUS DISEASES. 441 the hyperesthesia and general sensitiveness to noise, light, and motion in the room are so extreme and so characteristic that the attendants should be cautioned not to touch the child or the bed unnecessarily, and absolute quiet should be enforced in the room and throughout the house. The following cases illustrate cerebro-spinal meningitis ; where, as in some instances, the diplococcus intracellularis is not mentioned, it is be- cause these cases occurred before lumbar puncture was commonly used for diagnosis. A boy. thirteen years old, had never had any special diseases, but had been rather delicate for a number of months. He went to a Christmas party on December 25. and on returning from the party complained of the motion of the sleigh in which he rode home. On the following day, in the afternoon, he was found to be listless, to have his tongue coated but not dry, a temperature of 40.5° C. (105° F.), and a pulse of 140. He complained of tenderness and pain in the back of his neck ; there was also tenderness in the abdomen. He appeared to be somewhat dull. On the following day the temperature in the morning was 39.4° C. (103° F.), and the pulse was 120. He was much more dull and apathetic than on the previous day, and in the afternoon became delirious. In the evening he had involuntary passages of urine and loose discharges from the bowels. His temperature was 40° C. (104° F.). On the following day his temperature was 39.4° C. (103° F.), and the respirations varied from 40 to 80 and were regular. He was unconscious. Subsultus tendinum was present. There was retraction of the head. The pupils did not respond to light, but were equal in size. A tache cerebrate was present. On the evening of the following day, four days from the onset of the disease, he died. The autopsy showed the convex surface of the entire brain and cord to be covered with a thick exudation of pus, the spleen to be enlarged, and the case to be one of acute cerebro-spinal meningitis. A child, two years old, was brought to the hospital with the history that it had been showing symptoms of malaise for six weeks. Two weeks previous to entering the hospital it had a convulsion, and the indefinite and general symptoms had become more pronounced. There had been loss of appetite, with constipation, at times vomiting, slight cough, and a heightened temperature. The head was retracted, and the muscles of the neck were rigid. The eyes were staring, but the pupils reacted to light. There was, at times, slight opisthotonos. The abdomen was retracted. The emaciation was extreme, so that the vertebrae and ribs became quite prominent. The child was apparently unconscious, and did not notice objects which were brought before its eyes, although the eyes were open. It moaned at times, and occasionally the legs were drawn up. No efflorescence was de- tected anywhere on the skin. The temperature varied from 36.6° to 38° C. (98° to 100.5° F.). Sometimes it cried out sharply, as though in pain. A tache cerebrate was often present. The treatment of this case was simply the frequent administration of milk, with the addition of stimulants when indicated by the weakness of the pulse. The child was in so apathetic a condition that the use of any drug was unnecessary. Although at times it cried out as if in severe pain, yet these attacks were not sufficiently long to necessitate their control by an opiate. During the following month the child remained in very much the same condition. The head was retracted at times, and the emaciation became extreme, the abdomen being very much sunken (boat-shaped). In the next two weeks the nourishment was taken more readily, the head was less retracted, and he began to notice objects around 442 PEDIATRICS. him, but he vomited once or twice nearly every day. The temperature at this stage of the disease became normal. One month later, which was two months from the time when the child entered the hospital, he was able to sit up without help. There was no retraction of the head, but the muscles of the neck were very rigid, and the head showed a tendency to retraction. During the following month the child continued to improve slowly, increased in weight, recovered his appetite, and when seen one month later was found on physical examination to be in a normal condition. The following case of epidemic cerebro-spinal meningitis occurred in the service of Dr. Buckingham at the Children's Hospital. The child was two years and eleven months old. She was breast-fed for fifteen months. At eight months she had scarlet fever ; at eighteen months she contracted measles. With these exceptions she had always been well and strong. Two days before entrance to the hospital she fell and struck her head. She complained subse- quently of headache. The day before entrance she vomited several times, and held her hands to her right ear as if in pain. There was no history of disease of the ears, of retraction of the head, of rigidity of the neck, or of convulsions. The physical examination showed nothing abnormal aside from a considerable de- gree of rigidity of the posterior cervical muscles and pain wh^n passive movements of the head were made. There was some hypertrophy of the tonsils, with coated tongue and some secretion in the naso-pharynx. The temperature was 38.8° C. (102° F.), the pulse 130, and the respirations 32. A specimen of urine could not be obtained. Two days later there was marked retraction of the head, with internal strabismus. The child was very irritable, and was evidently very tender on pressure over the back of the neck. On the day after entrance the ears were examined, and the auditory canals were found full of epithelial scales, which were removed, leaving the drum membrane and walls of the canal reddened. On the following day an acute serous effusion was noted in the middle ear. Paracentesis of the membrana tympani was performed and wicks inserted. On the third, day lumbar puncture was performed. The cerebro-spinal fluid was cloudy, with slight formation of fibrin. The cells were chiefly polynuclear leucocytes, with some mononuclear cells. Occasional organisms were found within the cells. Cul- tures from the fluid showed the presence of the diplococcus intracellularis. There were several single colonies, as well as fine, diffuse, pin-point growths between, on the culture- medium. For six days the temperature gradually declined, and nearly reached the normal. The child sat up of its own accord, and freely moved its head. There was no strabis- mus. It then began to grow slowly worse. The temperature rose with considerable morning and evening variations, and for nearly a month ran a very irregular course, the evening temperature ranging between 39.4° C. (103° F.) and 40.4° C. (104.8° F.). The pulse varied from 120 to 146, and the respirations from 30 to 35. The aural symp- toms disappeared, but the child grew more irritable ; retraction, tenderness, rigidity, and strabismus all returned. There was cough and an associated bronchitis. There were no convulsions or coma. The child was quiet but easily aroused. There was no general hyperesthesia. The urine one month after entrance was examined and found normal. Loss of weight was very noticeable. Towards the end of the fourth week in the hos- pital the temperature began to fall, the symptoms gradually diminished, the mental and physical condition improved steadily, but there seemed to be a moderate degree of paralysis of the legs, which was slow in passing away. Convalescence was prolonged over a period of five weeks, when the patient was discharged to the convalescent home much relieved, but with the legs still not entirely under control. SPECIFIC INFECTIOUS DISEASES. 443 The following case was that of a girl eight years old, who represented that form of cerebro-spinal meningitis which is designated chronic, and only a few cases of which have been reported. Her parents were said to have been healthy, and there was no evidence of tuber- culosis or syphilis in the family. A brother whom I saw in consultation died of cere- bro-spinal meningitis. With the exception of an attack of measles and of whoop- ing-cough, the child had not had any other diseases. She had not been entirely well since an attack of pertussis, which occurred one year previous to entering the hospital, and her attack of cerebro-spinal meningitis had begun four and a half months previously. The onset of the attack was sudden. She went to bed in fairly good condition, but woke up in the night delirious, screaming, and apparently not recognizing her parents. These symptoms continued until the following week. There were no convul- sions. A week later vomiting occurred every two or three days. This was not de- pendent upon food, and had occurred at intervals up to the time of entering the hospital. The bowels were constipated. There had been more or less opisthotonos from the beginning of the illness, and also in the beginning there was decided retrac- tion of the head. The stiffness of the neck had gradually diminished, but at times returned. Up to the time of entering the hospital the child was said to have had constantly a heightened temperature, varying from 37.7° to 39.4° C. (100° to 103° F.), with a rapid pulse and quick respirations. Nothing abnormal had been found in the urine. There had been no efflorescence on the skin. Fig. 108. Chronic intermittent cerebro-spinal meningitis. Tache cerebrale showing on right thigh. Female, 8 years old. Four weeks previous to entering the hospital the child was noticed to be blind. This had occurred suddenly. The child had had constant headache, and shortly after the beginning of the attack showed a loss of power of motion in both legs. At times there had been incontinence of faeces and of urine. An examination of the urine showed it to have a specific gravity of 1015, to be normal in color, to have an acid reac- tion, and not to contain albumin or sugar. No evidence of syphilis was detected. She sometimes showed improvement in her general symptoms and became conscious. 444 PEDIATRICS. but she was unable to sit up or to walk. As shown in Fig. 108, she was somewhat emaciated. There was extreme hyperaesthesia of the body and extremities. The slightest mo- tion of the bed caused discomfort and pain. An examination of the thoracic and ab- dominal organs showed that they were normal. Fig. 109. The pulse was 80 and regular, the respirations were natural, the temperature was 37.7° C. (100° F.). She sometimes had an attack characterized by spasmodic contractions of all the muscles of the body, lasting for about thirty seconds. At these times there was no loss of consciousness, and the child screamed for some time afterwards as though in pain. During the attacks the pulse grew feeble and intermittent, the respirations slow and super- Secondary choroido-iritis occurring in ncial, and the extremities cold. Brandy was given cerebrospinal meningitis. subcutaneously, and reaction took olace. There was a decided tache cerebrale. Fig. 109 shows the condition of her eyes. The pupils reacted, and the retinae were evidently sensitive to light, yet apparently she was blind. In the middle of the eye was a yellowish mass with an irregular border. There was a very slight hyperaemia in the ciliary region. The iris seemed slightly pushed forward, and its pupillary edge was a little uneven. A yellowish or yellowish-white reflex appeared from the fundus of the eye even without the use of the ophthalmoscopic mirror, and it was not difficult to distinguish that this reflex did not come from the level of the lens, but that it was situated deeper. The tension of the eyeball was very much reduced, and there was very little tenderness on pressure. These yellowish appearances in the pupils are sometimes called pus emboli, and also metastatic choroido-iritis ; but while in other forms of meningitis metastasis may occur, it does not occur in the epidemic form, but is a direct extension. In the other forms where it does occur, both the meningitis and the lesions of the eye are due to metastasis. Sometimes this yellowish mass fills the vitreous entirely, sometimes only in part. It may have blood-vessels on its surface. The child remained in about the same condition for some time. At times she screamed as though in pain, but she took her nourishment fairly well. She had one slight convulsive attack, which involved mainly the upper extremities, the lower ex- tremities being only slightly contracted. During this attack her thumbs were turned in, her fingers clinched over them, and her arms, which were usually extended at her sides, were flexed at the elbows. Her face showed no sign of spasm, and during the attack the radial pulse was full, soft, and regular. After a few seconds the muscles again became relaxed, and there was no further tendency to contraction. The usual position in which she lay during the following weeks was with the thighs slightly flexed and abducted, and the legs flexed at the knee, with the heels almost touching each other. About two weeks after entering the hospital the right leg became flexed on the thigh to such an extent that the knee almost touched the chin and the heel rested on the vulva. Any attempt to extend the leg made the child cry out as though in pain, the left leg being naturally extended in bed. This condition of the right leg continued for several days and then disappeared. Some days later a slight convulsive attack took place, which seemed to affect the right side more than the left. The temperature during the eighteen days when the child was in the hospital varied from 37° to 38.8° C. (98° to 102° F.). The pulse during this time varied from 68 to 100 ; the respirations sometimes varied from 34 to 52, but were usually about 28. The fingers were flexed most of the time, and there was so much rigidity of the SPECIFIC INFECTIOUS DISEASES. 445 limbs that the reflexes could not be satisfactorily determined. Later in the disease there was slight cyanosis of the cheeks and lips, and an eruption of milia on the chest apparently arising from her continually perspiring day and night. She lay in a stupor all the time, except when she was moved, when she would cry out. She showed 110 signs of understanding anything that was said to her. Sometimes she would be seized with an attack of rapid breathing lasting several hours. The bowels had been constipated at first, but later diarrhoea occurred. There was incontinence of faeces and urine, but no vomiting. The teeth were kept closed, and had to be forced apart when she was fed. Once she had a convulsion, in which the head was drawn back, the body and extremities were Fig. 110. rigid, and the eyes rolled up. Eighteen days after entering the hospital the child was taken to her home, so that the daily record could not be obtained. An examination made two weeks after she left the hospital showed a spastic condition of the extremities and neck. When seen by Dr. Bullard at this time the child took no notice of her surroundings, and her eyes when opened had a vacant expression, due largely to the mental condi- tion, although she was undoubtedly blind. The extremi- ties were much wasted, and were all in a condition of spastic rigidity. There was slight flexion of the thighs on the body and of the legs on the thighs, while the feet were . Chronic cerebrospinal men- J ° ingitis. Spastic condition of extended in nearly a straight line with the legs. hand five and a half mon ths The hand, as shown in Fig. 110, was flexed almost at after onset of the disease. right angles to the wrist. The proximal phalanges of the fingers were hyperextended, while the other phalanges were flexed. The thumb was strongly adducted, and its distal phalanx was flexed. This is a position of the hand frequently found in the later stages of spastic paral- ysis, and is due to the preponderant contraction of the flexors of the wrist and weak- ness of the interossei and lumbricales. The child gradually grew weaker, and died of exhaustion a few weeks later. These chronic cases are rare. In two other cases which came under my observa- tion the children eventually died from a prolonged sickness of many months, during which they at times seemed to be recovering. Cases have been reported by others, as by Henoch, of Berlin, to have recovered. The following case was seen in consultation with Dr. Townsend : A boy, four and a half years old, had been previously well, with the exception of an attack of measles when he was one year old. On May 9 he was suddenly attacked with vomiting, which continued at intervals for two days. From the beginning of the attack he complained of severe pain in the head and abdomen. On the second day of the attack there was much contraction of the head, and he was slightly delirious, although rational most of the time. The temperature was raised from the beginning of the attack. There were no convulsions. The bowels were not moved during the first week of the disease. When first seen by Dr. Townsend the pulse was 124 and regular, the temperature 38.8° C. (102° F.), and the respirations 20 and regular. There was slight opisthotonos. There were no con- tractions of the muscles of the limbs. The symptom of Kernig was present. There was no tenderness along the spine. The cutaneous sensibility was everywhere normal. There were no cutaneous efflorescences or ecchymoses. The pupils were 446 PEDIATRICS. z fcl o i | uo cc i i TO I ' CM CO i i 5© OS 5" h ill °, _ / £|| e! 1 ! \A 1 k i Y' g J in ^ i T — t — cm r p > gl 1 ! If O) i>i a " f t-.i 1 1/ 1 CO 1 CO I ll 1 cc > s XI Je ! < 1 > CM CD < CO O ' M o> i OC ; < CO 'z 1 ( s X s s } 1 ,_• CO- <^ i T-l LO i re H rt 10 1 1 1 c~- II { CO | | £ I cr> i V " s. P?!| o OJ S CO J < CO 1 ! LS. < ^ ") / ^s 1/ CM CM f V 2 > S ~* < £ ^> - < 2 \2 ■ i CM / - ( s \ i o o o O o S § regular and reacted normally to light. There was no strabismus or photophobia. Nothing abnormal was de- tected on physical examination. The child was appar- ently in great pain, cried out a great deal, and moaned continually. The suffering during the next few days was so great that morphine in doses of 0.002 gramme (sV grain) had to be given. This dose had to be in- creased so frequently that it was found that the child took 0.015 gramme (£ grain) before relief was obtained. Applications of ice to the head and spine gave no relief, and for a number of days it was found that there was needed to control the restlessness and pain 0.01 to 0.02 gramme (£ to ^ grain) of morphine during the twenty- four hours. On the twenty-fourth day of the disease the temper- ature, which had varied from 37.7° to 39.4° C. (100° to 103° F.), became normal, remaining so until the forty- seventh day. During this time the head was only slightly retracted, and the child seemed free from pain, but remained in a very listless condition, not speaking, and taking but little nourishment or stimulants. He be- came emaciated, passed his urine and faeces involuntarily, and occasionally vomited. Nutritive enemata were not retained, but on the forty-first day of the disease pepto- nized milk was retained, and on the forty-sixth day he was able to take gruel, and at that times talked and laughed. On the forty-seventh day of the disease a relapse occurred, the temperature rising to 39.7 C. (103.6 F.). The head was rigidly drawn back, the eyes were staring, and the pain returned. The symptom of Kernig, which had never disappeared entirely, again became well marked. At this time I saw the child with Dr. Town- send. On the sixty-sixth day of the disease the con- vulsive movements of the left arm and leg, with turning in of the left eye, occurred. Several days previous to this relapse a number of sudamina appeared on the neck and trunk, and an evanescent erythematous erup- tion on the neck and face, lasting only a few hours. From the sixty -first to the sixty-sixth day of the disease his body was covered with a macular efflorescence, the macules varying in size. Ecchymoses were at no time seen, and repeated examinations of the chest and abdo- men showed nothing abnormal. From the seventy-first day to tbe seventy-third day the temperature was again normal, the child took his food well, the neck was straight, and his general appear- ance was encouraging. On the seventy-fourth day he again had convulsive movements, most marked on the left side of the body. The head was drawn back, and at noon the next day his temperature was 39.4° C. (103° F.). The pulse, which during the entire illness ranged from 120 to 140 and SPECIFIC INFECTIOUS DISEASES. 447 had previously been regular, was now at times irregular and intermittent. The bowels were constipated at this time. After this, although the temperature became normal, the child failed rapidly, and there was so much emaciation that the finger and thumb could easily encircle his thigh. He died quietly on the eighty-seventh day from the time of the onset of the disease. It was very difficult, indeed impossible, to give a prognosis in this case, as at times it seemed as though he would recover, and then the temperature would rise again and the unfavorable symptoms would return. The chart shows the temperature from the tenth day of the disease. TYPHOID FEVER. Typhoid fever (enteric fever, typhoidal ileo-colitis) is an infectious dis- ease produced by the bacillus of Eberth. The conditions and manifesta- tions of typhoid fever as it appears in the foetus, in the young child, and in the adult differ markedly. Typhoid in the Foetus. — The infection of the foetus may take place from the mother. Abortion occurs in from fifty to seventy per cent. It is now well established that the bacillus of typhoid can pass through the placenta from the mother to the foetus, and it seems probable that this can happen when the placenta is intact. In most cases the foetus dies in utero ; it may, however, be born alive but suffering from the infection. Again, the foetus may be born alive and healthy, after having passed through the infection in utero. Finally, it may not be infected at all, although the mother may have had the disease. When at birth the foetus is infected it rapidly succumbs, the infection showing itself in the form of acute cachexia without any special characteristics. The bacilli in these cases are most commonly found in the liver, spleen, and blood ; they may also be found in the intestine. Marked lesions in the intestine and mes- enteric glands are, however, never found, the organs usually being nor- mal. The liver and spleen are sometimes swollen, and may show minute hemorrhages. An explanation of these lesions is found in the entrance of the bacillus through the umbilical veins, — that is, the septicaemia is primary and not secondary to an enteritis. These cases correspond to those of typhoid fever in adults in which there are no intestinal lesions. There may also be an infection with other organisms besides the typhoid bacillus, especially the staphylococcus aureus. Typhoid in Infancy and Early Childhood. — The pronounced patho- logical lesions, severe symptoms, and great virulence in type which are so characteristic of typhoid fever of later years are so rare in infancy and early life that the following description will be confined to the latter period. Etiology. — Typhoid fever is exceedingly rare in the first two years of life, is uncommon under three years, and after the fifth year becomes more common as the child grows older. Under two years the number of cases reported, even if correct, is small. In fifty-five cases collated in 1895 by Stowells, the diagnosis in twenty-eight seemed probable : in the 448 PEDIATRICS. others it was doubtful, as no bacteriological examination was made. The youngest authentic case of typhoid contracted after birth is that reported by Gerhardt in an infant which presented the symptoms when twenty- five days old, and recovered in twelve days. In Stowells's series sixteen confirmative cases have been reported. Eight of these cases died. In- fection may take place in any way by which the germs of the disease can be carried from one individual to another. The germs are given off from the discharges, chiefly the faeces and the urine. The individual is infected largely through the gastroenteric tract, and the most usual mode of conveyance into the body is by infected milk or water. Direct trans- mission by the hands which have been infected from the surroundings of the patient, especially from the clothes and bedlinen, is possible. Pathology. — After birth in the earlier periods of life the pathological lesions are less definite in direct ratio to the age. After the second or third years the lesions are constant and the pathology definite. Although the more advanced and severe lesions of typhoid fever may occur in the early as well as in the later years of life, yet its characteristic lesions in young subjects are found in the milder and less severe pathological changes of the disease. These consist essentially of a hyperplasia of the solitary lymph-follicles and Peyer's patches, and the process, instead of going on to ulceration, usually terminates in early resolution with fatty degeneration of the cells. Hemorrhage and perforation are therefore rare complications in the typhoid fever of early life. There is, however, nothing distinctive of typhoid fever in this hyperplasia of the lymph- follicles in children, for it is not uncommon to find this condition when death has occurred from other diseases of the intestine. It may also be present in such diseases as measles, diphtheria, and scarlet fever. Very marked hyperplasia of the lymph-follicles may be produced in children by irritating substances and by foreign bodies, not only food, but also drugs, such as turpeth mineral. I have, in fact, seen, at the post-mortem examination of a child, marked enlargement of the lymph-follicles caused by doses of turpeth mineral given during life as an emetic. In addition to the lesions in the intestine, hyperplasia of the mesen- teric glands, granular degeneration of the liver and kidney, and granular or fatty degeneration of the heart may be found. Parenchymatous changes sometimes occur in the peripheral nerves and degeneration of the muscles. The pathological conditions in typhoid fever in the early years of life may be said to correspond with those which are met with in the aborted forms of the disease in later life. The specific efflorescence of typhoid fever, the rose-spots, have ac- quired additional importance in the diagnosis from the recent bacterio- logical investigations by Neufeld and Curschman in Germany, and Rich- ardson in this country. These observers have demonstrated the presence of the typhoid bacillus in the rose-spots in a very large proportion of the cases examined. In Richardson's series the diagnosis was made by this SPECIFIC INFECTIOUS DISEASES. 449 method on an average of six days before the appearance of the Widal reaction. Incubation. — The stage of incubation in typhoid fever may last from one to two weeks : a shorter time, however, five days, and a longer one, three weeks, have been observed. Symptoms. — The prodromal stage is usually short, young subjects having less power of resistance to the poison than adults, in whom the prodromal stage is often prolonged. The onset is more likely to be acute in young children, and nervous symptoms, especially vomiting, are com- mon. The duration of the disease is generally much shorter than in adults. This short duration depends largely upon the mild form of the intestinal lesions and usually indicates that marked ulceration has not taken place. As shown by the figures collected by Morse, the average duration of typhoid fever in children is a little less than three weeks, the younger the child the shorter the duration, and the proportion of cases in which the duration is ten days or less is twice as great in the younger children. As a rule, the temperature is moderate, but it may be high, as in adults, without, however, producing as severe symptoms, since children are generally less affected than adults by a high temperature. When the lesions are mild the temperature is not apt to show so typical a course as when they are pronounced. The temperature often rises rapidly in the beginning, and although it returns to the normal by lysis, it does not show so gradual a lysis as when marked lesions have occurred, and when other symptoms of toxaemia have complicated the disease. The younger the child the lower the range of the temperature and the sooner is the maximum reached. The remittent stage occurring in adults is much less in children and the defervescence is rapid. The pulse is usually accelerated, but is low in comparison with the height of the temperature in other diseases, and is not so apt to vary from the normal in strength and rapidity. Hsemic murmurs are not uncommon. The respirations are not especially increased unless some complica- tion is present. Although bronchial catarrh may in most cases be patho- logically present (Morse), yet clinically its importance in children has been rather over-estimated. In certain cases in young children, however, it is so marked as to be liable to lead to the error of considering the primary cause of pulmonary origin rather than intestinal. The abdomen may be distended and tympanitic, but this symptom is often not marked. In Morse's statistics distention occurred in from 50 to 70 per cent, of all cases. It is more common in older children, and not infrequently is extreme. Pain and tenderness of the abdomen are rather unusual. Vomiting, especially at the onset of the disease, is often met with, but is rare in the later stages of the disease. Constipation, especi- ally in young children is more common than diarrhcea. The discharges are not so characteristic as in adults, and when diarrhoea is present, the 29 450 PEDIATRICS. stools, as a rule, are not so frequent or so large in amount. All the fatal cases noted by Morse had diarrhoea. Intestinal hemorrhage is very unusual under ten years of age, and is fatal in about half the cases. Perforation is exceedingly rare. Although it is probable that in all cases of typhoid fever there is some enlargement of the spleen, it is often im- possible to detect this change by palpation, and percussion of the spleen in young children is well known to be very misleading. According to Morse's figures the spleen is demonstrably enlarged in 90 per cent, of all cases of typhoid in children, and the older the child the greater the enlargement. The return of the spleen to its normal size indicates con- valescence and recovery, while persistent enlargement shows that the dis- ease is still present. Epistaxis occurs more rarely than in adults. The rose-colored spots appear to be less frequently found in children than in adults. Morse's series of cases showed the spots in from 60 to 70 per cent, of all cases in children. They usually appear in the second week. They consist of small, light-pink maculae, usually scattered, chiefly or solely on the abdomen, and disappearing under gentle pressure of the finger. Other varieties of efflorescences are seen at times, but are un- common. Herpes labialis occurs in some cases. The tongue is not so likely to be dry as in older subjects, and although coated it soon becomes clean at the tip and edges. There is at times a slight albuminuria at the height of the fever, but a complicating nephritis is rare. The diazo-reaction is usually present in the urine after the first week. The Widal reaction can generally be obtained in the second week. The more severe nervous symptoms so pronounced in later life are not prominent in early childhood. Headache of a mild type is common ; severe headache is very uncommon. Crying out at night, especially in young children, and delirium of a mild type are not uncommon. Deep stupor is rare ; in fact, the characteristic of typhoid fever in young chil- dren, as I have seen it, is apathy. The child takes the nourishment which is given to it, is not especially restless, and usually lies in a half-somno- lent condition. As the disease progresses it gradually returns to a more natural mental condition. Convulsions are rare. In some cases cerebral symptoms, simulating somewhat those of meningitis, arise, and are frequently due to cerebral congestion or to toxic action. These symptoms are more common in younger children. Hypersesthesia, changes in the pupils, retraction of the head, and opisthotonos may be present, closely simulating meningitis. True meningitis caused by the bacillus of typhoid is rare, but can occur. A case of this kind with the bibliography has been reported by Wentworth in a girl four years of age, in the Transac- tions of the American Pediatric Society of 1899. Lumbar puncture in this case showed an enormous number of typhoid bacilli, but no other organisms were found. The higher the temperature the more pronounced are the nervous symptoms. SPECIFIC INFECTIOUS DISEASES. 451 In typhoid the leucocytes are usually diminished in number, but there is a proportionate increase in the lymphocytes. In the early stages the erythrocytes are increased, as is also the haemoglobin. In the later stages a condition of secondary anaemia may occur, producing a diminu- tion of the red blood-corpuscles and haemoglobin. Complications and Sequels. — Pulmonary complications, with the ex- ception of bronchitis, are rare. Neuritis is not an uncommon complica- tion. Aphasia occurs rather more frequently in children than in adults. In rare cases it may be due to some organic cause, such as embolism, but, as a rule, there is no demonstrable lesion. According to Morse's statistics, in most cases it occurs where the typhoid had been extreme, accompanied by other marked nervous manifestations, and coming on during convalescence while the temperature was falling. The intelligence is retained, and there is rarely any other paralysis. Recovery was the rule, and the average duration was three weeks. Even when partial paralysis has accompanied the aphasia, entire recovery may take place. Chorea and parotitis are not very uncommon, and otitis media is not in- frequent. Relapses are about as frequent as in adults. According to Morse's figures, the number of days of fever in thirty relapses was fifteen, the shortest seven days, and the longest twenty-nine days. His number of days of apyrexia before the relapse varied from none to nineteen days. They follow about the same course as the normal attack, but, as a rule, are of shorter duration, the symptoms being less severe. Diagnosis. — Widal Reaction. — During the first few days typhoid fever may often be mistaken for various forms of febrile gastro-enteric disease. The most important means of diagnosis is by the Widal serum-reaction. By this is meant the clumping and loss of motility of the typhoid bacilli when the serum of a patient sick with typhoid fever is added to a bouillon culture of typhoid bacilli. A freshly prepared bouillon culture not more than twenty-four hours old and grown at room temperature should be used. Not less than ten parts of the culture should be added to one of the serum. No reaction occurring after half an hour should be accepted. This reaction is usually not present until the beginning of the second week, but may last for weeks or months after the recovery. If, there- fore, a reaction is positive, it is necessary, in order to be accurate, to exclude a recent typhoid. While this is the most important method of diagnosis in typhoid fever, it is not absolute, as the reaction is not always present in typhoid, and may rarely occur in other diseases. The error is about five per cent, in either direction. Infants born alive or dead of mothers who have typhoid may or may not show the serum-reaction. The reaction may be transmitted to a healthy infant from the breast-milk. The reaction is less intense in the mother's milk than in her blood, and less in the infant's blood than in the milk. The agglutinating principle may not be transmitted to the infant through the milk. The transmission probably depends largely on 452 PEDIATRICS. the strength of the agglutinating power in the blood and milk. The re- action disappears in a few days after the cessation of nursing. Diazo-Reaction. — Not so much value as formerly is attributed to the diazo-reaction, because it is also found in acute tuberculosis, septicaemia, measles, pneumonia, and probably also in many of the acute febrile diseases. It does not develop, however, in acute tuberculosis until after the third week of the disease ; whereas in typhoid, if it is to appear at all, it is usually obtained by the end of the first or in the second week. White Blood Count. — Another important aid in the differential diag- nosis of typhoid may be obtained by the white blood count. The absence of leukocytosis is the characteristic point of the blood in typhoid, and serves to exclude many other diseases in which leucocytosis is present. It is always to be borne in mind, however, that a high white blood count may be found in a case of typhoid which is complicated by some disease which is accompanied by a leucocytosis. Typhoid fever, therefore, is not to be excluded because of a leucocytosis, unless complicating conditions can positively be proved to be absent. Typhoid Bacilli in the Rose-Spots. — The detection of the typhoid bacilli in the rose-spots is a point in the differential diagnosis which may be attempted in all doubtful cases ; their presence makes the diagnosis certain. In making the differential diagnosis, therefore, on a doubtful case of typhoid, the most important evidence is to be found in the results of the Widal and diazo-reactions, the white blood count, and the rose- spots. The onset of the disease, the course of the temperature, and the whole series of abdominal symptoms must be considered as supple- mentary and confirmatory evidence. The diseases which are most likely to simulate typhoid fever and render the diagnosis difficult are as follows : The Exanthemata and Pneumonia. — A number of acute diseases, such as the exanthemata and pneumonia may simulate in their prodromal stage those cases of typhoid fever which begin with violent symptoms. In pneumonia and scarlet fever there is leucocytosis, in typhoid fever there is none : moreover, in the former diseases there is no Widal reaction and no diazo. In measles, however, there is no leucocytosis, Avhile the diazo- reaction may be present. After the prodromal symptoms have passed, the distinctive efflorescences of measles and scarlet fever and the course of the disease will serve to differentiate them. Avhile the temperature curve and physical signs will determine the presence of pneumonia. Acute Ileo-Colitis. — Typhoid fever and ileo-colitis may sometimes simu- late each other. The intestinal symptoms of typhoid fever in young chil- dren, however, correspond so closely to the severity of the local lesions that it is rare in the early days of the disease to meet with the severe intestinal symptoms so common in ileo-colitis ; those of typhoid, as a rule, being much milder. Later in the disease the splenic enlargement, efflores- cence, and tympanites of typhoid are not found in ileo-colitis. The blood SPECIFIC INFECTIOUS DISEASES. ^53 of typhoid does not show leucocytosis, while this is usually present in other forms of gastro-enteric infection. While the Widal and diazo-reactions are generally present in typhoid, the former never occurs, and the latter rarely, in gastro-enteric disease. The temperature curve also, after the early days of the disease, is of considerable aid in diagnosis. Tubercular and Epidemic Cerebro-Spinal Meningitis. — The vomiting which occurs in the prodromal stage of typhoid fever may, in connection with the child's apathy, simulate the early stages of tubercular meningitis, but the higher temperature, enlarged spleen, and distended abdomen of typhoid, and the absence of the irregular respirations, slow, intermittent pulse, and retracted abdomen of meningitis serve to differentiate the two diseases. In tubercular meningitis the evidence given by lumbar punc- ture and the absence of the Widal reaction separate the disease from typhoid. In both diseases the diazo-reaction may be present, and leucocy- tosis is absent in both. In rare cases the bacilli of typhoid, as already stated, may be the cause of a meningitis and the disease be diagnosticated during life by lumbar puncture. In cerebro-spinal meningitis the diplo- coccus intracellularis, obtained by lumbar puncture, is not found in typhoid ; there is marked leucocytosis, and while the Widal reaction is always absent, the diazo may be present. Acute Miliary Tuberculosis. — The most difficult of all the diseases to differentiate from typhoid is acute miliary tuberculosis. The absence of leucocytosis and the possible presence of the diazo-reaction occurs in both diseases, but the Widal reaction is not present in tuberculosis, and thus becomes invaluable in diagnosis. Unless the tuberculin reaction is marked, and until other evidence of tubercular processes appear locally, as in the lungs, it is often only by the subsidence of the fever and prostration in typhoid at an early date that it can be distinguished from the slow pro- gressive prostration and continued fever of tuberculosis. It is especially in the typhoidal type of acute miliary tuberculosis that the resemblance of the two diseases is closest, and when in typhoid the rose-colored spots do not appear and the Widal reaction is negative, the delirium, distended abdomen, enlarged spleen, and even the irregular temperature at times common to both diseases, may make the resemblance so close that the diagnosis cannot be made until the post-mortem examination. Malaria. — The differential diagnosis between typhoid fever and mala- ria is, at times, especially in children under two years of age, very diffi- cult and perhaps impossible until the blood has been examined. The difference in the temperature curve, the presence of the plasmodium, the marked effect on the symptoms by the use of quinine, and the absence of the Widal and diazo-reactions in malaria, are of much value in the diag- nosis from typhoid. Leucocytosis is absent in both malaria and typhoid. Epidemic Influenza. — Epidemic influenza may in its onset simulate typhoid fever, but the period of doubt is very short. The presence of Pfeiffer's bacillus, if it can be found in the sputum or nasal discharge, is 454 PEDIATRICS. of importance, but the absence of the Widal and diazo-reactions are not of so much importance, as the disease has either run its course or de- clared itself by its temperature and irregular groups of symptoms before the time for obtaining these reactions has arrived. It is. therefore, impos- sible in the early days of the disease to make a positive diagnosis, and in some cases we are left in doubt as to the diagnosis at even a later period, when the symptoms of enlarged spleen, rose-colored spots, and tympanitic abdomen of typhoid are not present as a group. The white blood count is of little service, as it is generally normal in epidemic influenza. Prognosis. — The prognosis of typhoid fever in early childhood is good. Statistics show that the disease is much less fatal in children than in adults, and that the mortality increases directly with the age. The complications, whether arising from local disturbance of the intestine or from cardiac and pulmonary disease, are rare in comparison with those met with in later life. The disease, however, varies very much in its severity in different epidemics and in different stages, and a child may have a severe type of typhoid fever and die from it. Treatment. — The treatment of the mild form and that most commonly met with in young children is exceedingly simple. The child should be kept perfectly quiet in bed as long as the temperature is raised, and for three or four days after it has become normal. Although in adults quite a varied diet can be given, in young children milk in some form through- out the whole course of the disease is indicated. There are no drugs which will either abort or cure the disease. In the cases which begin acutely with vomiting, food should be withheld for some hours, and the prodromal symptoms treated symptomatically, as the same symptoms would be in the beginning of a number of acute febrile diseases. After the acute symptoms have passed, alkaline milk should be given with low percentages of fat, sugar, and proteids at first, and these elements should be gradually increased in their percentages, and varied in their com- binations to suit the especial age and digestion. It is usually better to heat the milk to 68.3° C. (155° F.) and to add lime-water, five per cent. Where the stomach is at all irritable it is often well to peptonize the milk for a time. It is seldom that the temperature is so high as to call for any- thing beyond bathing, and, as a rule, antipyretics should be avoided. As a hygienic measure the child should be bathed twice daily with water heated to 32° C. (90° F.). If the temperature rises to 39.4° or 40° C. (103° or 104° F.) a reduction by artificial means is not necessarily indi- cated, but we should be guided by the general condition of the child. According to our experience at the Children's Hospital, a large number of children of all ages pass through an attack of typhoid without any necessity arising for the reduction of the temperature by baths or sponging. The older the child the more likely is the bath to be indicated. Much pulmonary or cardiac weakness contra-indicates the bath. The child can be either sponged for five or ten minutes, or wrapped in a thin blanket SPECIFIC INFECTIOUS DISEASES. 455 and placed in the bath, while the body and limbs are actively rubbed. Where there is delirium and great restlessness, with a temperature of 40.5° or 41.1° C. (105° or 106° F.) baths should be given every three or four hours, but with caution, as children do not react so well as adults. A stimulant, such as a few drops of brandy, should be given at the time of the sponging or bath. Technique of the Bath in Typhoid Fever. — A very convenient method of administering the bath in typhoid fever, or in any other condition in which the treatment is indicated, is as follows : A large rubber sheet is placed under the child on the bed, and the sides and ends are bolstered up by rollers or bedding, making, if properly arranged, a shallow but sufficiently large tub without the inconvenience of moving the child. A towel or blanket may be placed under the child if it is made uncomfortable by lying directly on the rubber sheet. The water is brought in a foot-tub to the side of the bed, and its temperature regulated according to the indications. A wet towel or sponge is placed on the head ; the water is then squeezed from a sponge on to the naked body with one hand, and brisk friction is applied with the other. The chest, abdomen, arms, and legs should be taken in rapid succession. It is especially to be noted that it is the combination of friction with water which accomplishes the best result in reducing the temperature and at the same time stimulating the peripheral circulation. The child is then turned on its side, and the back is bathed and rubbed in the same manner. The duration of the bath should vary from five to fifteen min- utes, according to the height of the temperature and the manner in which the child reacts. The temperature of the water should vary from 37.7° C. (100° F.) to 23.8° C. (75° F.), according to the age of the child, the height of the fever, the number of degrees of reduction in the tempera- ture obtained, and the manner in which the child reacts. A drop in the temperature of one to one and a half degrees Centigrade is the object especially to be attained. The temperature is best taken one-half hour after the bath. Drops of two and three degrees are not desirable. If the bath is well given by an experienced nurse, a good reaction should usually be obtained. Slight blueness of the lips and finger-nails, cold hands and feet, and chilly sensations should be watched for and treated by a dose of brandy and water, an extra blanket, and heaters in the bed. Massage of the extremities under the blankets may be all that is necessary. Care of the Mouth and Skin. — The mouth should be gently but thor- oughly cleansed with a two per cent, solution of boracic acid in distilled water at least three times daily. The greatest care should be taken to prevent irritation of the skin by bathing the recumbent parts with alcohol and water. Diarrhoea, unless profuse and exhausting or very frequent, such as more than three or four in twenty-four hours, should not be checked. To control peristalsis bismuth and small doses of opium are indicated. 456 PEDIATRICS. Constipation. — There is usually more difficulty with constipation than with diarrhoea. Enemata and suppositories are indicated rather than laxa- tives, which should be only used in extreme cases, and necessarily sparingly and in a mild form, such as the milk of magnesia 3.75 to 6.50 c.c. (1 to 2 drachms), with an occasional small dose of castor oil. The discharges should be disinfected at once with a 1 to 20 solution of carbolic acid. All the clothing should be soaked in carbolic acid, twenty per cent., for six hours, and then boiled for one hour. Headache, Restlessness, Sleeplessness. — These nervous symptoms are best treated by bathing. If a sedative is desired, 0.12 to 0.3 gramme (2 to 5 grains) doses of trional are safe and efficient. Bromide of soda may be given alone or in combination with trional. Tympanites should be treated with hot cloths applied to the abdomen, or by turpentine stupes made in the following manner : one part of spirits of turpentine is mixed with six parts of sweet oil, and the mixture is then rubbed gently but thoroughly on the abdomen. A thick piece of flannel is then dipped in hot water, wrung out, and when sufficiently cool applied to the abdomen, covered with oiled paper, and kept in place by a thick swathe. If these precautions are taken, irritation of the skin will rarely be caused, and the treatment is very efficacious. Gentle irrigation of the colon with some saline solution, such as a two per cent, borate of soda or a three per cent, boracic acid solution, may be tried. In extreme cases the rectal tube may be used with caution. Hemorrhages and perforations should be treated as in the older cases, the former with absolute rest, with hypodermic injections of ergo tin 0.06 c.c. (1 grain), and sometimes of morphine and cold to the abdomen, and the latter with hypodermic injections of morphine 0.001 to 0.003 c.c. (-g-V to 2-V grain). Laparotomy for perforation in typhoid has not been attended by bril- liant results, but in certain cases may be deemed advisable. The same care should be exercised during the convalescence of the child as in the advanced convalescence of the adult. Stimulants are not called for, as a rule, in the early stages of the dis- ease. When used they are best administered in the form of brandy or whiskey. They are contra-inclicated in the stage of toxaemia represented by marked excitement, active delirium, cerebral congestion with delusions and great restlessness, and a strong, full pulse. On the other hand, when the pulse is small and weak, when the mental condition is expressed by depression, low muttering, delirium, and a general condition of nervous exhaustion, the use of stimulants, especially in the form of alcohol, is dis- tinctly indicated, and is highly beneficial. For an infant of one year the amount of brandy or whiskey in twenty-four hours should vary from 15 c.c. (} ounce) to 30 c.c. (1 ounce), but should never exceed 60 c.c. (2 ounces). In children of four years these doses may be doubled in corre- sponding conditions. In all cases the stimulant should be well diluted. SPECIFIC INFECTIOUS DISEASES. 457 It' in a hemorrhage from the bowels a stimulant must be given, it should be administered in small doses and in combination with opium. A table giving the doses of other cardiac stimulants will be found on page 470. The following case, Fig. Ill, was under my care at the City Hospital : A boy, five years old, was taken sick with general malaise and fever five days before entering the hospital. There had been no other symptoms, such as epistaxis or vomiting. On entering the hospital, an examination showed the tongue to have a thick brownish coat in the centre and a thin coat on the tip and edges. The child was in an apathetic condition. The pulse was rapid and regular. Nothing abnormal was found in the thorax. The abdomen was distended and tympanitic, and showed one rose-colored spot. The spleen could be easily felt 2.5 cm. (1 inch) below the border of the ribs, and on percussion the dulness reached as high as the seventh rib in the Fig. 111. J Typhoid fever. Male, 5 years old. axillary line. The enlargement of the spleen and the lower border of the ribs are marked in black in Fig. 111. The upper border of the splenic dulness is marked by a broken line, and the figure 7 marks the seventh rib. The blood showed no leucocytosis. The pupils reacted equally to light. The expression of the child's face was apathetic, and he took very little notice of anything. An examination of the urine showed the color to be normal, the reaction neutral, the specific gravity 1026, and that there was a slight trace of albumin. The sediment showed occasional hyaline and fine granular and fibrinous casts. A Widal reaction was not obtained. On the third day after entering the hospital, the eighth day of the disease, the child became very stupid and sometimes delirious. There was a slight cough. On the twelfth day of the disease the child cried out at times, and was delirious. The skin was dry and hot. There were no more rose-colored spots. There seemed to be slight tenderness in the lower iliac fossa, but there was no gurgling. On the fifteenth day of the disease the temperature began to fall by lysis, and the child began to be fretful. On the eighteenth day the temperature became normal. By the twenty-first day the child seemed bright, and was playing with its toys. The pulse was stronger. One week later it was sitting up in bed, and had a strong pulse and a good appetite. A few days afterwards it was up and about the ward, perfectly well. The following 458 PEDIATRICS. chart shows the temperature, pulse, and respiration from the fifth day of the child's illness until convalescence was established on the twenty-fifth day. The following notes and plate (Fig. 112) were given to me by Dr. S. S. Adams, of Washington, and occurred in an infant two years old. In this case the irregularity of the temperature curve and the prominent symptoms of cerebro-spinal irritation ren- dered the diagnosis so obscure that typhoid fever was not suspected until a few days before death. The post-mortem examination showed marked congestion of the entire brain, chiefly on the right side. The left hemisphere was covered with a glue-like CHART 12. DAYS OF DISEASE F. S « 7 8 9 10 11 12 13 14 1 5 1C 17 IS 19 20 21 22 23 24 25 C. 107 • • = 41 " f . 105 40 ' S „ ,0 * aj\ ~l z 40 '°„ !"• tJjL~*%1~ -d\ 39 ' 4 / 38 ' 8 » tvv, ;;■/ - V- 377 \S 36G a 3 " 36. 1^ \ 35.5^ 95 140 J-lJ- / ^ttl 2 t js/.^t ^ A / u ^ ^ -,aJ s 110 Z// 2 77 90 80 70 50 I s /V^/v/si& OIJ < 30 - ^=-7^ g 25 ^S 3 20 - A " 15 jr X Typhoid fever. Male, 5 years old. substance which filled the sulci and was especially abundant around the Sylvian fissure. The heart was normal. The lungs showed marked hypostatic congestion. The liver was normal. The gall-bladder was empty and pale. The spleen was enlarged. The kidneys were normal. The stomach was congested. The mesenteric glands were en- larged and soft. The intestines contained a quantity of yellowish watery faeces. The lesions were in the ileo-colic portion of the intestine. There was thickening and ulceration of Peyer's patches, and to a less extent of the solitary follicles. Swelling of Peyer's patches and of the solitary follicles is not dis- tinctive of typhoid fever, as this condition frequently occurs from irrita- tions of various kinds. Fig. 113 represents a section taken from the intestine of a child. The macroscopic appearances of this intestine so closely simulated the early stage of typhoid fever that cultures were made from it by Dr. Prudden to settle this question. No bacilli were found. This condition is often found in children in acute non- typhoidal ileo-colitis. Pig. 112. Typhoidal ileocolitis, showing ulcers of colon. Female, 2 years old. U. S. Army Medical Museum. Pig. 113. Enlarged Peyer's patches closely simulating the lesions of typhoidal ileo-colitis. Muc. Mem., mucous membrane ; Fol., enlarged follicles; Mus., muscle. SPECIFIC INFECTIOUS DISEASES. 459 TYPHUS FEVER. Typhus fever is an acute infectious disease, the cause of which has not yet been determined. In America typhus fever is an exceedingly rare disease, but in England it is well known to occur in children as well as in adults. According to Collie, out of 711 admissions to the Hunnerton Fever Hospital during a period from 1871 to 1880, 24 were under five years of age, 54 from five to nine years, and 113 were from ten to four- teen years. Buchanan has shown that typhus fever in early life is very mild, but that children are just as susceptible as adults. Symptoms. — The onset is acute. According to Ashby and Wright the attack begins with headache, pains in the limbs, drowsiness, sometimes vomiting, and rarely diarrhoea. The constitutional symptoms are of a severe type. The tongue is dry and coated, there are sordes on the teeth, and the gums bleed easily. On the fourth or fifth day the skin assumes a dusky, congested appearance, with an indistinct mottling. Sometimes there are rose-colored spots or maculae, larger than those seen in typhoid, appearing first, according to Collie, on the upper front portions of the chest, on the wrists, on the backs of the hands, and in the epigastrium. The temperature is usually continuously high, varying from 39.4° to 40° C. (103° to 104° F.), and the pulse 120 to 130, and rather weak. The temperature usually becomes normal by about the eighth or tenth day. Prognosis. — The prognosis is usually good. Out of 191 children under fourteen years of age only two deaths took place, while the total mortality for all ages was 20 per cent. Treatment. — Especial attention should be paid to the hygienic sur- roundings, such as fresh air, sunlight, and warmth. Daily sponging and the free use of stimulants are indicated. The diet should be milk and broths until convalescence is well established. DIPHTHERIA. Diphtheria is an acute, highly infectious disease, due to the Klebs- Loeffler bacillus. It is primarily a local affection, the constitutional symp- toms being due not to the presence of the organism in the blood, but to the absorption of the toxins caused by the growth of the bacillus. Although the term diphtheria, derived from the Greek word dctpdipa, implies a membrane, and the disease is usually accompanied by a pseudo- membrane, yet it must be understood that the disease is not diphtheria unless the specific germ is present. This germ may act ivith different degrees of intensity, and thus cause inflammation varying from a slight catarrhal condition to the most serious membranous one. In like man- ner, according as the form is mild or severe, there may be very slight constitutional symptoms or exceedingly serious ones. There is probably a concurrent infection with pyogenic cocci. These organisms produce the 460 PEDIATRICS. secondary inflammations occurring in the disease, and also by their toxins give rise to additional constitutional symptoms. Etiology. — The Klebs-Loeffler bacillus was first described by Klebs in 1883, and later was more fully identified by Loeffler in 1884. Its most striking features, morphologically, are its variation in form and the irregularity in its manner of staining. It does not form spores. Welch and Abbott have shown that in fluids it may be killed by an exposure of ten minutes to a temperature of 58° C. (136.4° F.). Under favorable conditions it may remain alive for weeks, or even months, in fragments of dried membrane. The pathogenic cocci most frequently found in the concurrent infec- tions are the streptococcus pyogenes alone, or associated with the staphy- lococcus pyogenes aureus, the former being the most important in its action. There is no true diphtheria where the Klebs-Loeffler bacillus is not present, but its presence in a healthy throat does not constitute the disease diphtheria, although the individual may be the source of infection to others. It is undoubtedly a contagious disease of local origin, and it does not originate spontaneously. The contagium of diphtheria is con- tained chiefly in the secretions of the throat and nose, and is communi- cated usually by direct or indirect contact, and not, as a rule, by the air. The area of infection is not so great as in scarlet fever. It is not found in the urine and faeces. Sewer gas and confined impure matter of any kind may act by weakening the resistance of the body to the action of the bacilli, or, by producing a benign lesion in the throat, may offer a suit- able nidus for the invasion of the bacillus. It is now, however, con- ceded that imperfect drainage and unsanitary conditions should not be considered important factors in increasing the frequency of the disease. Animals, such as cows, cats, dogs, and pigeons, may have diphtheria, and be a source of infection to those brought in contact with them. There is no positive evidence that the milk of cows affected by diphtheria contains the germs of the disease, but the probability is that the milk in some of these cases may be contaminated by the hands of the milkers. The cases in which the pharynx and nose are affected are the most contagious on account of the secretions. Generally an unhealthy condition of the mouth, nose, or throat predisposes to the disease, as a lesion of the mucous membrane is necessary for its entrance. The bacilli will not grow on an intact mucous membrane. An abrasion must be present for them to develop. There is a non-virulent form of the diphtheria bacillus which differs in a number of respects from the virulent form, both in its culture pecu- liarities and in its method of staining with Hunt's differential stain, and also with Neisser's stain. Although diphtheria may occur at any age, it is rarely met with in early infancy. It is most commonly seen from the second to the fifth or sixth year. It may occur more than once in the same individual. SPECIFIC INFECTIOUS DISEASES. 461 Pathology. — The lesions of diphtheria are due to the local action of the Klebs-Loeffler bacillus and associated bacteria, and to the absorption of toxins produced by the bacteria. The most constant lesion is a pseudo- membrane, produced by the local action of the bacilli in the upper air- passages, and due to exudation and coagulation necrosis. The exudation coming from the vessels of the tissue beneath the membrane meets the necrotic tissue containing a fibrin ferment, and coagulation takes place, the fibrin of the coagulum being intimately associated with the necrotic epithelium. The bacilli can also produce other lesions, such as simple inflammation, necrosis without membrane formation, and even abscess. There is no pathological condition directly characteristic of the action of the Klebs-Loeffier bacillus, and the same anatomical conditions may be caused by other bacteria, and even by irritants. The process may be simply a catarrhal inflammation, which does not go on to the formation of a pseudo-membrane. The primary infection in diphtheria is most commonly in the throat, from which the bacilli may extend into the adjacent mucous surfaces, pro- ducing, in some cases, membrane formation, in others only simple or puru- lent inflammation. They may also extend into the nose, producing nasal diphtheria, or along the Eustachian tubes into the middle ear, or from the nose into the accessory sinuses, downward into the trachea and air-passages, or into the oesophagus and stomach. There are certain differences in the membrane formation due to the anatomical character of the tissue. Thus the membrane in the pharynx clings tightly to the surface, while in the trachea and lower passages it is easily removed. The extension of the bacilli into the lungs may produce a membrane formation in the smaller bronchi, areas of broncho-pneumonia or even abscesses. The pathological process may be further modified by the association with the Klebs-Loeffler bacillus of the common pathogenic cocci, and it is difficult to determine exactly the part which these various organisms play in the production of the local lesions. It is certain, how- ever, that the lung lesions which are ordinarily attributed to these asso- ciated organisms may be produced by the Klebs-Loeffler bacillus alone. The membrane in diphtheria is usually of a peculiar grayish-white color, and, as a rule, cannot be easily detached ; in some cases, on the contrary, it may be white and easily separated. It sometimes assumes, early in the disease, a gangrenous appearance, which shows that the case is serious. Nasal diphtheria is characterized by a profuse nasal discharge, and often by a membrane. Transmission of the germ of the disease from the nose to the eye is infrequent, and does not always result in the forma- tion of a false membrane. Frequently the pharyngeal inflammation ex- tends through the Eustachian tube, causing inflammation of the middle ear, and in these cases a membrane may be formed. The membrane may extend downward to the larynx, causing marked dyspnoea. Below the vocal cords the membrane is not very firmly attached, and is fire- 462 PEDIATRICS. quently coughed up. If death occurs late in the disease in apparent con- valescence no macroscopic lesions, as a rule, are found. Microscopic ex- amination of the nerves, however, often shows marked degeneration of the nerve tissue. The internal lesions of the disease are not due to the presence of the bacilli but to the action of the toxic substances which are absorbed from the places where the bacilli are growing. These lesions consist chiefly in diffuse, degenerative changes, and in intense local processes, also of a de- generative character. The organs most commonly affected by these lesions are the kidneys and the lymph-nodes. The adjacent lymph-nodes are apt to be swollen, and on microscopical examination they often show small foci of cell-necrosis ; similar, smaller necrotic foci may be found in other parts of the economy, as in the liver, and are due to absorp- tion of toxins. There is also a general lymphatic hyperplasia, which is relatively greatest in the abdomen. The kidneys ordinarily show only parenchymatous degeneration, but in a few cases of concurrent infection may present acute lesions. Hemorrhages into the serous membranes are often met with, and the organs in general show degenerative changes due to action of the toxins. Endocarditis is rarely seen. Catarrhal bronchitis and broncho-pneumonia frequently complicate diphtheria, and are caused by the inspiration of the pyogenic cocci as well as by the invasion of the Klebs-Loeffler bacillus itself. Incubation. — The time which elapses after exposure to the infection until the first symptoms develop may be only twenty-four hours ; on the other hand, it may be two or three days. This period of incubation is a very indefinite one, since the interval between the access of bacteria to the mucous membrane and the time when the absorption of the toxins becomes apparent depends upon whether the tissues of the mucous mem- brane are vulnerable. Thus, it is probable that the Klebs-Loeffler bacillus may exist in the mouth for an indefinite time without infecting the indi- vidual. Symptoms. — Diphtheria must be considered a local disease at the onset, and the symptoms that occur later are, like the secondary pathological lesions, the result of the absorption of the toxin caused by the growth of the bacillus. There may be mild forms of diphtheria almost without con- stitutional symptoms. The severe form of diphtheria is attended by grave general prostration, cardiac depression, and anaemia, is frequently compli- cated with broncho-pneumonia and nephritis, and may be followed by localized or general paralysis. The constitutional symptoms are not due to the presence of the Klebs-Loeffler bacillus in the blood. The prodromal symptoms of diphtheria are not especially typical. They may be acute in character, or very mild and of a subacute variety. In young children there may be in the onset of the disease a slight convulsion. In certain cases, according to McCollom, a peculiar dark-red appearance of the mucous membrane of the mouth is seen, which is SPECIFIC INFECTIOUS DISEASES. 463 quite characteristic. There is apt to be a sensation of chilliness, some heightening of the temperature, and more or less pain in the back and limbs. There is nothing, however, to distinguish this stage from many other affections of children, such as simple tonsillitis. The child may often complain of discomfort on swallowing, and on examining the throat the fauces are found to be reddened. In from twelve to twenty-four hours, however, a more typical appearance will be seen in the throat. A white or grayish-white pseudo-membrane, commonly appearing first on the tonsils, develops, and on the second or third day extends to the soft palate and uvula. It may also extend backward to the pharynx. During this stage the throat becomes much swollen and the tonsils con- siderably enlarged, so as almost to meet at times in the median line. The diphtheritic membrane is usually firmly adherent to the mucous mem- brane, and, as the case progresses, assumes a brownish or yellowish-gray color, sometimes becoming gangrenous, with an extremely foetid odor. A profuse nasal discharge in severe cases may appear at this stage, and, if the patient becomes septic, spots of ecchymoses, which are of grave im- port, appear on various parts of the body, and are usually significant of a fatal issue. Listlessness is present, but delirium of an active type is not common. An efflorescence resembling scarlet fever may appear in a still later stage. In addition to these lesions in the throat, the cervical glands are usually involved and become considerably swollen. The child, as a rule, shows grave constitutional symptoms. The temperature is not characteristic. It is usually not especially high, and ranges from 38.3° to 38.8° C. (101° to 102° F.). It may, however, rise to 40° C. (104° F.). A subnormal temperature is more serious than a moderately elevated one. The pulse is somewhat increased in rapidity, and is weak in proportion to the severity of the disease, but does not always correspond to the tem- perature ; sometimes it is very slow. The slow pulse is indicative of the action of the toxin on the nervous centres, as well as to the weakness of the ventricles. Diarrhoea is a frequent but not a constant symptom. Loss of appetite, nausea, and vomiting frequently occur. In cases of a mild type the symptoms abate towards the end of the first week, the pseudo-membrane separates, leaving a raw surface behind it, the neck becomes less swollen, and the child feels much better. It is, however, usually left in a prostrated condition for a number of weeks ; and even in these mild cases the toxic effects of the disease may show themselves in the form of a neuritis with an accompanying paralysis many weeks after the diphtheria has run its course. There may also, even in mild cases, be a slight discharge from the nose, owing to the inflamma- tion of the posterior nares. Slight albuminuria is not infrequent. A very prominent symptom in all forms of diphtheria may be cardiac weak- ness. In some cases the child dies suddenly without any warning, or death may have been preceded by attacks of semi-collapse. In other cases there may be a weak intermittent pulse, which continues through- 464 PEDIATRICS. out the disease and during convalescence. Under these circumstances the child should be considered to be in a critical condition, as death is likely to occur suddenly. The following case represents one of the milder forms of diphtheria : A boy, five years old. had been sick four days. His pulse was somewhat rapid, but of good strength. His respirations were slightly increased. There was no thoracic retraction. There was a slight discharge from the nose, and the cervical glands were somewhat enlarged. He took his nourishment well, and seemed in a very fair condi- tion. The urine contained a small amount of albumin. An examination of the throat showed small patches of grayish- white pseudo-membrane on the upper part of the left tonsil, and corresponding to the left arch of the soft palate. This is represented in Plate XI., facing page 620. The membrane had also involved the right side of the uvula, the right arch of the soft palate, and the side of the right tonsil pointing towards the median line. There was also a patch on the right tonsil and on the posterior wall of the pharynx. The tonsils were moderately enlarged and reddened, and the mucous membrane of the soft palate was considerably inflamed. When lesions of this character and description are seen in the throat, there can seldom be any doubt as to the clinical diagnosis of diphtheria, and a bacteriological examination should at once be made. In this case a culture made on Loeffler's blood-serum of a shred of membrane taken from the throat showed the presence of the Klebs-Loeffler bacillus and a large number of streptococci. Variations in Type. — There are a number of variations which occur both in the severity of the disease and in the locality which is first attacked or principally invaded. Atypical Infections of the Throat. — In some epidemics the Klebs- Loeffler bacillus seems to be far more virulent than in others, and in some individuals it produces much more serious symptoms than in others. The severity of the attack does not always depend upon the extent of the pseudo-membrane. In general, the severity of the cases depends on three factors : (1) the virulence of the bacteria, (2) the local resistance, and (3) the general resistance. A number of what may be called atypical cases have been observed and carefully studied, especially by Koplik, in which no pseudo-membrane was detected and in which the morbid appearances in the throat were those of a simple catarrh or fol- licular tonsillitis. The virulent Klebs-Loeffler bacillus was detected in these cases, and other children infected by them presented the typical local lesions of diphtheria. Malignant Forms of Diphtheria, — In addition to these mild cases, the Klebs-Loeffler bacillus at times produces a most malignant form of diph- theria. In these cases the child either shows a fairly mild form of the disease for a few clays and then suddenly develops the severe form, or it may be attacked at once by very severe symptoms. It becomes dull ; the temperature is either slightly raised or may rise to 39.4° or 40° C. (103° or 104° F.), or higher; the pseudo-membrane spreads rapidly: there may be a dusky efflorescence on the skin, simulating closely that which I have described in the malignant form of scarlet fever. There SPECIFIC INFECTIOUS DISEASES. 465 may also be a purpuric condition of the skin. The picture of these septic cases is very characteristic. There is a peculiar, sweetish odor to the breath. There are cyanosis and a marked waxy pallor. There are hemorrhages from the throat and nose, with a profuse nmco-purulent discharge from the latter. The cervical glands are often enormously en- larged. The membrane has been known to extend in all directions, and sometimes even through the Eustachian tubes to the external ears. All degrees of severity are met with between the mild and malignant types of diphtheria. The membrane, instead of extending upward to the naso- pharynx, as occurs in the malignant cases just spoken of, may spread downward, attacking the epiglottis and the larynx, and cause serious obstruction. The pseudo-membrane most commonly appears first on the tonsils, thence spreading to the soft palate and to the uvula. The disease may, however, begin in the mucous membrane of any part of the mouth, nose, or throat. Nasal Diphtheria. — Diphtheria sometimes begins in the nose and spreads no farther. In these cases the disease is usually of a mild type, but it is infectious. The condition is especially liable to be overlooked, as the child for one or two days may show merely the symptoms of fever, malaise, loss of appetite, and a discharge from the nose. On examining the nose carefully, however, a pseudo-membrane will often be found. It is, therefore, very important in cases of this kind to have a bacteriological examination made, and to isolate the child until it is determined that the Klebs-Loeffler bacillus is not present. These cases are a prolific source of infection to the community at large, for even when antitoxin has been given it does not kill the bacilli, although it may stop the nasal discharge. When the naso-pharynx is affected, either primarily or secondarily through the nares or the pharynx, the constitutional symptoms are, as a rule, marked. This is in all probability accounted for by the great mass of absorbents in the naso-pharynx, where absorption takes place so easily that general septic poisoning quickly follows. When the naso-pharynx is attacked by diphtheria, we usually meet with the most fatal results. Laryngeal Diphtheria. — In some cases the Klebs-Loeffler bacillus pro- duces its effects first on the mucous membrane of the larynx. In these cases the mucous membrane of the nose and pharynx may never show any evidence of a pseudo-membrane. The first symptom, as a rule, is a cough of a harsh, ringing nature. The temperature may or may not be raised. As the toxic absorption is slight, on account of the locality affected, the constitutional symptoms are correspondingly mild. The child's symptoms are those resulting from laryngeal obstruction. There is dyspnoea, with retraction of the intercostal and supraclavicular spaces. and later of the epigastrium and the lower chest. This is accompanied by an increasing cyanosis. The child is very restless, is forced to sit up in order to breathe, and, for the same reason, bends forward with its head back. In these extreme cases, unless relief is speedily afforded, the child 30 466 PEDIATRICS, soon dies of suffocation. In another set of cases a slower form of suffo- cation may result from the extension of the membrane downward to the bronchi, while in still another set death may result from a complicating broncho-pneumonia. In diphtheria of the larynx there may be laryngeal stenosis, and yet no membrane be visible, and the cultures taken during life may be nega- tive. In almost every instance, however, these cases are shown to be diphtheria at the autopsy. Streptococci may cause a membrane in the air-passages, but a membrane of such an origin, as a rule, is not suffi- ciently tough or thick to impede respiration. Attacks of laryngeal dys- pnoea may occur very suddenly, even in mild cases of diphtheria. Complications and Sequelse. — There are a number of complications which arise in diphtheria besides those of laryngeal stenosis and cardiac weakness. The most serious of these are broncho-pneumonia and acute nephritis. The form of pneumonia which complicates diphtheria is broncho-pneu- monia, which is produced not only by the Klebs-Loeffler bacillus, but by pyogenic cocci which have been inspired. Broncho-pneumonia is most frequent and most fatal in laryngeal cases which have been operated upon. Albuminuria is so commonly met with in both the mild and the severe cases of diphtheria that it should be considered as a part of the disease rather than as a complication ; as a rule, the greater the amount of albu- minuria the more severe the case. When acute nephritis complicates diphtheria it is not usually accompanied by oedema or anasarca. Otitis media, occurs frequently. Among the more common sequelae are secondary anosmia and chronic naso-pharyngeal catarrh. The most common and serious sequela of diphtheria is a peripheral neuritis, with its accompanying paralysis. This paralysis often does not appear until con- valescence has been established, perhaps in the third or fourth week from the time of the attack. It may show itself in the form of a palatal pa- ralysis of such an extent as not only to cause a nasal voice but to allow the passage of fluids through the nose. The child may die of inanition from inability to swallow, and may require to be fed with the head low- ered or by the stomach-tube. Inability to read, dilated pupils, and double vision may arise from ocular paralysis. There may also be a more gen- eral distribution of the paralysis, the child only being able to raise its head or move its limbs to a limited extent. Again there may be a pe- ripheral neuritis with marked pain. In the more severe cases the lower extremities are affected, and the knee-jerks are absent. When the limbs are involved the electrical reactions are the same as in peripheral neuritis from other causes. Diagnosis. — The local lesions produced by the Klebs-Loeffler bacillus may be merely a catarrhal inflammation or those of a follicular ton- sillitis. All such conditions, therefore, should be looked upon with sus- picion until the absence of the Klebs-Loeffler bacillus has been demon- SPECIFIC INFECTIOUS DISEASES. 4(37 strated bacteriologically. Although a membranous laryngitis may be due to other causes than the Klebs-Loeffler bacillus, yet this is so rare that every case of primary membranous laryngitis should be considered to be diphtheria until it has been proved that it is not. A decisive diagnosis of diphtheria in any case can only be made by determining the presence of the Klebs-Loeffler bacillus. Recognizing that the same pseudo-membranous condition in the throat may occasionally be produced by pyogenic cocci as well as by the Klebs- Loeffler bacillus, the clinical diagnosis of a typical case of diphtheria is often difficult. A provisional diagnosis of diphtheria should be based upon the appearance of the throat of a pseudo-membrane which usually appears first on the tonsils, and has a tendency to spread to the uvula, soft palate, and pharynx. When in addition to this a nasal discharge is present, and the glands of the neck are much enlarged, a picture is presented which is not shown by any other disease. The most common difficulty met with clinically is in distinguishing between cases of acute follicular tonsillitis and diphtheria. In taking a culture, as has been pointed out by McCollom, a source of error in results is that the swab or platinum needle is rubbed over the surface of the membrane, a locality where the organism is most likely to die. The edge or, if possible, the under surface of the membrane are the proper places from which to take cultures. Cultures should also be taken from the secretions of the mouth and from the nasal discharge. Antiseptic gargles and applications should not be used a short time before the culture is taken. Efflorescences of urticaria and various forms of erythema may follow antitoxin, and even ecchymoses. Efflorescences may occur resembling scarlet fever and measles, often so closely that the most careful examina- tion and consideration of the symptoms are necessary, and even then the differential diagnosis is often impossible. Scarlet fever is differentiated by the presence of fever, vomiting, and the characteristic appearance of the throat and tongue ; measles by the absence of catarrhal symptoms and from the fact that the antitoxin efflorescence, as a rule, first appears on the extremities. The efflorescence from antitoxin may for a few days render the patient uncomfortable, but the symptoms pass off just as an urticaria does when resulting from one of its exciting causes. Prognosis. — Diphtheria is an extremely fatal disease, especially in the septic and obstructive cases. The mortality varies decidedly in different epidemics and according to the age. The mortality is greatest in children under two years of age, but has been lessened in cases in which the anti- toxin treatment has been thoroughly used. In the acute stage death may occur either from laryngeal stenosis or by the toxin generated from the growth of the bacillus. In the later stages or during convalescence it may be due to the action of the toxin on the nervous centres. Thus paral- ysis of the pneumogastric nerve with obstinate vomiting and heart failure is a frequent cause of death, occurring during apparent convalescence. ±68 PEDIATRICS. The symptoms which make the prognosis especially unfavorable are the extension of the membrane to the naso-pharynx or the larynx, profuse nasal discharge, marked septic odor, extensive glandular enlargement. hemorrhage from the nose or into the skin, a high grade of albuminuria, broncho-pneumonia, and a weak heart. Morse, in an extensive study of the leucocytosis of diphtheria, has shown that it has no prognostic value. In cases of post-diphtheritic paralysis the prognosis is good, as they almost invariably recover. The prognosis in all cases of diphtheria is uncertain and should be given with caution, and no case of diphtheria should be considered benign, for at times in certain mild cases serious symptoms of paralysis may arise, and death from heart failure is liable to occur at any stage of the disease. A child who has had diphtheria is liable to suffer from the deleterious effects of the disease for months and even years. Before antitoxin was used the mortality from diphtheria in the City Hospital was 50 per cent. Since its use in a series of 4500 cases in the diphtheria wards of the Boston City Hospital the mortality has been reduced to 13 per cent., and when the moribund cases, which numbered 179. by which are meant those dying within twenty-four hours after ad- mission to the hospital, are deducted the mortality was about 10 per cent. Prophylaxis. — All patients with diphtheria should be isolated until the Klebs-Loeffler bacillus has disappeared from the nose and throat. The time when this occurs varies from a few days to a number of weeks. In order further to protect the community, all cases of sore throat should be examined, and if the Klebs-Loeffler bacillus is found the patient should be isolated. It is especially necessary to carry out this precaution in schools. Avhere the conditions are so favorable for the spread of the disease. The throats and noses of all persons exposed to diphtheria or caring for chphtheritic patients should be repeatedly examined for the Klebs- Loeffler bacillus, and if this is found they should be given immunizing doses of antitoxin, the amount and frequency of the doses to be modified as our knowledge increases. If the Klebs-Loeffler bacillus is found in these individuals, they should be isolated so long as the bacillus is pres- ent. To shorten the period of isolation, mild antiseptic gargles or douches should be employed. It is very important to keep the teeth in good con- dition as a prophylactic- measure, as well as the mucous membrane of the •nose and throat. Whether the isolation of healthy persons who have the Klebs-Loeffler bacillus in their throat or nose is advisable or not is still a mooted question. Much confusion has arisen because of the so-called pseudo-diphtheritic bacillus. The weight of evidence at present, however. goes to show that it does not exist, and that the bacteria described are merely Klebs-Loeffler bacilli of diminished virulence. At any rate, even if the pseudo-diphtheritic bacillus exists, it is so rare that it may be safely excluded in clinical work. The fact that the Klebs-Loeffler bacilli found in healthy throats may not be virulent is not an argument against SPECIFIC INFECTIOUS DISEASES. 469 isolation, because it is well known that a non-virulent form may become virulent when transferred to a different soil. Examinations of many healthy throats have shown that the Klebs-Loeffler bacillus is a very rare inhabitant of the normal throat, and that when it is present diphtheria often develops later. Theoretically, therefore, although it may be impos- sible or inadvisable practically, it would seem wise to consider the Klebs- Loeffler bacillus virulent until it has been proved to be non-virulent, and to consider its presence a source of danger to the community until it is proved not to be. When an individual has been exposed to the contagium of diphtheria, immunization can be accomplished by the injection of antitoxin in doses varying according to the age. Thus, at six months the immunizing dose for infants is 300 units, and for older children 400 units. The immuni- zation lasts for from twenty-eight to thirty days. The length of time before a child Avho has had diphtheria may cease to be a source of contagion should be determined by three consecutive negative cultures from the nose and throat with twenty-four or forty-eight hour intervals. The greatest care should be taken both by the physician and the nurse not to become infected themselves by the secretions from the mouth and nose of the patient. Especial care should be taken to avoid getting these secretions into the eyes. It is probable that with extreme care there is not much danger of the spread of diphtheria in a household, as we know its tendency is not to disseminate itself in the surrounding atmosphere, hence it is likely that with proper precautions it can be confined to the room in which the child is sick, and that if the epidemic extends beyond this room it has been carried directly by the hands or clothing of the nurse or physician. The room should be cleared of hangings and all stuffed furniture, car- pets, and clothes. The hands of the attendants should be disinfected. No handkerchiefs should be used ; pieces of cotton cloth, which can be destroyed by fire, are to be preferred. Discharges should be disinfected with carbolic acid 1 to 200 ; mattresses, blankets, and utensils should be steamed. The floors and woodwork should be washed with corrosive sublimate 1 to 500. Books and toys should be destroyed, as there is no way of disinfecting these articles. Upholstered furniture should be im- mersed in boiling naphtha for two or three hours. The boiling-point of naphtha is 79.4° C. (175° F.), and is lower than the melting-point of glue. The vapor of formaldehyde is one of the most valuable germicides. Gen- eral disinfection of the room is described in the disinfection of scarlet fever, page 562. Pure air and plenty of sunlight are the most effective germicides. It is important to isolate doubtful cases, especially when the symptoms are associated with a profuse nasal discharge. Treatment. — The treatment of diphtheria consists (1) in attending to the hygiene and to measures directed to the general condition ; (2) in the 470 PEDIATRICS. administration of remedies, either by the skin or by the mouth, to combat the toxin which is producing the constitutional symptoms ; (3) in local applications to the nose, throat, or larynx ; and (4) in operative measures to relieve obstruction in the larynx. General Hygiene. — One of the most important parts of the treatment of diphtheria is the management of the room in which the patient is kept during the progress of the disease. It is known that pathogenic organ- isms, such as the Klebs-Loeffler bacillus, do not thrive where* they are exposed to sunlight and fresh air. The room should therefore be thoroughly ventilated, and fresh, pure air should be allowed to come continuously into it. It should also be one which has a sunny exposure. Stimulation. — In any treatment directed to the cure of diphtheria in young children, we must remember that the disease is so exhausting that the treatment, as a rule, should be forced upon the child as little as possi- ble. Any physical exhaustion produced by the treatment is to be con- sidered serious in young children. Diphtheria is such a depressing dis- ease that alcohol should be given from the onset, and the amount should be relatively large. Either whiskey or brandy are valuable stimulants. For a child, one or two years old, it is well to begin with 7.50 c.c. (2 drachms) every four hours, watching the pulse and general condition. When there are indications of beginning heart failure, digitalis is indicated early in the disease, and strychnine later. When there is collapse, nitro- glycerin should be given. Atropine is recommended as sometimes giving great relief when much mucus collects in the air-passages. The following table has been arranged to show the small and large doses of digitalis, strychnine, nitro-glycerin, and atropine, which may be used at different ages : TABLE 63. Age. Tincture Digitalis. Strychnine. Nitro-Glycerin. 1 per cent. Solution. (1 minim = T ^ grain.) Atropine. Minims. Grain. Minims. Grain. 3 months. xVto 1 2TT0 ^° TooT 75 tO A 3000 to -JJQ-Q- 6 months. iVto f 1 to 1 T3T TO 500 25 tO T V 2500 LU TTOT 9 months. I tol 1 to l 1000 bw 300 25 tO T V TT5T tO yi-Q- 12 months. i toll 1 to l TO 0" LO 2"5T 3fV tO | TToT tO -g-Q-^ 2 years. 1 to 2 500 l0 TT0 1 to 1 T5 I0 3 1 to 1 3 years. l to 3 tot to Too TO tO 1 TEST to 2^(T 4 to 10 years. 1 to 5 1 to 1 2 00 l ° TO 1 to | 270 tO T i 7 10 to 12 years. 3 to 8 T7o t0 To 1 tol 1 to l 200 LU ToT Serum- Therapy. — The treatment which, according to our present knowledge, is most efficacious in diphtheria, is essentially comprised un- der what is called serum-therapy. SPECIFIC INFECTIOUS DISEASES. 471 By serum-therapy is meant the treatment of the disease by injecting into the patient the serum of an animal which has been rendered immune to the special disease which is being treated by means of inoculation with the toxin of that disease. The serum taken from the animals which have been rendered immune to diphtheria has been called the antitoxin serum. The serum can be injected under the skin. The place selected should always be one on which pressure is not exerted when lying in bed. The dose of antitoxin serum of diphtheria should be from 1000 to 3000 units, according to the age of the child and the severity of the disease. McCollom prefers the use of from 2000 to 4000 units. The unit is the same in all reliable preparations. The beneficial results of antitoxin are decidedly greater if the injec- tion is made in an early stage of the disease than if later, although even when administered late in the disease it sometimes produces wonderfully curative effects. When given early, within the first forty-eight hours of the disease, even when the membrane is spreading rapidly, and inflam- mation of the glands with general systemic poisoning has taken place, one injection will often arrest the disease. When improvement does not take place within six or eight hours, a second dose, and if necessary a larger one should be used. Thus, if the dose was 2000 units, after eight hours a second dose of 2000 or 3000 units should be given, the latter in the more severe cases. In these very severe cases even much larger doses may be given and at shorter intervals. The signs by which Ave know that the antitoxin serum has produced a beneficial result, are indicated by the improvement in the general con- dition of the patient, and the effect of the antitoxin on the pseudo-mem- brane, which is characteristic. The dose should, therefore, be repeated if the general condition and the throat do not improve in eight hours. If at the end of twenty-four hours the membrane has not begun to roll up at the edges, and the cervical glands have not diminished in size, and if a profuse nasal discharge with a septic odor is present, a third dose, and perhaps a fourth or fifth dose, may be required. When the antitoxin has produced its characteristic effect, the pseudo-membrane besides rolling up at the edges, ceases to spread, whitens, shrinks, shows a line of demarka- tion, and usually within the next three or four days becomes detached from the mucous membrane. The temperature sometimes rises after the injection of antitoxin, and in a few days falls to the normal by lysis. In the more severe cases a single injection of the serum does not work so quickly. In these cases the temperature falls usually by lysis after the second or third dose, and the pulse becomes normal two or three days after the temperature has fallen. The irregularities of the pulse are not so frequent in diphtheria since the antitoxin treatment has been employed. Antitoxin does not seem to destroy the bacilli in diphtheria, but to 472 PEDIATRICS. have some special action on the tissue-cells. If the cells have been much damaged they do not respond, and this is an argument in favor of the early administration of antitoxin. The antitoxin, however, is not able to combat complications referable to secondary infection. It is not a fact that since antitoxin has been used the type of diphtheria epidemics has been less virulent, as has been suggested. The pains which occur during the course of diphtheria are probably forms of neuritis, and not the result of the antitoxin which has been given. The later forms of neuritis which occur two or three months after the disease has run its course have nothing to do with the administration of antitoxin. The arthralgia and efflorescences which occur during the disease may arise from the antitoxin, but are never serious, and, although the number of cases of neuritis arising in the course of diphtheria since the use of antitoxin is greater than before its use, they are rarely of a severe type, and seldom need cause any great amount of anxiety. Out of one million cases in which injections of antitoxin were given, only five deaths were reported which could be attributed to the effects of the anti- toxin. Albuminuria is one of the most constant symptoms of diphtheria. McCollom had the urine tested in two hundred cases before the adminis- tration of antitoxin, and in only ten cases was the amount of albumin in- creased after the administration of antitoxin, and these ten cases were of a severe type. There was no reason to suppose that the antitoxin had anything to do with the increase in the albumin. It is to be noted that, according to Baginsky's observations, nephritis may occur in mild cases of diphtheria as well as in severe cases. Antitoxin has no influence in preventing the later symptoms of paralysis and cardiac failure, excepting as prophylactic when given early. When there is a concurrent infection the antitoxin serum is less effec- tual, as it does not counteract the toxin absorption due to bacteria other than the Klebs-Loeffler bacillus. It is not safe to assume, however, that there is a concurrent affection because other bacteria are found in the throat. When the larynx is involved, with accompanying stenosis, the antitoxin serum is found to be very valuable, and has reduced the number of operative cases. The antitoxin has been found to have but little effect upon the length of time which the bacteria remain in the throat after the disappearance of the membrane. Antitoxin should be freely used in diphtheria of the eye. The pupils should be dilated with atropine, and the eye irrigated with a 2 to 4 per cent, solution of boric acid. The child, as soon as possible, should be placed in the hands of a skilled oculist. • At the South Department of the Boston City Hospital, in 4500 cases, all of which had on an average at least two injections of antitoxin, no bad results were reported, and one patient had 28,000 units of antitoxin given to him and was discharged well. SPECIFIC INFECTIOUS DISEASES. 473 In connection with the antitoxin treatment no especial drugs given internally by the mouth are indicated. Of course, symptomatic treatment of any kind is not contra-indicated. Technique of Antitoxin Injection. — A sterilized glass syringe should be used, and the needle should be comparatively small. The part to be in- jected should be thoroughly sterilized with corrosive sublimate. A needle previously sterilized by boiling should be plunged into the tissues and the injection made slowly. The place of puncture should then be closed with sterilized gauze and collodion. Local Treatment. — The local treatment of diphtheria consists in thor- ough cleansing of the mouth and nose with warm non-irritating solutions, such as normal salt solution or boracic acid four per cent. All strong and irritating applications to the throat in diphtheria are harmful. The tech- nique of the local applications to the throat and nose is important. The most simple, efficacious, and safe method, and that wmich produces the least discomfort, is by irrigation. The same method — namely, by means of a fountain syringe — should be employed for either the throat or the nose, except that in the former a larger glass nozzle should be used than for the nose, and one which is sufficiently long to pass over the base of the tongue. The method of irrigation as employed in the Boston City Hospital and at the Willard-Parker Hospital in New York is shown in Fig. 114. Fig. 114. Irrigation of the nose in diphtheria. The child should lie on its side, and the water should be made to pass up one nostril and down the other until the stream runs clear. In some cases the child prefers to sit up while the irrigation is done. Ordinarily the irrigation should be used once in two or three hours, perhaps with longer intervals at night. If the child resists this treatment it may be advisable, in order to save its strength, to omit it for a time. This rule ap- 474 PEDIATRICS. plies to all forms of local treatment. A similar method should be used for the throat, and is of great comfort to the patient. In the South Department of the Boston City Hospital irrigation of the throat is the routine treatment, and only in special cases is irrigation through the nose indicated. This is in order to avoid the passage of fluid infected by bacteria into the nasal end of the Eustachian tube, which might produce infection of the ear. Considerable suffering is at times occasioned by the enlargement of the cervical glands. These are best treated with flaxseed or ice poultices. The former, however, has a tendency to produce suppuration, and the latter in most cases is the best. When it is deemed advisable to use inhalations of vapors in stenosis of the larynx the following method may be employed, but it must be re- membered that the child should not be kept in this atmosphere continu- ously, and should be watched carefully to see if it is speedily relieved of the stenosis ; for if it is not, the continuous inhalation of steam in the comparatively small area of breathing-space which exists in the tent that is used for this purpose may of itself be detrimental to the child's re- covery, from lack of sufficient oxygen. When tracheotomy has been performed an atmosphere of steam is especially valuable. Dr. McCol- lom's experience at the South Department of the City Hospital is that the tent need never be used, and that it is better to intubate at once. The tent, as described by Dr. Northrup, who has used it so extensively in the Willard-Parker Hospital in New York, contains about fifty cubic feet of air. To extemporize a tent, a sheet is thrown over supports above the crib and allowed to fall over the four sides of the crib. The main point is to have a fairly large and tight enclosure. The apparatus for furnishing the steam must be free from the danger of upsetting and of setting the tent on fire. When there is a mild form of laryngeal stenosis, steam should be only moderately used, as the debility following a steam- bath is often great. Sometimes the steam will give more relief when it is medicated, but this is now considered very doubtful. Operative Treatment: Intubation; Tracheotomy. — When the antitoxin does not relieve the symptoms of stenosis, and when the progressive dyspnoea is not quickly controlled by steam, it is well not to delay opera- tive interference. In laryngeal stenosis operative interference is de- manded by intubation or tracheotomy. The indications are marked supra-clavicular, sub-sternal, and lateral thoracic retractions lasting for two or three hours and apparently increasing in severity, a cyanotic hue of the skin, either with or without such retraction, great restlessness, dila- tation of the alae nasi, and failure of strength, even if the other symptoms are not increasing or are absent. The folloAving is the technique of intubation : The patient is wrapped firmly in a blanket, so that he cannot move his arms, and then placed in a horizontal position, with the head slightly raised. The mouth is held SPECIFIC INFECTIOUS DISEASES. 475 open by the gag, with its jaws resting on the molar teeth. The gag should be on the left side. Care must be taken not to have the cheek injured by the gag, and special pains must be taken to prevent its slipping. The head should be steadied by the assistant who holds the gag. The operator takes the introducer in the right hand, with the index-finger around the hook on the under surface of the handle, the loop of silk passing over his little finger, and his thumb resting on the button on the upper surface of the handle. The index-finger of the left hand is then passed down to the epiglottis, which is hooked forward ; the tube is then passed into the mouth, with the handle well down on the chest of the patient : when the epiglottis is reached by the point of the tube, the handle should be given an abrupt turn, so as to bring the tube into a vertical position. As soon as the tube is well in the larynx, the button on the handle should be pushed forward, disengaging the obturator, which must now be removed, and the tube pushed into position by the index- finger. The loop of silk is passed about the ear and the gag removed. If the tube is in the larynx, the patient will immediately begin to cough with a peculiar sound, which, to be appreciated, must be heard. If the breathing becomes easier, if the cyanotic hue disappears, if the retraction of the thoracic walls diminishes, if the loop of silk does not shorten, we may be assured that the tube is in the larynx. After becoming satisfied that the operation has been properly per- formed, the gag is inserted a second time, the index-finger placed on the head of the tube, and one strand of the silk loop cut, so that it can be removed. It should be especially emphasized that the finger of the oper- ator must be a continuation of the posterior wall of the larynx, that the turn should be abrupt, and that no force must be used. If the tube is in the oesophagus, no cough will be heard ; there will be no relief in the breathing ; the silk loop will commence to shorten as the tube passes downward. In certain instances intubation does not give relief, and tracheotomy must be done. If the tube becomes clogged by membrane, as is some- times the case, it must be immediately removed. The first steps of an extraction are similar to those of an introduction. The extractor is passed into the lumen of the tube and the lever on the handle pressed so as to open the jaws, and the tube extracted by a reverse of the movements in introduction. Sometimes there is considerable difficulty in extraction, but by patience and gentleness the end can be accomplished. If the child coughs up and then swallows the tube, the accident may cause consider- able annoyance to the physician, yet it is not of serious import, for experi- ence has shown that the tube is passed by the rectum in from twenty-four to forty-eight hours, without causing discomfort. No definite rule can be given regarding the length of time that the patient should wear the tube. It is well to remove it at the end of the third or fourth day, but it is fre- quently necessary immediately to reinsert it. In some instances three or 476 PEDIATRICS. four extractions and introductions may be required. The must favorable cases are those in which the child coughs up the tube at the end of the third day, and does not require reintubation. Relief should come in live minutes. A child which has been intubated needs more careful watch- ing than one in whom tracheotomy has been performed, as the acci- dents following intubation occur more suddenly and are more difficult for a nurse to meet. O'Dwyer's tubes are preferably used at the South Department for the purpose of intubation. Tracheotomy should be performed if. after intubation, relief of the breathing does not come even when the tube has been removed and re- placed again. It is extremely rare for tracheotomy to succeed when in- tubation has failed. Feeding. — After intubation the administration of food is often diffi- cult, and various methods can be employed. (Esophageal feeding is the safest way of administering food, and is one of the important points to be remembered when intubation has been performed. In nasal feed- ing there is considerable danger of producing irritation in the middle ear, not always, however, from the Klebs-Loeffler bacillus. The method of feeding with the head lowered (Casselberry) is not devoid of danger, from the possibility of inhalation pneumonia following inspired particles of food. Nutritive enemata of peptonized milk, with stimulants, may, when retained, be an important adjunct to the treatment. Enemata, however, are not often retained. Digitalis in the enemata may be used in cases in which heart failure is present. Treatment of Sequela 7 ,. In the treatment of post-diphtheritic paralysis strychnine is the most valuable drug. When there is marked palatal paralysis oesophageal feeding is exceedingly important. Electricity, espe- cially faradism, is also indicated. Secondary anaemia should be treated in the usual way, with iron, a carefully regulated diet, and by general hygiene. INFLUENZA (LA GRIPPE). Etiology. — Influenza is an acute, highly infectious disease. According to Leichtenstern, there are two forms of influenza. One form, which is known as epidemic influenza, is a pandemic disease, caused by Pfeiffer's bacillus, and characterized by great rapidity of extension, varying symp- toms, a special tendency to attack the respiratory mucous membranes, an acute onset, a high degree of infection, and a tendency to become endemic during a succession of years after its first epidemic outbreak in a community. The second form is the common endemic or jiseudo-influenza, or catar- rhal fever, the etiology of which is unknown. Incubation. — The period of incubation is short, being usually under four days. One attack does not protect from another. SPECIFIC INFECTIOUS DISEASES. 477 Symptoms. — The onset of influenza is usually very acute, and the symptoms are variable. At times they are the same in children as in adults, but in infants and young children the symptoms are often not so severe as in the adult, although they vary in different epidemics. It is a characteristic of epidemic influenza that it has no distinct group of symp- toms of its own. The symptoms are chiefly a catarrhal affection of the nose and throat, and frequently of the bronchi. These symptoms in young children are accompanied evidently by great discomfort, at times amount- ing to pain, in the limbs and body, although on account of the age of the patient it is impossible to determine whether much pain is present. Sometimes the only marked symptom is a heightened and irregular tem- perature, with marked apathy, and the disease may be so slight as to be recognizable only during an epidemic. In older children the symptoms, although, as a rule, not of so severe a type as in adults, are at times quite serious, especially if continuous vomiting occurs. Severe headache and delirium are present in some cases, and extreme emaciation, out of pro- portion to the fever or to the morbid conditions detectable on physical examination. Severe symptoms connected with the larynx and the lungs may also arise and rapidly disappear. In young infants, even when no complications arise, the apathy and prostration may become extreme, and death take place seemingly from the overwhelming intensity of the infection. In addition to the complications already mentioned, various forms of efflorescences may appear on the skin and render the diagnosis more diffi- cult. There is a tendency to the development of tuberculosis after influ- enza. Relapses and recurrent attacks are not uncommon, and it should be remembered that a reinfection at times seems to take place in the sick- room. Out of a large number of cases in children examined by Schloss- mann, albuminuria occurred in eight per cent., but nephritis was rare. Anaemia is a common sequela in young children. Leucocytosis in un- complicated influenza is not present. The mental disturbances so com- mon in adults and multiple neuritis are not marked sequelae in children. Variations in Type of the Disease. — It is now generally recognized that there are distinct types of the disease. Respiratory Type. — In this, the most common form of the disease, the influenza bacillus may attack any part of the respiratory tract from the nose to the pulmonary alveoli, the symptoms increasing in severity according as the latter are approached. In the milder forms there are the usual symptoms of acute coryza, fever, and headache, but these symptoms are accompanied by a far greater degree of prostration than is met with in the ordinary attacks of catarrhal rhinitis. These milder cases, without complications, may last only a few days ; the temperature is usually mod- erate 38.2° to 39.4° C. (101° to 103° F.), but the prostration is marked. An annoying, persistent cough is commonly present. This form is sometimes much intensified, may last longer, have a 478 PEDIATRICS. higher temperature, and show a greater tendency to complications, espe- cially in the development of otitis media and cervical adenitis. In another set of cases of the pulmonary type, the disease, instead of retrograding steadily, progresses, bronchitis develops, and the accompany- ing delirium and extreme prostration may simulate typhoid. This bron- chitis has no especial peculiarities, but in young children it assumes at tunes a very intense grade, reaching the finer bronchi and producing cyanosis and asphyxia. In certain instances an influenza pneumonia develops, depending either on the Pfeiffer's bacillus or on a mixed infection. This pneumonia is usually lobular, although rarely lobar. Generally, there are small areas of broncho-pneumonia diffusely scattered, and often giving rise to no other physical signs than scattered moist rales. The sputum in these cases. of influenza broncho-pneumonia is never "rusty," but is muco-purulent and generally of a greenish-yellow color. A diagnosis can be made by finding the influenza bacilli in large numbers within the polynuclear leuco- cytes. The resolution of such a pneumonia is prolonged, ending by lysis. This class of cases is very serious, and much of the mortality of epidemic influenza arises from these pulmonary complications. The broncho-pneu- monia is of the ordinary type, although possibly more irregular than in other cases. Pleuritis may occur in the course of influenza, but is rather rare ; when present, however, it is apt to become an empyema. Nervous Type. — In certain cases there may be no catarrhal symptoms but nervous symptoms of the most varied forms. Pains in all parts of the body and limbs, cerebral symptoms simulating meningitis, convulsions, delirium, opisthotonos, symptoms simulating pneumonia without, however, the physical signs of that disease, or a typhoid condition with weak, rapid pulse, a temperature of 40.5° to 41.1° C. (105° to 106° F.), and irregu- larity of the heart. All these severe and alarming symptoms may pass off in two or three days and leave no trace of any of the simulated diseases, although the resulting prostration may last for a long period. Gastro-Enteric Type. — In this form of the disease the prominent symptoms are nausea, vomiting, abdominal pain, diarrhoea, and a ten- dency to collapse. The spleen is enlarged in a certain number of cases, and this, according to Osier, depends on the intensity of the fever. These symptoms may last only two or three days, and, as a rule, are not followed by an unfavora- ble result. Febrile Type. — The temperature in influenza is very variable, and. as stated by Osier, may. with its accompanying prostration, be the only manifestation of the disease. It may be remittent and associated with chills, or. on the other hand, may be of a continued type, and so prolonged as to simulate typhoid fever. Diagnosis. — The diagnosis of epidemic influenza is often difficult, un- SPECIFIC INFECTIOUS DISEASES. 479 less influenza is present in the community, and is to be made by the care- ful elimination of other diseases, and the detection of Pfeiffer's bacillus, either in the secretions of the nose or in the sputum. The profound prostration out of proportion to the intensity of the disease is of great diagnostic value. In the early days of the disease it is often impossible to differentiate from pneumonia, malaria, the acute exanthemata, and meningitis, but later the differential diagnosis is made by the disappear- ance of the especial symptoms of these diseases, and the failure to find their special infecting organisms. The diazo-reaction is absent in influ- enza. Prognosis. — The disease in itself is not dangerous, but complications are especially liable to arise and make the prognosis much more serious. These complications are very numerous. They may be meningitis, otitis, ileo-colitis, broncho-pneumonia, and lobar pneumonia. The most com- mon and dangerous complication of influenza is pneumonia, which is usually a broncho-pneumonia, and is of serious import, especially if the child is debilitated at the time of the attack by some previous disease. The broncho-pneumonia of influenza is of more serious import than that arising from other causes, with the exception of infections due to tuber- culosis or diphtheria. Treatment. — In the treatment of epidemic influenza in infants and children I have found that drugs have very little effect upon the general discomfort caused by the pain or cough. Small doses of phenacetine, 0.06 gramme (1 grain) once in three or four hours, with ten or fifteen drops of brandy, seem to yield as good results as any other mode of treatment. When there is severe and continuous vomiting, small doses of iced cham- pagne by the mouth, enemata of bromide of potassium, and, if neces- sary, hydrate of chloral, are indicated. The child should be kept in bed and isolated. The bronchial and nasal secretions should be disinfected. Stimulants are especially indicated when pneumonia is present, and strychnine is valuable as a heart stimulant. A high temperature, nervous and gastro-enteric symptoms, should receive the appropriate treatment as in other diseases. When the convalescence is prolonged, especially if the case has been one of the pulmonary type, or when there is a tendency to tuberculosis or to a recurrence of the attack, a change of climate is decidedly indicated and is frequently beneficial. The diet should be milk and beef tea. Careful feeding is very important after an attack of influ- enza, as there is often left a tendency to infantile atrophy. During the epidemic of influenza which occurred in Boston in 1891 I had under my care at the Infants' Hospital seven infants, varying in age from a few months to one and a half years, all of whom had epidemic influenza. Pneumonia occurred in two of the cases, and in both of these the infants died. The following charts (Charts 13 and 14) show the tem- perature of these cases during the course of the disease, and the rise when the infants were attacked with pneumonia. 480 PEDIATRICS. CHAETS 13 and 14. Influenza. Pneumonia. Da V s °f Disease Influenza. Pneumonia. IF. 1 2 3 4 6 1 2 3 c. 107° 106° 105° 104° 103 102° 101 100 99° NORMAL TEMP. 98° 97° o 96 95 M E M E M E M E M E ME M E M E M E M E ME ME M E ME ME ME M E M E M E M E M E 41.6° -s: 3 Q 40.5° 40.0° 39.4° 38.8° 38.3° 37.7° 37.2° 37.0° 36.6° 36.1° 35.5° 35.0° / -^ / Vxl ^ J / / / 7 L V y\ / r A / / / ' [ 1 / / / LJ r r 1 Infantile atrophy. Epidemic influenza. Pneumonia. Male, 4 months old. Previously healthy. Epidemic influenza. Pneumonia. Female, 3 months old. CHAET 15. 1 Influenza Days of Disease Pneumonia F. 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 11 12 13 C. 107 106 105 104 103 102 101° 10O 99 NORMAI TEMP 98 97° 96° 95° M EJM E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E 41.6° 41.1° 40.5° 40.0° 39.4° 38.8° 38.3° 37.7° 37.2° 37.0° 36.6 36.1° 35.5° 35.0° / / / / V / 1 / / \t / / / t ( / / k k r f \ \ ' Epidemic influenza. Pneumonia. Recovery. Male, 16 months old. Another case of influenza was complicated on the eleventh day of the disease by a lobar pneumonia. The infant, sixteen months old, was attacked with catarrhal symptoms of the nose and throat, a slight cough, and a temperature of 40.5° C. (105° F.). The respira- tions were only slightly increased ; the pulse was rapid. Nothing abnormal was found on physical examination. The infant was very fretful, had no appetite, cried inces- SPECIFIC INFECTIOUS DISEASES. 481 santly, and seemed to have considerable discomfort. On the ninth day from the onset of the attack the temperature fell to 39.1° C. (102.5° F.), and on the following day to 38.6° C. (101.5° F.). On the evening of this day the infant, who had begun to be brighter and to notice its playthings, again seemed very sick. Its respirations in- creased in frequency, there was motion of the alae nasi, and the temperature rose to 40.8° C. (105.4° F.). On the following day the temperature fell in the morning, but began to rise in the evening, and by the next day had reached 41.0° C. (105.8° F.). On this day. the thirteenth from the beginning of the attack and the third from the fresh invasion, marked flatness was detected in the right lower back, with bron- chial respiration and increased tactile and vocal fremitus. This area of flatness in- creased, and finally involved the whole lower lobe of the right lung. On the fourth day of this new invasion the temperature fell to 38.8° C. (102° F.) ; on the following day it rose to 39.7 C. (103.5° F.) in the evening, and in the next two days gradually fell to 37.2° C. (99° F.). On the following day it rose to 38.6° C. (101.5° F.), and in the next forty-eight hours fell gradually to 36.6° C. (98° F.). At this time the dulness began to disappear, moist rales appeared, the infant became much better, and in a few days, although very weak, seemed bright and well, and the physical signs in the lung had entirely disappeared. Chart 15 shows the temperature during ten days of the influenza, when a lobar pneumonia appeared and ran a course of five days, after which the temperature gradu- ally fell to the normal point. It is possible that this case was one of pneumonia from the beginning of the attack, but it showed all the characteristic symptoms of epidemic influenza, and no flatness was found in the lung until the infant had apparently re- covered from its influenza. MALARIA. Malaria is an infectious disease, transmitted from an infected human being by means of mosquitoes of the genus anopheles to another human being. There may be other sources of infection not yet determined. Etiology. — The specific infection of malaria is primarily shown in the blood in the form of certain micro-organisms which, like the amoeba coli, belong to the class of protozoa and inhabit the blood of the infected indi- vidual. The micro-organism of malaria has not been found in any part of the body except in the blood and within the blood-vessels, and malaria may therefore justly be said to be a disease of the blood. The work of Ross, Grassi, Bignami, Bastianelli, Daniels, and Koch has shown that the most important and very probably the only manner of infection in malarial fever is through the bites of mosquitoes of the genus anopheles, which, with man, form the regular hosts of the parasite. The malarial parasite, like the coccidia, has been shown to possess both an asexual and a sexual cycle. The sexual cycle takes place in the human body and ends in segmentation, each segment attacking a new red cor- puscle, and beginning again a new cycle as a fresh young parasite. Cer- tain bodies, however, when they reach full development, do not undergo segmentation. These are the large, full-grown, sometimes wrongly called "extra-cellular bodies" of the tertian and quartan parasites, and the crescentic and ovoid forms of the cestivo-autumnal parasite. When a mosquito of the genus anopheles bites an infected human being, certain 31 482 PEDIATRICS. of these forms, the male elements, develop flagella in the stomach of the mosquito. The flagella attack and fecundate the female forms, which penetrate into the muscular coat of the wall of the mosquito's stomach and there undergo development. After seven days these bodies, which protrude from the external wall of the mosquito's stomach, rupture, setting free great numbers of small spindle-shaped structures, which accumulate in the veneno-salivary glands of the mosquito. When such a mosquito bites again, these bodies are introduced. Each one of these is equivalent to one of the segments of the asexual cycle, and is ready to attack a new red blood-corpuscle and pursue a similar cycle. In this country there exist several varieties of anopheles, one of which, the anopheles quadrimaculatus, has been shown by Thayer and Wooley to act as an intermediate host for the parasite. It is not yet settled whether the anopheles can obtain the parasite from other sources than from man, although it seems probable that this is not' the case. The facts which so far have been accumulated in Italy and in this country appear to show that the first cases in the spring and early summer are relapses. With the appearance of mosquitoes of the genus anopheles, which occurs probably in July or August, according to the part of the country, the spread of the disease begins, the fresh cases arising as a result of the transference of the infection from relapses. The disease gradually increases during the season in which the anopheles prevails, only to diminish again with the frosts and the disappearance of this type of mosquito. The ordinary house mosquitoes, which we see in most of our cities and towns, excepting in the very malarious districts, do not belong to the harmful class. They belong to the genus culex. The main differences between the culex and the anopheles are readily made out. In the first place, all the common forms of culex which Ave see have wings free from marking, beyond the ordinary veins. All three varieties of anopheles positively known in this country have spotted wings. The most important and simple distinction, however, is the manner in which these varieties of mosquitoes sit on the wall. The culex sits on the wall with its body parallel to the surface to which it is attached and the posterior pair of legs raised over its back. The anoph- eles, on the other hand, sits with its body sticking out from the wall at an angle of forty-five degrees or greater, with the posterior pair of legs, which are very long, resting against the wall or hanging down. When such a mosquito is sitting on the ceiling he looks often as if he Avere hanging from his proboscis. This distinction is readily made out by any layman. The anopheles and culex are represented in Plate XII.. opposite page 874. A third point is the difference of the mouth parts. The ordinary house mosquito, the culex, has a single long proboscis, at the root of which are tAvo little, short, stump-like processes, the palpi. In the anopheles these palpi are of a length almost equal to the proboscis, so that on superficial examination the mosquito looks as if he had three proboscides. SPECIFIC INFECTIOUS DISEASES. 483 The frequency of malaria in infants and young children, which has been recognized for a good while, has been strikingly brought out by Koch's studies in Java. This frequency is in all probability in part due to the well-known fact that very young children are especially subject to mosquito-bites. A rather interesting point in connection with this is that Koch uses the presence or absence of malaria in infants as an index as to whether a district is or is not malarious. In adults it is always pos- sible that the disease may have been imported. Infants, however, have usually acquired the disease at home. The proportion of cases in infants appears to be greater than at any other age. When, then, the infants are free from malaria, or occasional cases occur among adults, it is prob- ably safe to say that the disease is imported. The germs of this parasite may be contained in the blood-plasma, or in the substance of the erythrocytes. The name plasmodium has been given to the germ found in the red blood-disks. According to Thompson, in acute paludism (malarial fever) the plasmodium is found in the form of amoeboid bodies, occupying a place in a certain number of the ery- throcytes or adhering to them. These bodies derive pigment (melanin) from the erythrocytes, and, after undergoing a certain degree of develop- ment, increase in size at the expense of the erythrocytes. They are found to contain this pigment in distinct granules and rods. They vary in size, and some are as large as the erythrocytes. They are at first colorless and transparent, and at the height of their development they undergo segmentation. This amoeboid form of the parasite is the one commonly found in what is designated as the tertian variety of malaria, and is the most common of all the known forms of the parasite of malaria. In addition to these amoeboid forms, crescentic shapes of the germ, ac- cording to the investigations of Laveran, are common in the blood of certain types of paludism, irregular forms of the disease, and malarial cachexia. Like the amoeboid forms, they are transparent and colorless, except for the pigment granules which they contain in their centres. They are larger than the amoeboid forms, are much more rare, are much less affected by the action of quinine, and are one form of the cestivo-autumnal variety. Councilman describes flagellate bodies as being most commonly found in blood which has been aspirated from the spleen ; and in acute cases of malaria they may sometimes appear in other situations. They exhibit from three to eight vibrating cilia. It is still a matter of dispute whether the plasmodium malaria? is poly- morphous and thus may produce the different types of malaria, or whether there are certain distinctly separate organisms to which the name Plasmodium malarise is applied. There is no doubt that two distinct forms of parasites of malaria can be diagnosticated by the appearance of the plasmodium in the blood, and that these two forms can be separated clinically. 484 PEDIATRICS. Golgi is the investigator who has most clearly shown that there is more than one parasite of malaria, while Laveran is the exponent of the polymorphous theory. The malarial parasite may be most simply and surely found by exami- nation of a fresh unstained specimen of blood. A small drop of fresh blood is placed on a glass slide and covered with a cover-glass, making a very thin layer, and examined with an oil-immersion lens. The slide and cover must be perfectly clean and dry. Dried and stained specimens are only to be used when an examination of fresh blood is impossible. There are definitely three varieties of the malarial parasite, tertian, quartan, and cestivo-autumnal. The sestivo-autumnal is usually associated with paroxysms occurring about forty-eight hours apart ; these paroxysms, however, being considerably longer than those in tertian or quartan fever. Very commonly, however, owing to multiplicity of groups of parasites, the fever is irregular, remittent, or continuous. The relation of these three varieties of malarial parasites to the periodicity of the disease is shown in Table 64, on page 486. The tertian parasite first appears in the red blood-corpuscles as small hyaline bodies with amoeboid movements. It increases in size and de- velops fine, dark, pigment granules, which are in constant motion, due to the amoeboid contractions of the protoplasm of the individual parasites. The red cells which contain them become slightly enlarged and gradually decolorized. Each parasite when fully grown nearly fills the red corpuscle. In the stage of segmentation, which occurs at the time of the paroxysm, fifteen or twenty segments appear, which invade fresh red corpuscles, and begin the cycle again as hyaline bodies. The quartan parasite resembles the tertian, but its amoeboid move- ments are slower, the pigment granules are coarser, darker, and less active, the full-grown organism is smaller, and the red cell in which the organism develops becomes somewhat shrunken about the parasite, and of a deeper, old-brass color. It segments into only five or ten parts. The azstivo-autum.nal parasite is smaller than the others and contains less pigment. The corpuscles containing them become shrunken and brass-colored. About a month after the onset of the attack, character- istic crescentic or ovoid bodies appear, which have coarse pigment granules clumped in the centre. Flagellate forms of the tertian, quartan, and aestivo-autumnal parasites may appear. The segmentation of the organ- ism is always coincident with the paroxysms, and the interval between the paroxysms is characterized by a distinct and early stage of develop- ment of the parasites. The tertian form is the one which is by far the most common in this part of the country, and the one Avhich is most influenced by the admin- istration of quinine, the other form, represented by the quartan, being peculiarly difficult to manage with quinine. In young infants the tertian form in its quotidian variety is met with most commonly. In older chil : SPECIFIC INFECTIOUS DISEASES. 485 dren, in my experience, it is the pure tertian that is most common. It will be noticed, on examining the table on page 486, that the quartan form of paludism can never represent by its intervals and paroxysms the pure tertian form. Pathology. — There are no especial differences between the patho- logical lesions found in the malaria of children and those which occur in adults. According to Thayer, in acute cases of malarial fever, on exami- nation with the microscope, the cerebral capillaries are found to be crowded with malarial parasites. There is usually a marked granular de- generation of the endothelium of the vessels. The spleen is always enlarged, often only moderately. The parenchyma is cyanotic, of a slaty-gray color, and almost diffluent. The pulp of the spleen is found to contain enormous numbers of red blood-corpuscles, many of which contain parasites. Great numbers of white cells are also seen, some of them being necrotic. The capillaries are usually filled with red blood-corpuscles containing the plasmodia, while the splenic veins show relatively few, although they always contain large cells enclosing pigment or the remains of red blood-corpuscles. The liver is swollen and has usually a slaty-gray color. The capilla- ries are filled with leucocytes, which contain numerous pigmented bodies. Relatively few plasmodia are found in the blood-corpuscles in the vessels. Areas of disseminated necrosis similar to those in other acute infectious diseases have been described. The vessels of the kidneys contain relatively few organisms. The glomeruli may be considerably pigmented. There may be marked de- generation of the epithelium of the capsule, and at times changes in the parenchyma, especially areas of necrosis of the epithelium of the con- voluted tubules. The other viscera show no special characteristic changes, except, at times, that of melanosis. Symptoms. — The symptoms of malaria as the disease occurs in infants and young children are much more varied and far more uncertain than those which we are accustomed to meet with in adults. The prominent symptom of malaria being the paroxysm, earlier authors naturally classi- fied malaria according to the time when the paroxyms appeared, using the term quotidian when they occurred with intervals of twenty-four hours, tertian when they occurred with intervals of forty-eight hours, and quartan where they occurred with intervals of seventy-two hours. The term tertian is somewhat misleading unless we understand that it is a word derived from the Latin method of counting the day of the be- ginning of the febrile manifestation as the first day. The terms tertian and quartan, therefore, are simply used empirically to represent intervals of forty-eight and of seventy-two hours between the paroxysms. Again, the terms intermittent and remittent have been used commonly. The in- termittent form is characterized by entire absence of fever between the paroxysms. The remittent form is characterized by the presence of more 486 PEDIATRICS. or less fever of a continued type which does not cease between the paroxysms. These terms should not be used as classifications of distinct types of malaria, as the conditions which they represent may, according to chance, appear in any of the types, and are merely caused by a varia- tion in the behavior of the parasite. In general, in children there is a tendency in all types of malaria towards a deviation from the regular arrangement of parasites in groups, so that even in tertian and quartan fever the regularity of the manifestations appears to be not quite so striking as in adults. According to Koplik, in pure types of paludism, either tertian or quartan, one generation of the plasmodium will be found to predominate. In the cases of tertian variety, when the paroxysms are found to be of daily occurrence, several generations of parasites, each with a different cycle of development, will be found in the blood. The same observation will be found to be true when irregular types of fever with the tertian parasite are carefully examined, and also when the blood in quartan fevers is examined. If more than one generation of parasites exists in the blood in a tertian case, the fever may become quotidian, with daily paroxysms due to the ripening of distinct sets of parasites on different days, each set of parasites taking forty-eight hours to mature. In like manner, in cases of quartan fever, through the ripening of distinct sets of parasites on different days, different combinations occur, according to the number of sets 'of parasites. Thus, while in the form in which there is only one parasite the intervals between the paroxysms are seventy-two hours, in that in which there are two parasites there may be an interval between the paroxysms of only forty-eight hours, and when there are three parasites there may be an interval of only twenty-four hours, thus representing the quotidian chills described by Mannaberg. The following table explains the different types of paludism as they are now understood by the most recent investigators : TABLE 64. The Principal Combinations of Paroxysms caused by the Plasmodium Malarias. Intervals. 1st day. 2d dav. 3d dav. 4th dav. Tertian. Pure tertian ( One parasite. ) Double tertian (Two parasites. Quotidian.) 48 hours. 24 hours. Paroxysm. Paroxysm. No paroxysm. Paroxysm. Paroxysm. Paroxysm. No paroxysm. Paroxysm. Quartan. Pure quartan (One parasite.) Double quartan (Two parasites.) Triple quartan (Three parasites. Quotidian. ) 72 hours. 48 hours. 24 hours. Paroxysm. Paroxysm. Paroxysm. No paroxysm. Paroxysm. Paroxysm. No paroxysm. No paroxysm. Paroxysm. Paroxysm. Paroxysm. Paroxysm. SPECIFIC INFECTIOUS DISEASES. 487 The table explains how the different intervals in the paroxysms are caused by the development of the parasite on different days. It will therefore be understood that it is according as the parasite happens to de- velop that we have a regular or an irregular periodicity. Thus, it may happen that we have two parasites, and these two parasites may develop on the same day, but at different hours. In this case, supposing that they are of the tertian type, two paroxysms may occur on the same day, fol- lowed by an interval of forty-eight hours from the time of the full de- velopment of each of the parasites until this development occurs again. In this way different broods of parasites may cause an almost infinite variety of symptoms. The younger the individual the more likely are the pronounced chills to be replaced by some other symptom, such as vomiting, delirium, and convulsions. The paroxysms come more frequently in children than in adults and in young children a condition of apathy and somnolence, some- times with fever, and sometimes accompanied by coldness of the extremi- ties and a collapsed condition, very commonly replaces the chill of the adult. These symptoms, representing the onset of the disease, may often disappear as the disease becomes established, and in their place we may meet with the symptoms of some other disease, such as bronchitis, torti- collis, and many other affections. The symptoms of these other diseases will often continue and be very intractable until quinine is given, when they will disappear, and thus we shall be led to believe that we have been dealing with one of the masked and misleading manifestations of the Plas- modium malariae, as illustrated by the case described on page 490. The susceptibility of the nervous and respiratory systems in young children to produce variations in the form and type of malaria is most misleading in regard to diagnosis, the symptoms referable to a particular organ often completely overshadowing the real disease, malaria, and pro- ducing an entirely new clinical picture. The symptoms often are so indefi- nite and the disease frequently comes on so insidiously that the physician does not see the case until it has made considerable progress and the diag- nosis is thus much obscured. In addition to the other symptoms, severe pain in the head and some- times in the epigastric region is met with. In the form in which the in- vasion is gradual, the prominent symptoms are anaemia, loss of appetite, and frontal headache of moderate type. The spleen in the majority of cases is found to be enlarged, but the well-known difficulty of detecting an enlarged spleen in young children makes it possible that in many cases there is enlargement of the spleen without our being able to detect such enlargement by percussion or palpation. Splenic and hepatic tenderness, pains in the back, extremities, and neck, and general cutaneous hyperes- thesia are occasionally observed. As the capsule of the spleen is less resistant in young children than in adults the organ seems to enlarge more rapidly and also to subside more quickly in children. 488 PEDIATRICS. The time and character of the onset of the disease and of its parox- ysms are very irregular, so much so, indeed, that it would not be prac- ticable to dwell upon the exact differences which occur from those in the adult. In general, the fever is relatively higher, and the sweating stage is apt to be absent. According to Holt's record of his cases in New York, the onset is acute with vomiting and prostration. The temperature is high, ranging from 40° to 41° C. (104 to 106° F.). The respiration is feeble or harsh over the back of one or both lungs, sometimes with coarse moist rales, and usually a slight increase of vocal fremitus and slight dulness on percus- sion. These signs and symptoms may disappear in the course of a few hours with the fall in temperature, and may recur on the following days until quinine is administered. Bronchitis was found to be the most fre- quent of all the complications occurring in the course of malaria, and again and again proved to be intractable until its malarial origin was dis- covered. Certain of these acute cases appeared to be dependent upon pulmonary congestions analogous in their pathology to the congestions of the spleen and the liver. Pneumonia, both lobar and lobular, was occa- sionally found as a complication of malaria. Spasmodic asthma of ma- larial origin was seen in some cases. These attacks were accompanied frequently by marked splenic enlargement, and were promptly relieved by quinine. The condition of the intestinal tract varies as much as do the other symptoms. Sometimes constipation is present and sometimes diarrhoea, the latter being the more prominent the younger the child. Subacute and chronic forms of malaria occur in children as in adults, characterized by anaemia, splenic enlargement, a low grade of fever, and the presence of the parasites. Diagnosis. — Malaria as it occurs in early life is far more difficult to diagnosticate by its symptoms than when the disease runs the typical course usually seen in the adult. It is the most protean disease which we are called upon to deal with in young children, and it simulates so closely so many other conditions we are likely to meet with that we should always be on our guard, and allow the possibility of the existence of the plasmodium malariae in making a diagnosis in a doubtful case in which a periodicity is noticed in the symptoms. The only rational method of determining whether we are dealing with a case of malaria is by an examination of the blood, which at once settles the question if the Plasmodium is discovered. The parasite can usually be found in a patient who has had little or no quinine, if the blood is thoroughly examined during a paroxysm by a person who has had considerable experience. The absence of leucocytosis in malaria is an important aid in the exclu- sion of chills and fever dependent upon septic processes. Prognosis. — The prognosis of malaria in children is good, provided that the child is removed from the malarial district and is treated with SPECIFIC INFECTIOUS DISEASES. 489 quinine. Relapses occur, even after long intervals of apparent immunity, and the disease can recur a number of times. When a child has been once attacked by the plasmodium malariae it seems to be peculiarly vul- nerable to a second attack of the organism. Prophylaxis. — The value of mosquito-nets from a prophylactic stand- point is significant, and observations in malarious districts during the last year or two strongly support this idea. The fact that a patient with ma- larial fever in a malarious district is a source of danger to those about him is a very important one, the deduction being, of course, that one should insist upon such an individual sleeping under a mosquito-net. The im- portance also of early and thorough treatment of all cases of malaria, par- ticularly relapses in the early malarial season, is evident. In some regions destruction of the mosquito larvae may accomplish a great deal, although much further research is necessary to determine the places in which these particular varieties of mosquito breed. Treatment. — Quinine is the only drug which can be relied upon to eradicate the plasmodium malariae from the blood, and is therefore the only medicine for this purpose which I shall mention. The sulphate or hydrochlorate of quinine may be given to an infant under six months in doses of 0.03 gramme (J grain) : at one year the dose may be 0.06 gramme (1 grain) ; at two years it may be 0.12 gramme (2 grains), and it can be increased up to 0.3 or 0.36 gramme (5 to 6 grains) at five and six years. There is little danger of giving too large doses of quinine to children, as they tolerate the drug very well. The bisulphate of qui- nine is much more soluble than the sulphate, and for this reason is pre- ferred by many physicians. The hydrochlorate of quinine is very much more soluble in water than either of the sulphates, requiring only thirty- five times its own weight of water as compared to eight hundred times its weight when the sulphate of quinine is used. The addition of hydrochloric or sulphuric acid renders the hydrochlorate of quinine soluble in less than its own weight of water, and the sulphate in ten parts of its weight of water. The dose of the hydrochlorate of quinine is the same as that of the sulphate. It is sometimes desirable in very severe cases to get the organism promptly under the influence of quinine. For this purpose the very soluble double hydrochlorate of quinine and urea may be given sub- cutaneously in doses of 0.06 to 0.3 gramme (1 to 5 grains), according to the age of the child. The latest investigations have shown that the plasmo- dium is most sensitive to the action of quinine when it is corpuscular. Hence the quinine should be given shortly before the paroxysm. It has been noticed that the administration of quinine tends to inter- fere with the regularity of the time of the paroxysm, and in this way other variations may occur. If the paroxysm comes earlier in the day than usual, the disease is apt to be of a severe type and to be growing worse, while if the interval is lengthened and the attack is found to come at a later hour in the day than usual, it is a sign that the disease is 490 , PEDIATRICS. amenable to treatment, is of a benign character, and is tending towards recovery. The manner of administering quinine is rendered somewhat difficult on account of the bitter taste of the drug and its insolubility in water. In very young infants, and in fact in the first six or eight months of life, it is well to try the effect of quinine in suppositories. In older infants and in children it can usually be successfully concealed in a small amount of chocolate cream. Quinine should never be given in pill form, but always in capsules or in solution to make sure that it is absorbed. The time for the administration of the quinine does not have to be regulated so carefully as in the adult. The dose should be given three or four times in the twenty-four hours, and one of the doses should be given from four to six hours before the paroxysm, so that the blood-serum shall be charged with the quinine at the time when the young and more sensitive parasites have just broken out from the blood-corpuscle. It is well to continue the treatment with quinine for some weeks after the paroxysms have ceased, as the symptoms often return if the quinine is omitted at once. The anaemia which always accompanies the disease to a pronounced degree should be treated with arsenite of potash, or with some mild form of iron, such as the saccharated carbonate or the tartrate of iron and pot- ash, as described under Secondary Anaemia, on page 896. The following prescriptions, varied to suit the individual, are what I am in the habit of using in cases of malaria : Prescription 74. For an Infant under Six Months. Metric. Apothecary. Gramma. R Quininse hydrochloratis 0J36 R Quininae hydrochloratis gr. vi ; Olei theobromae 11 25 Olei theobromae ^iii. M. M. Ft. suppos. no. 12. Ft. suppos. no. 12. S. — One suppository to be used every 6 bours. Prescription 75. For Older Children. Metric. Apothecary . Gramma. R Quininse hydrochloratis 6 Acidi hydrochlorici dil q.s. Aquae destillatae 60 M. M. Sig. — Teaspoonful once in 6 hours. 00 R Quininae hydrochloratis 5jiss Acidi hydrochlorici dil. q.s. 00 Aquae destillata? 3 ii The following case of an infant, a few days old, was probably one of malaria, but no examination of the blood was made : The infant's mother had malaria during her pregnancy, and some of the manifes- tations of the disease appeared ten days before the birth of the infant. The infant SPECIFIC INFECTIOUS DISEASES. 491 from the earliest days of its life showed symptoms of severe digestive disturbance, characterized by vomiting and diarrhoea, and far beyond what could be accounted for by the lack of equilibrium of the function of the mother's mammary gland. A care- ful physical examination failed to detect anything abnormal in its thorax or abdomen. Observations of the temperature in this case, taken both in the axilla and in the rec- tum, showed that it was of an irregular type, varying from 37.2° to 38.3° C. (99 c to 101° F.) rectal, and that at times in the latter part of the day it rose to 39.4° to 40° C. (103° to 104° F.) axillary. Every day at about 1 a.m. there was a parox- ysm, represented by cyanosis, coldness of the entire skin, both of the body and of the extremities, collapse, and somnolence. These attacks, beginning at the seventh day of life, lasted until the twelfth day, when quinine in 0.03 gramme (J grain) doses, given in suppositories and administered every two hours for seven doses, at once and com- pletely checked the paroxysms. From this time the attacks entirely disappeared, the food was well digested, and the infant seemed perfectly well. The following cases occurred in my service at the Children's Hospital : A boy, nine years old, was admitted on the 13th day of February. He lived in a malarial district until one year ago. He had had a slight cough, anorexia, malaise, night-sweats, and rapid loss of flesh for several weeks. The movements of the bowels were rather irregular. According to his mother's report, he had never before had any symptoms of malaria. The child was pale and emaciated. On physical exami- nation there was resonance over both lungs, and on auscultation a few moist rales and an occasional sibilant rale were heard. The area of cardiac dulness and the sounds Fig. 115. Boy, 9 years old. Enlarged spleen. Plasmodium malarise found in the blood. of the heart were normal. The liver was not enlarged, but the spleen was very much increased in size, the limits of its enlargement are marked in black in Fig. 115. The upper border rose as high as the sixth rib in the axillary line, and extended down into the left inguinal region. The urine was normal. The case represented the tertian form of malaria. The child had never had a chill 492 PEDIATRICS. until 3 p.m. two days after entering the hospital. The chill lasted about one hour, and was followed by sweating. A paroxysm of some kind, represented either by a chill or by a decided rise in temperature with chilly sensations, occurred on the 17th, 19th, 21st, 23d, 25th, 27th, and 29th of February, March 2, and March 4, and on March 6 there was a decided rigor at 4 p.m. On March 8 the paroxysm occurred in the morn- ing at half-past twelve. On the morning of March 10 the paroxysm occurred at about half-past eleven, and was followed by marked sweating. Between the paroxysms the boy appeared to be very well. He had a fair appetite, and gradually gained in weight and strength. On March 10, immediately after the paroxysm, the blood showed the Plasmodium malaria?. The appearance of the blood in this case is shown on Plate XII., facing page 874. The count gave the following results : Erythrocytes 2,935,000 Haemoglobin 36 per cent. Leucocytes 25, 500 A large number of the erythrocytes contained the Plasmodium malaria?. The leucocytosis Dointed towards some complication, but none was at any time discovered. CHAET 16. Days or Disease. F 107° «C6° 105° 104° 103° 102° 101° 100° ■88? 98° 97° 96° 95° 150 140 130 120 110 100 90 80 70 60 50 45 40 35 30 25 20 15 23 24 25 25 27 28 2 9 |30 31 32 33 34 35 36 37 38 39 40 41 [42|43 G 41 6 s 41. I s 40. 5< 40.0* 39.4* 38 a s 38.3' 37.7 s 37.2^ 37 0° 36 6° 36.1* 35.5* M E M E M K MY. 5[ F. Si (Km ■lit t MB *E H F 1 m"e Si E M R M E M r m r H R MF H ME M f. c a li ^ } | I C i c c C \ n V A A A \ f U 1 I / J 1 / v I V 1 / 1/ j "7 s --jf~~ ... u ^V V J \j 1 \ i \ i\1Vv n/ V V 15 - Double tertian forin of malaria (quotidian), (c, chills.) On the day of entering the hospital (the 13th) the child's temperature was raised, but there was no chill. On the following day, the 14th, there was a chill at 4 p.m. On the 15th there was a marked chill, with a considerable rise of temperature. Immediately after the paroxysm an examination of the blood was made with the following result : Erythrocytes 3,396,250 Haemoglobin 30 per cent. Leucocytes 5,000 Plasmodium malaria? present. It was noted that the splenic enlargement was greatest during the chill. On the 16th there was a chill, and the temperature rose to 40.6° C. (105.2° F.), the maximum attained durinsr the course of the disease. SPECIFIC INFECTIOUS DISEASES. 495 On the 17th and 18th the chills recurred. On the 18th 0.36 gramme (6 grains) of sulphate of quinine was given at 12.30 p.m. On the 19th there was no rise in the temperature, and no quinine was given. On the 20th and 21st there were no chills, but a slight rise of temperature, and 0.12 gramme (2 grains) of quinine was given four times daily. On the 22d she had a chill, and the temperature was 40.50 C. (105° F.). For the next sixteen days 0.6 gramme (10 grains) of quinine was given in the course of each twenty-four hours, the spleen gradually growing smaller. As the tem- perature was still irregular, the quinine was then increased to 0.72 gramme (12 grains). The temperature remained normal for three days, and then was again slightly raised and irregular. Two weeks later the quinine was omitted. The following are the records of two infants who apparently were suffering from the effects of the Plasmodium malariae, although no exam- ination of their blood was made : The first one was one year and ten months old. The infant had lived in a mala- rial district until within a few weeks of the time when I saw him. The history which was given to me by his mother was that for several weeks he had had attacks represented by a chill or chilly sensations, occurring every day about noon. These attacks had recurred for about a week or ten days before I saw him. In connection with the chill and the fever the infant usually became unconscious, and its feet and hands were cold and clammy. 0.06 gramme (1 grain) of quinine Avas given to the infant on the 29th of April, and on the following day none of the usual manifestations occurred at noon, but at about 4.30 p.m. he had a chill and a slight rise of temperature, but was not unconscious. 0.03 gramme (^ gram) of quinine was then given, and on the following day, April 30, 0.06 gramme (1 grain) of quinine at 10.30 a.m. On this day there was a decided chill, and the rectal temperature rose to 40.5° C. (105° F.). During the attack the child breathed rapidly ; its feet, hands, and nose became cold, and it was practically unconscious for some minutes until its circulation was restored by injections of warm water and brandy. 0.03 gramme (£ grain) of quinine was then given three times during the twenty-four hours. On the following day none of these abnormal symptoms occurred. On the next day 0.03 gramme (J grain) of quinine was given in the morn- ing and again at night, and this dose was continued for a few days. From this time the symptoms of malaria entirely disappeared, the infant grew less and less emaciated, became stronger, had a good appetite, and continued to thrive. No enlargement of the spleen was detected in this case. The next infant was nineteen months old, and was brought from a decidedly mala- rial district. It had previously been well until three weeks before it was brought to be treated for the following symptoms. At the time when its bath was given to it, which was be- tween 11 and 12 in the morning, it had symptoms characterized by drowsiness and cyanosis, and it would fall asleep, and after about half an hour would wake up bright and well. These attacks, although short in duration, were very alarming and apparently serious, as, although the infant did not have any pain or convulsions, it could not be roused while in the attacks, and became so blue and cold that it was feared that it might die in one of them. At the time of the attacks the rectal temperature varied somewhat, but was usually about 38.3° C. (101° F.). The treatment of this case was with sulphate of quinine, sometimes given by the mouth and sometimes by means of rectal suppositories. After the administration of the quinine for four or five days the attacks entirely ceased and did not return. The infant from that time continued to thrive. 496 PEDIATRICS. TETANUS NEONATORUM. Tetanus neonatorum is an acute infectious disease, usually occurring in infants from the third to the twelfth day of life, and is almost always fatal in two or three weeks. Etiology. — The cause of the disease is the same as that of tetanus in the adult, — that is, the bacillus of tetanus, — and the organism is supposed usually to gain its entrance at the umbilicus. This disease is epidemic in tropical climates, but as we see it is usually of a sporadic nature. Symptoms. — After considerable restlessness and muscular twitching, lasting for some hours, the infant assumes a very characteristic appear- ance. There is extreme rigidity of the legs and body. This rigidity sometimes takes the form of opisthotonos and trismus (rigidity of the in- ferior maxilla). The eyes are almost closed, but the infant is sleepless. The trunk and limbs are so stiff that the infant remains in whatever position it is placed. It is unable to nurse, and has a high temperature, occasionally reaching 40° C. (104° F.), and a pulse of 150 or 160. At times it will have slight convulsive attacks. Prognosis. — It is extremely fatal. When recovery takes place the improvement is very gradual, the temperature and pulse decreasing and the rigidity of the muscles passing away very slowly, with at times a re- currence of the symptoms. Treatment. — The treatment of this disease has thus far been very unsatisfactory. The possibility of successfully treating these cases with the antitoxin of tetanus must be considered ; but the results so far obtained have not been brilliant, and it is doubtful if the cases so treated show a lower mortality than those in whom the treatment has been only symp- tomatic. The form of treatment which appears to me most rational is to place the child during the continuation of the tonic spasm in a warm bath and to give it 0.06 gramme (1 grain) of hydrate of chloral every hour until the effects of the drug are shown by the lessening of the muscular rigidity and by a disposition to sleep. In addition to this treatment, small quan- tities of milk, 15 c.c. (about J ounce), should be given to the infant by means of a dropper every hour, and to each feeding three minims of brandy or some other stimulant should be added. Under this treatment a certain number of cases have been known to live. The following case may be considered as one of the milder forms of tetanus neonatorum : An infant, said to have been healthy at birth and to have nursed without difficulty during the first week of its life, refused to nurse, apparently from inability to open its jaws. It sometimes cried, but feebly. There were no convulsions, no vomiting, and no rigidity in any other part of the body. The temperature was not taken. On physi- cal examination it was found that, although the infant could swallow, the jaw could not be opened wider than 1.2 cm. Q inch). On forcing the finger between the jaws, SPECIFIC INFECTIOUS DISEASES. 497 nothing abnormal was discovered in the mouth or pharynx. The respiration was regular, but rather shallow, and there was no evidence of injury. Nothing else ab- normal was discovered. It was given 0.06 gramme (1 grain) of hydrate of chloral three or four times in the twenty-four hours, and two days later showed marked improvement, with the excep- tion of still being unable to open the jaws widely, nothing else abnormal was discovered. The rectal temperature subsequently became normal, and it finally recovered. ERYSIPELAS. Erysipelas is an infectious disease, caused by the streptococcus pyo- genes. The term is applied to an inflammation of the skin, subcutaneous tissue, and mucous membranes which has the following characteristics. It especially involves the lymph-spaces and lymph-vessels. It has a tendency to spread, and is attended by unusual swelling of the sub- cutaneous tissue and an intense red color of the skin or the mucous membrane. In addition to these local appearances it is accompanied by constitutional symptoms, which are mostly the result of a heightened temperature. The disease runs an acute course, is contagious, enters the individual through some abrasion of the skin or mucous membrane, and is self- limited. Pathology. — The tissues may be swollen by an accumulation of serous fluid, which may be nearly transparent, or turbid from admixture with pus-cells. The pus-cells may infiltrate the tissues either sparsely or in dense masses. Sometimes vesicles are found on the surface, or there may be crusts. At times more or less of the affected region is filled with abscesses or becomes gangrenous. In other cases, aside from the local lesions petechia? are found in the serous membranes, and swelling of the spleen and parenchymatous degeneration of the kidneys and liver. When the mucous membranes are affected they show the same appearances as the lesions of the skin, except so far as these are modified by the different structure of the tissue. The disease may attack the larynx and upper air-passages and result in oedema. Pneumonia may occur as a compli- cation. Although the different organs, such as the spleen, kidney, heart, and liver, at times show pathological changes, nothing characteristic of erysip- elas has been found in these organs, but only such changes as may occur from a continued high temperature or as the result of sepsis. Symptoms. — Erysipelas may be divided into two forms, — migrans, ex- tending from surface to surface, and ambulans, occurring in different parts of the skin. It may also be acute or chronic. In erysipelas migrans, which is the most common form, the whole surface of the body may be attacked. It is very prone to return, passing over the same surfaces of the skin again. The face and head are not so commonly attacked in infants as in adults, and the disease seldom spreads from another part of the body to the head. When it does attack the head, it is apt to be fatal 32 498 PEDIATRICS. from a secondary purulent meningitis. It at times causes great swelling and tension, and may go on to gangrene in certain localities, such as the scrotum. The stage of the incubation of erysipelas lasts, according to Osier, from three to seven days. After the first year erysipelas so closely resembles the disease as it occurs in adults that we need not consider it in this later period of life. It is a somewhat frequent disease in infants up to six months of age. It then becomes less frequent up to the first year, and after that and in childhood is rather rare. I shall, therefore, speak of erysipelas as it affects infants only. The erysipelas of infancy may be divided into erysipelas of the new- born and erysipelas of sucklings. Erysipelas of the New-Born. — When erysipelas occurs before the end of the third week the infant seldom lives, and indeed it is a most dangerous disease up to the end of the third or fourth month. Erysipe- las of the new-born is apt to occur during an epidemic of puerperal fever. If the mother has any septic symptoms, the infant should be im- mediately taken away from her. I have seen a case where the mother had puerperal peritonitis following her delivery, and the infant, who was allowed to nurse her, was attacked by erysipelas. In many cases occurring in the early days of life the disease starts on the genitals, and may be complicated by other diseases, such as empyema and especially pneumonia. During the course of the disease the fonta- nels sinks, the spleen is enlarged, convulsions may occur, and peritonitis accompanied by vomiting may arise as a complication. The disease is liable to invade the tissues at any point of abrasion, whether from the forceps or from vaccination, or at the point of separation of the um- bilical cord. The latter is the most common locality for the infection to take place. From this point the infection may extend and produce a gangrenous condition of the stomach or abdomen. Although the temperature in the early hours or even days of the disease may not be raised, yet, as a rule, fever soon appears, the temper- ature varying from 39° to 41° C. (102.2° to 105.8° F.). Reddening and swelling, not of a high grade at first, appear on the part affected. The infants show symptoms of a general sepsis. Vomiting frequently occurs, followed by collapse and. almost without exception, by death. Treatmext. — The treatment of this severe form of erysipelas is by stimulants and a substitute food adapted to the infant's digestion. Erysipelas of Sucklings. — When the disease occurs in the early months of life, its beginning is usually accompanied by cold extremities and collapse. The temperature is raised, and the higher its degree the graver the prognosis. The temperature curve, as a rule, is intermittent with considerable morning and evening variations, except in the more severe forms, in which there is continued high fever : in the latter cases icterus is apt to develop. SPECIFIC INFECTIOUS DISEASES. 499 The efflorescence, although very similar to that which is seen in the adult, differs somewhat on account of the more delicate structure of the infant's skin. It begins as a faint erythema, which spreads rapidly and as quickly disappears, sometimes within twenty-four hours, and twenty- four hours later desquamation may occur. The light color of the efflo- rescence soon becomes darker and more intense, and is accompanied by swelling, heat, and tension of the subcutaneous tissue. After the efflo- rescence has continued for a certain number of days, depending upon the amount of the surface of the skin involved, the extension of the disease ceases and the temperature falls. The redness gradually disap- pears, and the skin becomes covered with yellowish-brown crusts. Finally, desquamation takes place, and the skin recovers its normal appearance, the disease extending over a variable period according to the greater or less extent of the surfaces invaded. Although the disease when involving large surfaces is dangerous, yet cases in the later months of infancy recover even when the attack has been a severe one. An instance of this kind came to my notice in which an infant ten months old was attacked with erysipelas, the point of infec- tion being the right labium. In this case the whole vulva shortly became very tender and the disease extended to the pubes and abdomen. It invaded every part of the body and extremities and the head and neck. The eyelids and lips were the last points of attack. Even the palms of the hands and soles of the feet were affected. From the time that it ap- peared at one part of the body until the skin of that part assumed its normal color again was four days. When the erysipelatous inflammation extended to the feet there was marked oedema. The duration of the attack from its first appearance at the vulva to its disappearance at the eyes and mouth was about fifteen days. The infant was treated with small doses of iron and quinine, and recovered entirely. Treatment. — Xo treatment of which I know is of any avail in cutting short the disease in early life. According to Dr. J. C. White, the exten- sion of the efflorescence in adults can be controlled and the attack frequently aborted by the continuous application of the following wash : Prescription 76. Metric. Apothecary. Gramma. R Acidi carbolici (xtals) 3175 R Acidi carbolici (xtals) ~i ; Alcohol, Alcohol, Aquye aa 240> Aquaa aa 5 viii. Where large surfaces are affected, the application of cold compresses tends to depress the vitality of the infant, which it is so important to sus- tain. During the height of the disease the infant's strength should be supported by stimulants and by the frequent administration of a food adjusted to its digestion. Plate X.. facing page 610, represents the typical efflorescence of the erysipelas of sucklings as it occurred in a female infant six months old. 500 PEDIATRICS. It had always been healthy, and was nursed until within three weeks of the time of entrance, when it was weaned from the mother and nursed by another woman. It was of normal weight and general development. The first symptoms which were noticed were vomiting and a temperature of 39.5° C. (103. 5°F.) in the axilla. It seemed weak and languid, looked badly, and refused to take the breast. An examination of the breast-milk showed a peculiar green color, which not only appeared in the milk when drawn from the breast, but also, when the analysis was made, appeared in the curd resulting from the precipitation of the pro- teids. The analysis of the milk was as follows. The nature of the micro-organism which produced the green color was not determined. Fat 4. 56 Sugar • 6.36 Proteids 3.46 Mineral matter 0.13 Later in the day a pink efflorescence appeared just above the pubes. and there was found to be considerable irritation in the neighborhood of the vagina. The red- ness extended from the vagina to the suprapubic efflorescence. The efflorescence was CHA"RT 18. Daj/s o/ \Dlsgczsg F 107° 106°' 105° 104° 103° 102° 101° 100°' 99° TEKVP. 98° 97° 96° 95° 5 6 7 8 |9 10 II | 12 13 14 15 16 17 18 19 20 21 22 23 24 25 c 4l6 d 41. L° 40.5° 40.0° 39.4° 38.8° 38.3° 37.7° 37.2° 37.0° 35 6° 36.1° 35.5* 35.0° II E M E a e U E H E !>I E M E ME H E M E U E a e M E VI E H E H E a e M K M E H E y: l _4 A, 7 V V J 1 Z_ Y~ L— / / ,/ r u I .__ — — — .... — — --- - ~K~ T 1/ 1 [\ I V i Erysipelas of leers. Female, 6 months old. of an erythematous type. On the following day it spread to the left thigh, and then to the left lower leg. The temperature continued to be raised, and the infant refused to nurse. Small quantities of a substitute food with the following percentages. which had to be varied from day to day. were given to it : Prescription 77. Fat 2.50 Sugar 6.00 Proteids 1.50 There were no convulsions or other symptoms, but the infant lost somewhat in strength and weight and its face looked pinched. SPECIFIC INFECTIOUS DISEASES. 501 The efflorescence on the left leg began to fade on the ninth day of the disease, and on the tenth day the temperature became almost normal. On the following day, however, it again rose, and a fresh efflorescence began to appear on the right thigh continuous with the efflorescence of the suprapubic region. This efflorescence ex- tended down the right leg to the ankle. On the twelfth day the skin of the left leg was in some places almost normal, in others was covered by thin brownish-yellow crusts. The suprapubic region and the right leg as far as the ankle were covered with a bright red efflorescence sharply bounded by normal skin below, just above the ankle, as though it were a stocking. The whole leg was swollen, was hotter to the touch than the sound skin, and presented a somewhat raised, glistening appearance. No external applications and no drugs were employed in this case. The milk was carefully modified, and small doses of brandy were given. A few days later the temperature became normal, the efflorescence began to fade, desquamation subsequently took place, and the skin finally recovered its normal ap- pearance. The infant gradually regained its strength, became perfectly well, and had no return of the disease. Chart 18 shows the temperature during the course of the erysipelas in this case. This form of erysipelas may become chronic, and this is more apt to occur in children than in infants. It is also most common in children who are in a debilitated condition, and may occur at intervals of three or four years. It is in older children frequently connected with chronic in- flammations of the Schneiderian membrane, and in these cases is peculiarly intractable to treatment. AMCEBIC ILEOCOLITIS. [Synonyms. — Tropical or Endemic Dysentery). — Etiology. — The later researches of Flexner and others seem to point towards the fact that there are at least two forms of tropical dysentery. One form, the bacil- lary. is as yet sub judiee, while the other, the amoebic, has been established as a specific infectious disease, caused by a well-recognized organism called the amoeba coli. The amoeba coli is an animal micro-parasite belonging to the group of protozoa. The disease is of rare occurrence in children, and is very infrequent in northern climates. It is seen for the most part in the tropics. A common source of infection is by means of drinking-water. Pathology. — Amoebic ileo-colitis has its own definite anatomical lesions, which consist of round, oval, or irregular ulcers, the edges of which are infiltrated and undermined, so that individual ulcers may be connected by submucous sinuses. Amoebae are found in the lesions and in the intestinal discharges. The large intestine is more commonly the seat of the disease, especially the caecum, hepatic and sigmoid flexures, and the rectum. The disease may advance by progressive infiltration of the connective tissue of the intestines, giving rise to large sloughs. In the same manner the liver may become infected, producing lesions in the nature either of local necroses of the parenchyma or of abscesses, which may be single or multiple. Cultures taken from the abscesses are generally sterile, but the 502 PEDIATRICS. amoebae may be in the walls of the abscesses. Similar abscesses found within the lungs are a result of direct extension from the liver through the diaphragm. Symptoms. — The disease is usually acute in its onset, but sometimes it may be gradual. The duration may be two or three months. The diar- rhoea at first may be transient and trifling in character, but in the severe gangrenous forms is abrupt and intense. The course of the disease is irregular. The diarrhoea is characterized by exacerbations and remissions, and progressive loss of flesh and strength. The fever is moderate, and in some cases is absent. Nausea, vomiting, abdominal pain, and tenderness are usually only present in the severer forms. The stools present a variety of appearances ; they are generally watery and mixed with mucus, and sometimes with blood, but in the intermissions and convalescence are formed. The amoebae, with their characteristic movements, may be found when the stools are fluid, but rarely if they are formed. Diagnosis. — There are no especial symptoms by which to distinguish this form of ileo-colitis from other forms of ileo- colitis, which are de- scribed on page 820. and the only positive proof of the existence of the disease is the presence of the amoebae in the discharges. Prognosis. — The prognosis is very unfavorable. Recovery is slow. The anaemia and weakness delay convalescence, and relapses are com- mon. An involvement of the liver generally leads to a fatal issue. Treatment. — The treatment which has been followed by the most favorable results is, in addition to frequent and thorough irrigation of the intestine, injections of solutions of sulphate of quinine (1 to 5000). This treatment, however, affects only the amoebae which are in the intestine, and not those which are embedded in the tissues. The anaemia should be treated as described on page 896. The diet should be carefully regu- lated and adapted to the age of the individual. Milk, beef-juice, egg albumin, and broths should constitute the principal food, and in the con- valescence it is necessary to exercise especial care in the management of the digestion. CHOLERA INFANTUM. Cholera infantum is an infectious disease caused by a specific organ- ism not yet discovered, and characterized by acute gastro-enteric disturb- ance with intense choleriform symptoms. The term cholera infantum should be exclusively restricted to this class of cases, and should not be used to designate the many acute and serious attacks of vomiting and diarrhoea which are so often designated cholera infantum. It is a rare disease. Etiology. — The organism which has been found most commonly in cholera infantum is in the proteus group. The disease occurs in the first two years of life, and in its development is probably closely associated with the food, for it has been noticed that infants who are fed exclusively SPECIFIC INFECTIOUS DISEASES. 503 on pure and sterile foods, such as breast-milk, are not liable to be attacked by it. It is also significant that the disease occurs only in hot weather. Pathology. — The pathology of cholera infantum has not yet been satisfactorily determined, but it seems to be a non-inflammatory disturb- ance of the whole gastro-enteric tract, without any gross lesion beyond a desquamative catarrh, and sometimes hyperemia of the mucous membrane. Symptoms. — The onset of cholera infantum may be sudden, but, as a rule, it is preceded by some form of gastro-enteric disturbance, which, by causing an irritation of the mucous membrane, renders the infant vul- nerable. When, however, the disease has once gained a foothold, the development of the symptoms is very rapid. After a variable but generally short period of restlessness and ap- parent abdominal discomfort, the infant begins to vomit. The vomiting is either accompanied or quickly followed by profuse diarrhoea. After the stomach and intestine have been emptied of the food which may happen to be in them at the time of the onset, the vomitus and the diarrhceal discharges are chiefly serous ; and it is this watery consistency of the discharges which especially characterizes the disease. As a rule, the dis- charges are odorless, and consist of serum mixed with epithelial cells and many bacteria. Although the disease is more likely to attack weak and debilitated infants, yet it often attacks those who are healthy and robust. It may run its course to a fatal issue in from twenty-four to forty-eight hours. The extremities soon become cold, the skin is pallid or even cyanotic, and the face pinched. The abdomen may be a little distended, but is soft, and soon becomes rather retracted. The pulse is rapid and difficult to count. The respirations are somewhat quick and superficial. The temperature of the entire surface of the body is low, but the deep rectal temperature is high, 39.4°, 40°, or 40.5° C. (103°, 104°, or 105° F.). The thirst is great and is a very prominent symptom. The fonta- nelle very soon becomes depressed. The urine is very scanty and some- times suppressed. It is concentrated, highly acid, almost always contains albumin, and often casts and blood, and nervous symptoms, such as twitching of the arms and great restlessness, are present. Rapid emaci- ation takes place, and all the symptoms increase in severity. At first the infant whimpers, but soon it becomes listless, falls into, a stupor, or may have convulsions. The infant may die in this stage, which closely re- sembles the algid stage of cholera Asiatica. The disease appears to be self-limited, and if the infant survives the first two or three days a crisis comes, the skin becomes less cool and of a better color, the vomiting and diarrhoea grow less frequent, and finally it is left with a slight amount of simple diarrhoea and occasional vomiting. These symptoms may become chronic, in which case the infant finally dies of exhaustion or from an attack of one of the other gastro-enteric diseases, to which it is left very susceptible. Diagnosis. — The diagnosis of cholera infantum is not difficult if the 504 PEDIATRICS. characteristic symptoms are borne in mind ; these are rapid onset, con- stant vomiting, frequent serous discharges, intense thirst, high rectal temperature, low surface temperature, collapse, depressed fontanelle, sudden loss of weight, and distressed, restless expression, suggesting speedy death, all developing in from twenty-four to forty-eight hours. Prognosis. — The prognosis is bad. The more violent the attack, the higher the temperature, the less the vitality, and the warmer the weather, the worse is the prognosis. When the infant has survived the very acute symptoms which appear in the first two or three days, the prognosis is much more favorable. Treatment. — Cholera infantum is so formidable in its attack that it must be treated most energetically if we hope to succeed in saving the infant's life. The indications for treatment are (1) to assist the effort which nature is making to free the stomach and intestine from the poison which is in them ; (2) to restore the surface circulation, which is so seriously in- terfered with ; (3) to supply water to the tissues, which are being drained to so grave an extent ; and (4) to support the strength until the disease has run its course. The poison seems to act with especial virulence on those portions of the economy where it is most concentrated, — namely, the stomach and the intestine. We therefore have at first extreme irritation of these parts, which causes increased peristalsis, and later vasomotor paralysis, with great transudation of serum. This condition of the gastro-enteric tract is to be especially borne in mind during the whole course of our treatment. In this disease we should not attempt to use any remedy which works slowly. The condition of the mucous membrane is in all probability such that absorption of drugs does not take place readily. The adminis- tration of drugs is, therefore, contraindicated, for they may later, when absorption is being restored, prove fatal by their cumulative action. During the acute stage of the disease the digestive functions fail to act, and therefore food of any kind will be only an additional source of irri- tation. Early in the attack, and when the vomiting has not caused much prostration, the stomach should be thoroughly washed out with warm water and the intestine should be irrigated. If the rectal temperature is very high, ice-cold water may be used for irrigation. When the vomiting has continued for some time and there is prostration with great thirst, the infant should be allowed to suck sterilized ice-cold water from the bottle. At first nothing else should be given by the mouth. The infant should be placed at once in a warm pack. This should be done by wrapping it to the chin in sheets wrung out of water at least as hot as 38° C. (100.4° F.). It should then be enveloped in a hot blanket. This procedure should be repeated as often as the infant shows signs of collapse or much cyanosis and coldness of the skin. This is the best method that I know of to restore the surface circulation. In extreme SPECIFIC INFECTIOUS DISEASES. 505 rases the subcutaneous injection of normal salt solution can be tried. Care should be taken not to introduce in fifteen minutes more than :37.5 c.c. (1 drachm) for every pound of the child's weight. While the infant is in the hot pack, water can be given freely by the mouth, and, if necessary, small and frequently repeated doses of stimu- lants, unless they appear to excite vomiting, in which case they should be given hypodermically. If the vomiting and diarrhoea continues to be excessive after this treat- ment, small doses of morphine, 0.0006 gramme ( T ^ grain), and atropine, 0.00008 gramme (jio grain), for an infant a year old, can be tried hypo- dermically. The effect should be carefully watched, and the dose re- peated if necessary. If, after the vomiting and diarrhoea have ceased, the heart's action continues very weak and does not respond to stimulants, small doses of digitalis should be given. The greatest caution should be employed in using drugs, however, as they generally do more harm than good. If an absolutely fresh and sterile milk can be obtained, it can be used as a food, as in any of the other forms of gastro-enteric diseases which I have already described, but for some days the percentages of the elements in the milk must be much lessened, and the child's strength must be sup- ported mostly by stimulants freely diluted with sterilized water. CHOLERA ASIATICA. Cholera Asiatica is a highly infectious disease, caused by the comma bacillus of Koch, which manifests its most violent symptoms in the gastro- enteric tract. Its symptoms very closely resemble those of cholera in- fantum. The disease in infants should be diagnosticated from cholera infantum by finding the comma bacillus in the vomitus or in the dis- charges. There are no especial differences between cholera Asiatica in the adult and the same disease in the infant. It is exceedingly fatal during infancy and childhood, and young infants who are attacked by the disease during a cholera epidemic seldom live. The treatment is the same as that which has just been described for cholera infantum. PERTUSSIS. Pertussis (whooping-cough) is a highly infectious disease, affecting the respiratory tract, characterized by periods of spasmodic coughing, suc- ceeded by a prolonged inspiration and accompanied by a peculiar sound called the "whoop." Etiology. — The cause of pertussis is probably a micro-organism, but this organism has not yet been definitely determined. Zusch found in twenty-five cases peculiar small bacteria in the sputa. They were sometimes seen in clumps, or masses, or in leucocytes. They were more numerous in uncomplicated cases, while when marked bron- 506 PEDIATRICS. chitis or pulmonary complications supervened they diminished in number and were replaced by other organisms. This, according to Wright, seems to indicate that the organism does not infect the lungs. It is described as a short, small-sized bacillus, which grows on ordinary culture media. Animal experiments with the bacillus have so far given no positive re- sult. Koplik, Czaplewski, and Hensel have also described a bacillus in the sputum which may possibly be the specific organism, but its connection with the disease is still open to doubt. It is supposed that the contagium can be carried by a third individual, but usually it is directly communicated from one person to another. This contagium is probably contained in the expectoration, and in this way the disease may become a source of infection. The disease com- monly occurs in epidemics during the winter and spring. Sporadic cases occasionally appear, and in large cities the disease is often endemic. Per- tussis seems to have some especial relation to measles, as children with the latter disease are liable to contract pertussis, and in like manner those with pertussis are liable to contract measles. Children with pertussis are also especially vulnerable to the tubercle bacillus. Pertussis may occur at any age, but it is especially apt to attack the very young infant, and the disease has even been known to be contracted in utero. One attack usually protects from a second. Debilitated children with catarrh of the respiratory tract are more subject than others to the contagium of pertussis. Ixcubatiox. — The period of incubation is not definitely known, but is estimated at from one to two weeks. The disease may be transmitted from one patient to another from the beginning of the catarrhal symptoms. Pathology. — There are no pathological lesions distinctive of uncom- plicated pertussis. The condition which characterizes the paroxysmal at- tacks is extreme congestion of the different organs, such as the meninges, the lungs, the heart, and the kidneys. In grave or fatal cases the lesions are those which arise either from mechanical accidents, as emphysema or hemorrhage in various parts, as the eye or the meninges, or from such complicating diseases as broncho-pneumonia with its accompanying bron- chitis and atelectasis. The bronchial nodes are often found to be en- larged. An examination of the blood generally shows an early and marked increase in the white corpuscles in which the lymphoid cells predominate. Symptoms. — It is customary to divide the disease into three periods, — the catarrhal stage, the spasmodic stage, and the stage of decline, but any such differentiation is arbitrary and inexact, as all three periods overlap to a considerable degree. The symptoms in the beginning, and often for several weeks, are simply those of a bronchial catarrh with a slight rise of temperature and a cough which, although sometimes spasmodic, is often indistinguishable from that of an ordinary bronchitis. After a period varying from a few days to two or three weeks, the cough becomes more severe and of a more decidedly spasmodic character, and the peculiar SPECIFIC INFECTIOUS DISEASES. 507 whoop which characterizes the disease appears. The cause of these paroxysms seems to be a spasm of the larynx. This is accompanied by a feeling of suffocation. The paroxysm begins with a number of short, spasmodic, expiratory coughs, succeeded by a long-drawn inspiration and by the peculiar whoop. During the paroxysm, especially in severe cases, the face and mucous membranes become cyanotic, the eyes protrude, the conjunctivae are congested, and the child looks as though it would die of asphyxia. After a few seconds the child, with a convulsive cough, expels some tenacious mucus, and is then relieved, or the attack returns again, and again subsides, and the symptoms of asphyxia pass away. These paroxysms are often followed by vomiting. They may occur only four or five times in the twenty-four hours, or again much oftener, — at times thirty, forty, or fifty times. At the onset of the attack the children are usually very much frightened, and either run to the mother or nurse for aid, or go to some part of the room where they can be undisturbed during the attack. In certain children, after the severe paroxysms have lasted for some time, a small ulcer is formed on the frsenum of the tongue, from being driven against the edge of the lower teeth during the paroxysms. During the course of the paroxysmal stage of pertussis it is quite common to have subconjunctival hemorrhages ; rarely deeper-seated hemorrhages take place in the meninges and in the deeper parts of the eye. In pro- tracted cases petechiae sometimes appear in the skin. Epistaxis may also occur. Examinations of the chest during the attack have shown that the pul- monary resonance is lessened during the expiratory stage and is clear during the prolonged inspiration. The auscultation usually shows dimi- nution or absence of the respiratory murmur. Bronchial rales are heard occasionally. Koplik has noticed an increase in the area of the relative cardiac dul- ness during the paroxysmal stage of pertussis, which is often accompanied by a slight blowing murmur limited to the apex of the heart. This may well occur from the engorged condition of the right side of the heart, which subjects the heart to a great strain and may thus result in dilata- tion. The heart-sounds are apt to be irregular during the paroxysm, and in protracted cases during the intervals the pulse is often irregular and accelerated, while the respirations are not especially increased unless some complication has arisen. In severe cases of pertussis the kidneys are sometimes congested, as shown by the appearance in the urine of albumin, casts, and blood-cells. Sugar has also been frequently found. After the disease has lasted for some weeks there is usually a certain amount of oedema of the face, especially under the eyes. The paroxysms are precipitated by nervous excitement or by an irritation in the throat or the respiratory tract, such as may result either from swallowing or from the inhalation of dust. The stage which is accompanied by the whoop and the more exaggerated paroxysms commonly lasts for three or four 508 PEDIATRICS. weeks or even longer. The paroxysms then become less severe, and, although the cough continues, the whoop gradually becomes less frequent, and after three or four weeks ceases entirely. When uncomplicated, the duration of the disease is usually three or four months. Slight changes in the atmosphere or exposure will give rise to a relapse. The relapses, however, are not, as a rule, of a severe type, and in these cases the cough seems to arise from renewed irritation of the sensitive mucous membrane of the respiratory tract rather than from a fresh infection by the specific germ. A persistent cough following an attack of pertussis may sometimes be caused by an insidious form of broncho-pneumonia. Fig. 11 Fig. 117 represents a child during a paroxysm of coughing in pertussis. She had just begun to cough, had become decidedly cyanotic, and was aiding the expiratory effort by bending forward and placing her hands on her knees at the moment the photo- graph was taken. The period of infection is supposed to last for a certain time after the whoop has ceased, and if the cough continues it is well to allow for a period of infection of three weeks after this cessation. It is possible, however, that the whoop may occasionally occur for long periods after the child has ceased to be a source of infection to other individuals. Complications. — The complications which arise in pertussis are usually of a grave nature. The dangers from hemorrhages, unless in the form in which they occur in the meninges, are not great. The complication of SPECIFIC INFECTIOUS DISEASES. 509 broncho-pneumonia is very serious, and often fatal. The especial suscep- tibility of these cases to the development of some form of tuberculosis, especially a tubercular broncho-pneumonia, renders the stage of con- valescence or decline one which demands most careful observation. Severe and even fatal emphysema may occur in pertussis. Convulsions may arise not infrequently in infants and end fatally. They are usually caused by general reflex disturbance, by cerebral con- gestion, or by some cerebral lesion. Spasm of the glottis may also very rarely cause death in greatly debilitated children. Excessive and obsti- nate vomiting at times becomes a serious complication, and may reduce the child's strength to a point which often gives rise to a doubt as to its recovery. It is an especially grave complication in infants who are already much debilitated. Grave intestinal complications are liable to occur, especially in the summer, and a pronounced atrophic condition is not uncommon when the disease is at all prolonged. Diagnosis. — The diagnosis of pertussis cannot, as a rule, be made until the child whoops. Sometimes, however, when another child in the family has undoubted pertussis, a spasmodic cough may allow the diag- nosis to be made before the whoop has developed. It is probable that a child may have pertussis without at any time developing the whoop. In doubtful cases an examination of the blood in reference to the presence of an increased white blood count consisting largely of lymphocytes may aid in making the diagnosis. In some children a simple catarrhal laryngitis will simulate pertussis quite closely ; but, although in these cases there are paroxysms of spas- modic coughing, a pronounced whoop does not occur, and the symp- toms do not progressively increase and last for a long period. The diag- nosis of pertussis can usually be made by the swollen aspect of the face, the paroxysmal cough followed by the expulsion of tough mucus and vomiting, and the long duration of the attack. Prognosis. — Pertussis is a very serious affection in young infants, and also in older children who are debilitated or poorly cared for. When it is complicated it is one of the most fatal diseases which occur in early life. When it occurs in older children the prognosis is favorable, pro- vided that they have previously been well and strong, that they are well cared for, and that no complications arise. In some cases young infants, if their vitality is unusually good, and if they are carefully nursed and made to take a sufficient amount of food, show remarkable powers of resistance during attacks of pertussis. A case of this kind that came under my care was that of an infant five months old. In March she suffered from an attack of epidemic influenza, which lasted about twelve days, and from which she finally recovered. She was then attacked with measles, and after the temperature had fallen to the normal point she was taken with pertussis. After two or three days the cough increased in severity, and after two weeks the infant began to whoop. The attack lasted for two months, and she finally 510 PEDIATRICS. recovered. During the whole course of the disease she took over 600 c.c. (20 ounces) of modified milk in the twenty-four hours, and for a short time small doses of brandy were given. No drags were administered. The temperature varied from 37.2° to 37.7° C. (99° to 100° F.). Prophylaxis. — Pertussis is so highly contagious a disease, and may be so serious an affection in certain children, that a rigid prophylaxis should be enforced. It is the duty of those who take care of children with per- tussis to see that they are isolated during the whole course of the disease. Treatment. — In the treatment of pertussis we must take into con- sideration the age of the individual, the stage of the disease, and the pres- ence or absence of complications. In the early months of life, after the disease has lasted for a week or ten days and has become more severe, the infant will usually show symptoms of general circulatory disturbance. The great strain thrown upon the heart during the paroxysms quickly affects the general strength of the infant, a marked interference with its nutrition soon appears, it loses in weight, and often refuses its food. At times it will become somewhat cyanotic even between the paroxysms, and there is danger not only from the severity of the paroxysm, but also from the vitality of the infant, which may be so much interfered with as to prevent its recovery. In cases of this kind the nursing is of the utmost importance. The infant should never be left alone, should always be taken up whenever a paroxysm is approaching, and should be assisted in appropriate ways until the paroxysm is over. Holding the infant in dif- ferent positions, sometimes bending the head and body forward at the end of the paroxysm so as to aid by gravity the expulsion of the tenacious mucus, is desirable. At times, also, the finger covered with a thin cotton cloth can be quickly introduced into the throat and the mucus Avithdrawn in this way. It is of the utmost importance that the infant should be surrounded continually by fresh air. For this purpose two rooms should be used, if possible, one of which should have all the windows thrown wide open, so that the air can be completely changed before the infant is brought into it, and the patient should be alternately taken from one room to the other, the temperature of the rooms being kept as equable as possible. The nutrition of the infant is so easily affected that the utmost atten- tion should be paid to the administration of the food. Small quantities of a milk carefully modified to suit its digestion should be given at frequent intervals, preferably after the occurrence of a paroxysm, as it is then more likely to retain the milk in its stomach a sufficient length of time for it to be absorbed before the next attack. The amount of food which the infant retains in the twenty-four hours is an important factor in the treatment. In infants of from six to twelve months at least 600 to 750 c.c. (20 to 25 ounces) of milk should be taken and retained in the twenty-four hours. When the amount is lessened to 360 or 450 c.c. (12 or 15 ounces), the SPECIFIC INFECTIOUS DISEASES. 511 infant's nutrition, as a rule, suffers to such an extent that unless this amount can be increased a fatal issue is likely to result. Stimulants, in the form of brandy or whiskey, should be given early in the attack. When the cyanosis is a prominent feature and the pulse is irregular and intermitting, small doses of digitalis should be given, adapted to the age of the child, as in Table 64, on page 486. In these cases, also, the administration of oxygen is a valuable adjunct to the treatment. At the height of the attack, when the paroxysms are severe and espe- cially frequent at night, the burning of cresoline in the room at night is sometimes beneficial. In the milder forms of the disease which are not accompanied by the more severe symptoms just enumerated, belladonna or atropine often proves valuable. There is no drug, however, which is a specific for pertussis at any age. For older children whose health has previously been good, there is no especial treatment, except that they should have as much fresh air, free from dust, as possible, and that food should be given them after they have vomited. When complications arise, the treatment is that of the complicating disease. In cases which are protracted, a change of air, either to the country or to the sea-shore at suitable seasons, is often followed by an apparent shortening of the duration of the attack. In some cases, even in older children and where no complications are present, the attack of pertussis may be so severe as to prove serious. Northrup reports the case of an infant, under one year of age, wiio died during a violent paroxysm in pertussis, and in whom the autopsy showed extensive vesicular emphysema with great distention of the walls of the alveoli. The following case occurred in my practice : A boy, six years old, had had pertussis for five weeks. For two weeks previous to my seeing him the cough had been so frequent and so constantly accompanied by vomiting that the child had been unable to retain any food. He was very much ema- ciated, and was so weak that he could not stand. This condition lasted for a week or ten days : he then began to improve, and finally recovered entirely. There were no complications. ACUTE INFECTIOUS OSTEOMYELITIS. Acute infectious osteomyelitis is an acute arthritis attended by sup- puration at the joints. It has been described under various other names, such as acute arthritis of infants, acute purulent synovitis of infants, acute epiphysitis, and pyaemia of the bone. Etiology. — Nichols has shown that acute infectious osteomyelitis is an acute inflammation of bone due to any one of a number of patho- genic organisms, hence osteomyelitis is not a specific disease, but belongs to the group of septic pyaemias. The staphylococcus pyogenes aureus is the organism that most commonly produces the disease. An early period 512 PEDIATRICS. of development and the exanthemata predispose to osteomyelitis. Trau- matism must be recognized as an exciting cause. Pathology. — In infants the disease commonly originates from a septic infection of the umbilicus or pharynx. The process attacks the bone- marrow primarily, and the joints become secondarily involved if the process originates or extends to the end of the bone and is not limited by the shaft. The joint infection may come either from separation of the epiphysis, which is wholly or in part intra-capsular, or from a growth of pyogenic organisms along the blood- or lymph-channels of the epiph- ysis, frequently setting up an osteomyelitis of the ossified portion of the epiphysis and spreading thence into the joints. The two affections, therefore, represent different phases of bone infection, rather than different diseases of the bone. The morbid process sometimes involves the entire structure of the bone, including the periosteum. Osteomyelitis begins as a hyperemia of the bone-marrow. Later, suppurative foci of a dull-yellow or grayish color appear, while in severe cases the entire marrow becomes purulent and the Haversian canals of the cortical portion become filled with pus. Metastatic abscesses and thrombosis of the veins of the marrow may follow. When the infection enters the joint the cartilage is softened and destroyed and an abscess is formed. Osteomyelitis may, however, be the cause not only of a sup- purative but of a simple inflammation of the joint. Symptoms. — The onset is sudden and sometimes marked by a chill. There are severe constitutional symptoms of fever and intense pain usually sharply localized. The part affected is swollen, reddened, and tender, and if a joint itself is involved, the swelling which is at first tense soon becomes fluctuating. From the beginning of the disease the signs of sepsis are manifest by the high intermittent fever, rapid pulse, pronounced leucocytosis, and great prostration. In exceptional cases these severe constitutional symptoms may not be present. In rapid cases death may occur in three or four days, but the disease is generally pro- longed for one or two weeks. Diagnosis. — The differential diagnosis is to be made chiefly from articular rheumatism, from which it is to be distinguished by the sur- rounding soft parts being much less involved and the general symptoms much more severe in osteomyelitis, and, if the disease occurs in the first two years, by the rarity of rheumatism at so early a period. From tuberculosis, osteomyelitis is to be differentiated by the slow onset of the former and the primary lesion generally showing itself in the shaft of the bone in the latter, while in the former the epiphysis is usually first attacked. The process of osteomyelitis may, however, attack the epiphysis and extend to the joint. The presence of a leucocytosis in osteomyelitis is also of great aid in the diagnosis. Prognosis. — The prognosis is very unfavorable unless immediate and radical surgical interference is carried out. PLATE VII. Osteomyelitis of the lower end of the femur, with spontaneous fracture. Boy, 9 years old. A, lower end of upper fragment ; B, upper end of lower fragment ; C and D, portions of cortical bone which have been sequestrated, and were subsequently removed by operation ; E, callous tissue. Tumor albus of three years duration in a girl of 6% years. The destruction of bone tissue is mainly confined to the external half of the epiphysis cf the femur and to the adjacent portions of the diaphy- sis. A, subcutaneous cheesy abscess, communicating with the diseased area of the bone ; B, probably a sequestrum surrounded by necrotic tissue ; C, shows enlargement and squaring of epiphysis of tibia, as comx>ared with the normal, indicating congestion and proliferation before absorption of the bone tissue has begun. SPECIFIC INFECTIOUS DISEASES. 513 Treatment. — The treatment is essentially surgical. Where osteomye- litis of the shaft of a long bone is found at operation, all of the affected portions should be removed, even if a considerable portion of the shaft is taken, experience having shown that new bone will soon form, and that a serviceable limb is the usual result in the leg and forearm. Prevention of septic infection of the umbilical cord, and of the wound after the cord has fallen off, is important as a matter of prophylaxis. The following case came under my observation at the Infants' Hospital : An infant, one month old, was admitted to the hospital November 16. The parents, who were Italians, were seemingly healthy and had one other child, a girl, who Avas also reported to be healthy. One week previous to entrance, what was described as a "red rash" appeared on the abdomen and spread down the left leg. It lasted about four days. Two nights previous to entering the hospital the .infant had cried seemingly from pain on movement of the legs. There had been some dis- charge of pus from the umbilicus which had never healed. The infant appeared to be well nourished and of good color, with no abnormal appearances, excepting that the umbilicus had not healed, and also that the lower third of the left thigh was swollen so as to be twice as large as the right thigh, and that the skin in this region was red and shiny. The left leg was held stiffly and somewhat flexed, the knee being bent almost at a right angle, and both in front and over the anterior tibial group of muscles and over the calf there was a brawny feeling without fluctuation or localized tenderness. On the day following entrance, the brawny infiltration was less extensive. The temperature, however, remained over 40° C. (104° F.). On November 19, a vertical in- cision was made from the inner side of the head of the tibia about four inches down- ward. This revealed a tibial abscess under the periosteum, which was separated for two inches both in front and behind. The cartilaginous epiphysis was separated and freely movable, and the bone of the shaft was red, rough, soft, and covered with small bleeding points. The upper two inches of the shaft were removed, revealing what ap- peared like hard, healthy bone. A counter-opening was made in the calf, and after irrigation a sterilized dressing was applied. The temperature continued between 39° and 40° C. (102.2° and 104° F.). On changing the dressing in the afternoon, the lower surface of the upper epiphys- eal cariilage looked gray and opaque, but at the next dressing several bleeding points were seen in the epiphysis and the wound looked well. A swelling had suddenly appeared over both malleoli, and an incision let out some greenish pus. A small area of the bone was curetted at this time. Some hours later a swelling appeared over each wrist, which was drained by two incisions, one over each styloid process. No communication was found with the bare bone. The skin was found to pit on pressure, and to be slightly reddened over the biceps. On the following day, November 22, the infant was found to be jaundiced. Fluctuation appeared and the arm was freely opened from the coracoid process to the elbow. An opening was also made at the posterior border of the deltoid, as pus was discovered along the long head of the biceps. The shoulder was then irrigated and drained. The cultures which were taken from each of these abscesses showed no growth excepting the one from the tibia, where staphylococcus aureus was found in abundance. It was afterwards noted that this growth had not been found elsewhere because the oven where the cultures had been baked had been overheated. On the following morning the hand and arm were blue, cold, and swollen. No 33 514 PEDIATRICS. pulse could be felt, and the tissues in the wound were almost black. The child died nine days after the first symptom pointing to an affection of the bone. The autopsy was made three hours after death, and was interesting in that it showed no abscesses which could not be traced to multiple osteomyelitis. There was almost entire absence of pathological changes in the viscera. A separation of the epiphysis had occurred at the lower end of the left tibia and fibula, the upper end of the left femur, the lower end of both radii and ulnae, and the upper end of the right humerus, with softening of the bone and pus. No thrombi were found in the right axillary vessels, the whole right arm to the wrist being swollen and discolored, and on cutting into it a red serous fluid flowed out of this phlegmonous inflammation. Cul- tures from the heart's blood, kidneys, and liver showed no growth, but from the hip- joint and tibial marrow there was an abundance of pure staphylococcus aureus, and from the phlegmonous arm a faint growth of streptococci. Blood-serum was the cul- ture medium. The case showed a rapid septic infection confined to the bone-marrow and bone of the shafts. Several long bones were affected, unaccompanied by any inflammation of the lymphatic glands or of the internal organs. Pure cultures of staphylococcus aureus were obtained from the left tibia and hip, and as there was no discernible difference in the appearance of the three bones, it is probable that the same micro-organisms had existed in all the inflamed bones. The streptococcus infection of the arm was probably due to accidental inoculation at the time of the operation. The shoulder- and hip-joints contained pus, but the knee and wrist escaped. This is to be explained by the anatomical relation of the epiphysis to the capsule of the joint. When the epiphyseal line reaches within the joint-capsule pus can reach the joint whenever the epiphysis is separated by suppuration, and this rela- tionship existed in the hip- and shoulder-joints. In the wrist the capsule is inserted into the epiphysis of the radius and ulna, and not into the shaft, so that pus to reach the joint has to perforate the cartilaginous epiphysis. This is more difficult than when the suppuration can pass directly from the epiphysis into the joint. The same is true of the upper epiphysis of the tibia, for the capsular ligament of the knee does not cross the epiphysis but is inserted into it, therefore, when separation occurs, the pus burrows under the periosteum, but does not break into the joint. RHEUMATIC FEVER. Rheumatic fever (acute articular rheumatism) is an acute infectious disease, non-contagious, affecting usually a number of joints, and showing a tendency to inflammation of the endocardium and pericardium. Etiology. — The cause is unknown, but there is such an intimate rela- tion between articular rheumatism and endocarditis, a disease which has been proved to be of bacterial origin, that the disease is now considered to be produced by some specific organism. Tonsillitis is such a frequent initial symptom that it is possible that it may be the point of entrance of the infection. Although acute articular rheumatism may occur at any age, it is very rare in infancy, and comparatively rare in early childhood. The subacute attacks, characterized by a moderate heightening of the temperature and milder symptoms, may occur in children, and are more apt to be complicated by endocarditis and pericarditis in childhood than in adult life. They may last for many weeks and finally become chronic. Exposure to dampness, to cold, and to sudden and great changes in tern- SPECIFIC INFECTIOUS DISEASES. 515 perature are important predisposing causes. One attack predisposes to another. The symptoms are so varied and so similar to those of a septic infec- tion, as evidenced by the character of the fever, the involvement of the serous membranes, the tendency to relapse, the sweats, and the leucocy- tosis, that it corresponds closely to the type of an acute infection. Pathology. — There are no lesions which especially characterize the pathology of the disease. According to Osier, the affected joints show hyperemia and swelling of the synovial membranes and of the liga- mentous tissues. There may be a slight erosion of the cartilage. The fluid in the joint is turbid, albuminous in character, and contains leuco- cytes and a few fibrin flakes. An extensive effusion into the joint is, how- ever, uncommon. Pus is very rare in uncomplicated cases. The blood usually contains an excessive amount of fibrin. In the secondary rheu- matic inflammations, such as pleurisy and pericarditis, various pus organ- isms have been found, possibly the result of a mixed infection. Symptoms. — The onset of the disease is usually acute, and is charac- terized by loss of appetite, fever, swelling, tenderness, and redness of one or more joints. Pronounced redness and swelling of the joints are not so marked as in adults. The temperature and pulse are usually moderate, although in the beginning of the attack, following the rule of acute infec- tious diseases, a sudden rise of temperature to 39.4° to 40° C. (103° to 104° F.) is not uncommon. The pulse and temperature soon fall several degrees in the course of the disease, and then gradually become normal, unless some complication arises. As the disease progresses the tongue becomes coated, although not especially dry. The urine is diminished, high-colored, and very acid. On cooling it deposits urates. The chlorides are diminished. A characteris- tic symptom is profuse and acid sweating, having a sour odor. Later in the disease, if the sweating is persistent, the perspiration, according to Osier, may become neutral or alkaline. The mind is usually clear. The joints are apt to be invaded successively, the joint first affected sometimes becoming decidedly less painful and swollen as the next joint is involved. The child presents a picture of dread, fearing that the attendants will touch or try to move it ; in fact, any change in the posture necessitating motion of the affected joints is strenuously objected to. Anaemia de- velops with great rapidity, and a marked leucocytosis is present. The dis- ease runs a varying course of from three to six weeks, unless complicated by some other disease. In some cases an endocarditis may appear before the development of the rheumatic symptoms. Delirium occurs not infre- quently in cases of rheumatic fever, and may often be traced to the toxic effects of overdoses of the salicylates. Complications. — The most frequent complication of articular rheuma- tism in children is endocarditis. The onset of the complication is usually characterized by precordial pain, rise of temperature, and, on physical 516 PEDIATRICS. examination, a soft-blowing systolic murmur of mitral origin. Although hsemic murmurs may develop in the course of acute articular rheumatism, yet the organic murmur of endocarditis is so much more common that its presence should be looked upon as a possible grave lesion in every case, and the heart should be carefully examined at each visit for the purpose of detecting a murmur as soon as it is perceptible. In some cases the endocarditis begins very insidiously without noticeable symptoms referable to the heart, and in children there is a special tendency to dilatation. Next to endocarditis the most frequent complication is pericarditis, which begins with a pericardial friction-rub, usually under the middle or upper part of the sternum, with pain and precordial distress, and later with the usual mechanical symptoms of dyspnoea and orthopncea, as de- scribed under pericarditis. The disease is often associated with endo- carditis, but does not usually occur at so early an age as endocarditis, the middle period of childhood being most prone to the disease. Especial mention should be made of the delirium connected with pericarditis. When a pericarditis is accompanied by effusion, the fluid, in children, is especially likely to be purulent. Of the other more rare complications can be mentioned myocarditis, pneumonia, pleurisy, and peritonitis, also certain cerebral complications usually associated with hyperpyrexia and represented by delirium, coma, and convulsions. The relation between chorea and rheumatism is stated on page 917. Various forms of erythema appear in the course of rheumatism. A rather uncommon symptom in this country, although seemingly more frequently met with in England, is the development of small subcuta- neous fibrous tumors attached to the tendons and fasciae in any part of the body or limbs. They seem to be closely associated with rheumatism, are especially frequent in children, and are connected with rheumatic endocarditis. Diagnosis. — The diagnosis of rheumatic fever is made by the presence of the characteristic symptoms of high fever of acute onset, followed by localizing symptoms in one or several joints of redness, swelling, tender- ness, marked pain on motion, and leucocytosis. The disease is to be differentiated from several affections which closely resemble it. From Acute Osteomyelitis. — The diagnosis is made principally by the greater intensity of the localizing symptoms, the involvement of the epiph- yses or the shaft of the bone, rather than the joint, and the presence of more pronounced constitutional symptoms in osteomyelitis. Moreover, there is less tendency to a multiple affection of the joints. From Multiple Secondary Arthritis. — Infections of the joints may occur in connection with gonorrhoea, scarlet fever, dysentery, and cerebro-spinal fever, but the differential diagnosis can usually be made without diffi- culty by the course of the symptoms, the tendency to involve but one joint, and the recognition of the disease in which the arthritis occurs as a complication. SPECIFIC INFECTIOUS DISEASES. 517 Prognosis. — The prognosis of rheumatism in children is very favor- able, unless complications arise, in which case it depends upon the severity of the complication. Endocarditis and pericarditis make the prognosis especially grave, as rheumatic attacks are liable to recur, and at each recurrence the cardiac lesions show a tendency to become more pronounced and serious. Treatment. — The child should be kept in bed, and made to wear soft flannel night-gowns so fashioned that they can be changed with as little disturbance as possible, and fresh gowns should be put on as often as severe sweats occur. It is desirable that patients should sleep between blankets in preference to sheets. Milk is beyond doubt the most appro- priate diet. The thirst can be satisfied by lemonade, or oatmeal- or barley- water. Soups and broths may be used to vary the milk-diet. There are no drugs which act directly upon the disease, either to shorten its course or prevent its serious complications. For the relief of pain, however, the salicylates are especially valuable. They should be given in fairly large doses, 0.3 gramme (5 grains), for the first twenty-four hours until toNic symptoms, such as slight disturbance in hearing and ringing in the ears, are produced, or until the pain has subsided. When the pain is once under control, small doses of the salicylates three or four times a day will usually keep the patient comfortable. With the fresh involvement of another joint, an increase in the quantity of the salicylates may be needed temporarily. The ammonium salicylate is perhaps the most useful preparation. Salol, salicin, and oil of wintergreen (two to four minims) may be tried. The alkaline treatment is often effective, and may advantageously be combined with the salicylates. Ten or fifteen grains of the citrate of potassium in two or three ounces of water, and the addition of thirty grains of bicarbonate of soda with a half-ounce of lemon-juice, makes an agreeable effervescent drink. This may be given every three or four hours until the urine is slightly alkaline, and then in such quantities as to keep the reaction just perceptibly alkaline. Phenacetine in small doses, 0.06 to 0.12 gramme (1 to 2 grains), guarded with stimulants, may be used to control exacerbations of pain when it is not desirable to increase the salicylates. Especial attention should be directed to the heart, and its complications treated symptomatically. The local treatment of the joints, in the acute stage, consists in the application of hot laudanum fomentations for the relief of pain. The weight of the bedclothes should be kept off the affected joints by means of a cradle. When the pain has subsided, the joints should be wrapped in cotton-wool. When the process has become subacute or chronic, great improvement, as evidenced by diminution in the swelling, stiffness, and pain on motion, often follows the application of dry heat for an hour every day or several times a week. This may best be applied by the ovens especially adapted for the purpose. The disease will generally run a course of from four to six weeks. 518 PEDIATRICS. during which time the patient should generally be kept in bed, and care be taken to maintain an equable temperature in the room. Owing to Fig. 118 1 4 R4 V Acute articular rheumatism. Adult type of disease. Male, 3% years old. the tendency to a recurrence of the disease, it is often advisable to re- move the child to a warm, dry climate during the cold and unsettled weather which prevails in the winter and early spring in the North. The following cases illustrate rheumatic CHART 19. DAYS OF DISEASE F. 4 | 5 i 6 | 7 I 8 ' 9|l0|ll|l2|l3Jl4|l5|l6 C. •0" M E • E 1 E '■■ E ME ' E ME M E " E ME M E M E '.' E 41:6 41.1 -0.5 40.0 3 -05 -.0 3 -.02 101 •oc 22 98 97 96 9b 2 ) < J 22 \ 22.2 3 7.7 37.2 27.0' 32.3 35.5 35.0° \ \A / s / NO — /■ / S- '" FEf 150 t40 '30 120 100 ao TO 60 _./ L2 — ^ \ / 1 1 S | 1 J - 1 V / / / 1 1 / --' 1 1 / / 2 45 40 35 20 2 2 20 1 5 10 Z o < tr a. ai en 1 J M ' M \ \V 1 i h fever A boy, three years and four months old, was treated in the hospital for bronchitis, and when convalescent from that disease was attacked with acute articular rheu- matism. There was no rheumatic history in his family, and he had never had rheumatism nor any other disease ex- cept bronchitis. After having been feverish for two days, the temperature varying from 37.7° to 38.8° C. (100° to 102° F.), he complained of pain and tenderness in his shoulders, wrists, and elbows. On the follow- ing day these symptoms increased, being especially marked in the left hand and left knee. There was an expression of anxiety on his face, showing that he feared that the tender joints would be touched. The weight of the bedclothes was kept from the knee by a cradle, and the arm was comfortably arranged on a pillow. These details in the nursing of a rheumatic child are very important. Fig. 118 shows the affected knees and wrist. He was being treated with oil of gaultherium, 4 minims every three hours. The temperature varied from 38.3° to 39.4° C. (101° to 103° F.). An exami- nation of the cardiac region did not reveal any cardiac complication. The child suffered considerably for four weeks, but at the end of that time the joints gradually grew less painful, and he was entirely well thirty-three days from the onset of the attack. Acute articular rheumatism. Acute endocarditis on seventh day from .beginning of attack. SPECIFIC INFECTIOUS DISEASES. 519 The next child, a girl, five and one-half years old, was interesting as illustrating a number of characteristics in connection with the rheumatism of children. She was attacked eight days before entering the hospital with pain, swelling, and tenderness in her left ankle. On entrance her temperature was 40° C. (104° F.), her pulse was 145. and her respirations were 40. There was very slight pain in the joints, and. although her appetite was lessened, she otherwise seemed well, and had not com- Fiu. 119. ] Rheumatism. Subcutaneous fibrous nodules. Male, 13 y plained of any pain since the beginning of the attack. On the sixth day the tempera- ture fell to 37.2° C. (99° P.). It is interesting to note the extreme latency of the dis- ease, and how the child seemed to be perfectly comfortable from the beginning of the attack, except when the ankles, both of which were swollen and tender, were touched. On the seventh day of the disease the temperature rose to 38.6° C. (101.5° F.). and an examination of the chest showed a mitral systolic murmur. The murmur became more marked, and was transmitted into the axilla and the back. The area of superficial cardiac dulness was slightly increased, and extended to the middle of the sternum. By the end of the second week of the attack the pain and tenderness had left the ankles, and the child seemed quite well. The area of superficial cardiac dulness was 520 PEDIATRICS. found to be normal, but the systolic murmur still continued. Chart 19 shows the rheumatism gradually subsiding up to the seventh day of the disease, when the endo- carditis arose as a complication. Fig. 119 represents a boy who during an attack of rheumatism developed the subcutaneous fibrous nodules which have been referred to. When he was seven years old he had an attack of rheumatism affecting his ankles and the muscles of his neck. His temperature was 37.2° C. (99° F. ) ; his urine was normal. During this attack a systolic souffle transmitted into the axilla developed, and the area of superficial cardiac dulness was increased. This attack lasted eight days. From that time until he was thirteen years old, that is for six years following his first attack of rheumatic fever, he had more or less dyspnoea on exertion, and at times cardiac pain, but never had any marked return of the rheumatism. At the end of that time he no- ticed small lumps appearing under his skin. When they were first observed he had indefinite pains in his limbs, severe headache, and malaise. - Some of the lumps were slightly tender, and were distributed on the chest, arms, abdomen, and legs, mostly on the anterior surface. Although acute articular rheumatism is rare in infancy, I have met with a number of cases at this early period of life. Reference has already been made, on page 95, to the little girl, two years old, who, after exposure, was attacked with acute rheumatism in both hip-joints. Two other cases are of special interest on account of their early occurrence. The first case was one of rheumatic fever, attacking all the joints, in an infant two weeks old, after exposure to a cold draught while being bathed. Any movement of the joints caused the infant to scream. He lost rapidly in weight, his surface circulation was disturbed, and the attack lasted for four months ; but when he was six months old he was perfectly well, and no cardiac complication developed during the attack. Another case of this kind was an infant who was attacked with rheumatic fever when she was seven months old, the attack lasting until she was fifteen months old, when she recovered without any cardiac complication, and became well and strong. SYPHILIS. The specific organism which causes syphilis has not yet been dis- covered. The disease as it is manifested in early life appears in two forms, — (1) acquired and (2) hereditary. The former differs in no respect from the disease as it occurs in adults, and is transmitted by direct infection, usually through one of the mucous membranes. Its treatment and general characteristics are the same as in adults. HEREDITARY SYPHILIS. The hereditary form of syphilis plays an important part in the dis- eases of the early months of life, and is an affection which in all its phases should be thoroughly understood by those who practise among children. By inherited syphilis we mean a congenital disease which has been transmitted to the child through one of the parents or through both. It makes its appearance either in the early months of life, syphilis of the SPECIFIC INFECTIOUS DISEASES. 521 new-bom, or at a later period towards puberty, retarded syphilis. The stage which is met with at birth usually corresponds to an early stage of acquired syphilis, while that which is delayed until later childhood or puberty corresponds to a later stage. Inheritance and Transmission. — The question whether the infant can inherit syphilis from the father without the infection of the mother is one which has not yet been determined finally. The weight of evidence is in favor of the view that its occurrence in this way is not possible. The probability is that some mild and transient form of the disease has been overlooked in cases where the mother has been apparently healthy, es- pecially as the mother of a syphilitic infant is always immune to infection by her infant. Instances, however, occur in which it is impossible to say that the mother of an undoubtedly syphilitic infant is also syphilitic. The following case illustrates this point : An infant with marked syphilitic lesions was brought to me for treatment. The father of the infant acknowledged having been treated for a primary syphilitic lesion which was followed by pronounced secondary symptoms. The mother was a healthy, strong woman, who had always been perfectly willing to give any information required either as to her own or as to her husband's condition, in order to aid in the preserva- tion of her infant's life. She stated that she had never had any miscarriages, that she was perfectly well both before and after the birth of this infant, and that she had never had an efflorescence on her skin, a sore throat, nor any lesions of the mucous mem- branes. She came under my observation when her infant was six weeks old, and has since then been seen sufficiently often for me to say that so far as I can determine she has had no symptoms that in any way could be attributed to syphilis. She had always had a plentiful supply of breast-milk, which was evidently of good quality. A syphilitic infant does not infect its mother (Colles's law). It can infect a woman, however, who either has never had syphilis or who has never given birth to a syphilitic infant. It is probably possible for a syphilitic foetus to infect its mother in utero. This theory of retro-infection, however, has not been universally accepted. Fournier believes that there is a class of cases in which the father at the time of marriage has no lesion which would necessarily infect the mother, where the mother never shows any initial lesion and remains free from syphilis so long as she is unimpregnated, and where after impregnation she becomes syphilitic and either aborts or gives birth to a syphilitic infant. In connection with the subject of retro-infection the question arises whether a mother who becomes syphilitic during her pregnancy can infect the foetus (post-conceptional syphilis). There is no doubt that she may abort from her own syphilitic infection. The same authority believes that the foetus is also syphilitic. This doctrine, how- ever, is not universally accepted. There is no doubt but that infection may take place ; whether it always does is not yet settled. It has been found that when a woman is syphilitic it is exceedingly common for her to abort. Miscarriage is more frequent when a woman 522 PEDIATRICS. is passing through the early stages of syphilis than later when she has become more or less habituated to the disease. The treatment by mer- cury in these cases soon after impregnation, and continued during the pregnancy, is a valuable means of averting abortion. Although the aborted foetus of a syphilitic woman is usually macerated, yet such a condition of the foetus may be produced by other diseases as well as by syphilis. Birch-Hirschfeld has found from an examination of a large number of macerated foetuses that seventy per cent, were undoubtedly syphilitic. Although the tendency to transmit the disease is greatly lessened by time, yet the thorough treatment of the parents by mercury is the most efficient means of preventing such transmission, and the careful use of this drug in proper doses is never contraindicated. It is, therefore, evident that a pregnant syphilitic woman should be treated with mercury whether she was infected before or after conception. When both parents are syphilitic, and when their syphilis is in the early stages, the infant is most likely to inherit the disease, and under like conditions the disease is apt to be of a severe type. Infants entirely free from syphilis, either at birth or later, have been known to be born of parents of whom one or both were undoubtedly syphilitic. The following cases illustrate this question of immunity : Two children of a family of five were under my care, all of whom were healthy at birth and had never shown any symptoms of syphilis. The father was infected with syphilis before marriage, and later infected his wife. They were both carefully treated with mercury. The wife had never had any abortions. She had had five children, and had lost none. Both father and mother had had undoubted secondary and ter- tiary lesions, some of which still existed at the time I saw them. The father of another such case was a rag-sorter, who had a primary syphilitic lesion on his hand twelve years previously. This lesion was followed by secondary symptoms. He had never had any lesion on the penis. While he was being treated his wife showed symptoms of syphilis and was also treated with mercury. This child had always been healthy, and was one of three, none of whom had ever developed any syphilitic lesions. Pathology. — The pathological tissue-changes which take place in the hereditary form of syphilis are of the same nature as those which occur in the acquired form. Diffuse interstitial hyperplasia is much more common in the hereditary form than are circumscribed gummy tumors. Changes in the bones are very common in hereditary syphilis, and in fact so much so that it is usually considered necessary to find these osseous changes in order to establish a diagnosis of syphilis in the foetus. Osseous System. — The changes in the bones which take place in heredi- tary syphilis are so important, not only on account of their pathological interest, but also because of their clinical significance, that especial atten- tion should be paid to them. In this connection it should be remembered that in the latter part of SPECIFIC INFECTIOUS DISEASES. 523 infra-uterine life the long bones are cartilaginous and the process of ossi- fication is intra-cartilaginous. As the cartilage changes to bone the carti- lage-cells increase in number and are closely crowded together. Then comes the area of osteoblasts, then the calcareous matter, and deeper down in the ossified portions are the blood-vessels running in from the periosteum. The epiphyses of the bones of the arm are cartilaginous at birth, and they remain separated from the shaft of the bone for some time by a narrow cartilaginous layer. It is in this cartilaginous sepa- rating layer, called the zone of proliferation, represented in the drawing of a normal infant's bone (page 329, Fig. 82 I.), that certain changes are found in hereditary syphilis. It is also at this zone of proliferation that the growth in the length of the bone takes place, and it is here that syphilitic changes are most often found. This lesion is an osteochondritis, and may occur together with lesions of the spleen and other parts of the body, or as the only manifestation of the disease. Osteochondritis is ordinarily the form of bone-disease in infants. Osteoperiostitis belongs almost exclusively to the later forms of heredi- tary syphilis as they appear in older children and in young adults. The bones which are affected most commonly are those of the arms and of the legs. Besides these common osseous lesions a morbid condition of the fingers and toes, called dactylitis, occurs quite frequently. In this condi- tion the fingers and toes assume a peculiar pyriform shape. In addition to these purely syphilitic changes, local thinning of the bones of the skull, called craniotabes, occasionally occurs. In this condi- tion the bone-substance is absorbed, leaving only the integuments and membranes. Liver. — The liver is always larger than in the normal condition. The hepatic tissue is harder and more elastic than usual ; it is of a yellow color, and there are small white granulations scattered throughout the parenchyma. The hepatic acini under normal conditions are in contact, except at the prismatic spaces formed by their union, in which spaces the capsule of Glisson forms an envelope to the afferent portal vessels of the lobule. It is in these spaces that the round lymph-cells form and collect into small nodules representing microscopic gummata. The gum- mata of the liver which are found in young children with hereditary syphilis resemble those which occur in adults. Spleen. — Next to the osseous system the spleen is the part most often affected by syphilis. It is enlarged, and the degree of splenic enlargement is usually characteristic of the severity of the disease. Pancreas. — Birch-Hirschfeld has pointed out the fact that the pancreas is frequently found to be affected in hereditary syphilis. He remarks that the interstitial changes which he found in the pancreas are analogous to those which occur in other organs, especially the liver, and that, while these changes are not constant, they come next in frequency to the altera- 524 PEDIATRICS. tions in the spleen. The interference with the function of the pancreas, which must occur when it is diseased to any great extent, is probably the cause of the gastro-enteric disturbances so common in hereditary syphilis. Lungs. — In cases of hereditary syphilis born before term, and in those born at term who live but a few days, the lungs present certain patho- logical conditions represented by nodules or small tumors, usually super- ficial and varying in size. Sometimes an entire lobe may be involved, and the dense, altered lung-tissue is colorless gray or white, both on its surface and on its section. This condition has been called by Virchow pneumonia alba, white hepatization. Kidney and Testicle. — The kidney and testicle may show the lesions of syphilis. It is to be noted that the lesions of these organs are amenable to treatment. The disease in the testicle is represented by a gradual enlargement, and is usually bilateral. Throat, Upper Air- Passages, Thymus Gland, and Heart. — Extensive lesions are at times found in connection with the pharynx, larynx, trachea, and neighboring parts, and also with the thymus gland and with the muscles of the heart. Early Manifestations of Hereditary Syphilis. — Symptoms. — The severity of the disease determines the type of the efflorescence, and is also influenced by the time when the infection of the foetus took place. Thus, the later the period of infection the milder will be the form of the efflorescence which first appears, while the less severe the general symp- toms the better will be the prognosis and the greater the amenity of the disease to treatment. The reverse of these rules is found when the in- fection has taken place early, and when, as a result, the infant is born dead, or at birth shows such advanced stages of the disease as are repre- sented by the more intractable forms of efflorescence and severe general symptoms, making the prognosis exceedingly grave. In the mild form of the disease the infant may be born apparently healthy and may show no indications of its syphilitic inheritance for some weeks. It is rare, however, for the symptoms to be delayed beyond the first three or four months of life. The earliest symptoms of heredi- tary syphilis correspond to the secondary symptoms of acquired syphilis. Commonly, unless the infant is born with the efflorescence, it is noticed at birth, or within two or three weeks, to have occlusion of the nares (snuffles), and, soon after, a hoarse cry and an efflorescence of a macular or a papular variety. The efflorescence is general, includes the palms of the hands and the soles of the feet, and is especially prominent on the forehead. The condition of the infant depends considerably on that of the mother. The rule is that these infants when born are emaciated, but I have seen them well developed and apparently in good condition. The disease, with appropriate treatment and good feeding, may in some cases SPECIFIC INFECTIOUS DISEASES. 525 be arrested in this stage, and be cured so that it will not return, or it may advance to another group of symptoms, which are represented by lesions of the mucous membranes, and sometimes by pseudo-paralysis of one or both limbs of a greater or less degree. All these symptoms may arise, run their course, and completely disappear, sometimes never to return. Again, they may reappear at various times during the indi- vidual's life, but they are especially liable to recur during the middle period of childhood and at puberty. The course of syphilis is so influenced by treatment that the symp- toms must necessarily be irregular. When the disease is untreated, as a rule, all the symptoms grow worse. The infant becomes more and more emaciated, and either it dies in a few weeks of inanition, or the disease progresses still further and serious lesions of the various organs, such as the lung, liver, spleen, and kidney, may finally produce a fatal result. Efflorescence. — We can judge to a great degree as to the severity of the disease by the type of the efflorescence, and also by the time when it occurs after birth. The mildest and most benign form of syphilitic efflorescence is represented by maculce, the next by papuloe, and the next by pustular and bulke. Another form of efflorescence simulating psoriasis is one of the more severe manifestations of syphilis, as is also that form which is called rupia, where the efflorescence consists of thick layers of crusts arranged one above the other, forming a conical mass, the skin at the base being somewhat infiltrated. All of these types of the disease have been known to be cured. Finally, one will meet at times with a very dangerous form of the disease, which is almost uniformly fatal no matter what the treatment may be. This is what is called syphilitic pemphigus, and is represented by large and numerous bullae. The syphilitic efflores- cences, unlike most other lesions of the skin, appear commonly on the palms of the hands and the soles of the feet. Alopecia. — In addition to these general symptoms there occurs in the hereditary form of syphilis the loss of hair which is so common in the acquired form of the disease. This alopecia may be caused by any of the dermal lesions which occur during the course of the disease, but is probably due mostly to the general lack of nutrition in which the skin participates with the other organs of the body in syphilis. In certain cases the eyebrows and eyelashes are lost, and Barlow believes that the former condition is characteristic of the disease, or at least should excite a suspicion of its presence. Lymph-Nodes. — Enlargement of the lymph-nodes, adenopathy, seems to be less marked in hereditary syphilis than in the acquired form. This enlargement may be due to reflex irritation from the more severe dermal lesions, but in certain cases it is found where no dermal lesion exists. The enlarged nodes may be in the inguinal, the axillary, or the cervico- maxillary regions. They are distinct, movable, multiple, and non-inflam- 526 PEDIATRICS. matory. The older the child the more likely the glands are to be en- larged. Nails. — According to Post, the nails are involved quite frequently in hereditary syphilis, and more frequently than in the syphilis of the adult. The onychia occurs in two forms. In the first form a papule or pustule appears on the skin at the side of the nail. This ulcerates and extends along the side of the nail, at times involving the matrix and causing the loss of the nail. The thick and everted edges of the ulcer, its sloughing base and sanious discharge, are somewhat characteristic, and are accom- panied by a painful enlargement of the distal phalanx. (For another form of onychia, see page 538.) Teeth. — The effect of hereditary syphilis on dentition is quite marked. The first teeth instead of being cut in the sixth or seventh month may not appear until the fourteenth or fifteenth month, and sometimes even later. These primary teeth are especially liable to decay early. There is nothing sufficiently characteristic to be of diagnostic value in the ap- pearance of the teeth of the first dentition. Eye. — Hutchinson has observed twenty-three cases of iritis in syphi- litic infants. The average age for the beginning of the iritis was five and a half months. The oldest was sixteen months at the time of the outbreak, the youngest six months. Both eyes were affected in eleven cases, and in fifteen cases the effusion of lymph was copious. The cornea was affected in a few cases. In seven cases the cure was com- plete, in twelve the pupil was partially occluded. Iritis is one of the rarest of the symptoms of hereditary syphilis, and at times escapes notice on account of the very slight symptoms which usually attend it. The diagnosis in these cases is not dependent on the iritis alone, but the infants always show other well-marked symptoms of syphilis. There is great danger of the disease resulting in blindness if it is left untreated, and mercurial treatment is most efficient in effecting a cure. Digestive Organs. — In regard to the digestive disturbances which arise in these cases of hereditary syphilis, it is well to remember that they may depend upon a syphilitic lesion of the liver, spleen, and pancreas, as well as of the stomach and intestines. It is, therefore, necessary to treat these disturbances of the gastro-enteric tract in a different manner from what is customary where a local non-syphilitic cause is supposed to be present. In fact, mercurial treatment will produce the best results in these cases. Hemorrhages. — An affection called syphilis hcemorrhagica neonatorum is met with at times. Bumstead and Taylor have reported two cases of this kind, and state that the disease is rare, less than twenty cases having been noted. The hemorrhages vary in their extent, and may occur in either the skin or the mucous membranes. This class of cases is difficult to differentiate from the hemorrhagic disease of the new-born which has already been described. There is no doubt that syphilis has in a number SPECIFIC INFECTIOUS DISEASES. 527 of eases an etiological significance in the umbilical hemorrhage which occurs in the early days of life. Dr. Uracek has reported a series of hemorrhages in the different internal organs apparently depending upon a syphilitic taint in the infant. Nose. — The occlusion of the nares may increase to such a degree that the breathing of the infant is seriously interfered with, and, without any other syphilitic lesion, it may die from imperfect oxygenation of the air which enters its lungs. This occlusion of the nares may cause great loss of sleep. We must, however, understand that, even where this lesion is not of any great ex- tent, syphilitic infants suffer from insomnia. This insomnia is usually accompanied by crying, so that it is probable that the restlessness and in- somnia are due to pain in the bones, as these symptoms are often present where there is no digestive disturbance. In connection with these syphi- litic lesions of the nose, flattening of the bridge of the nose is at times a noticeable symptom. Anus. — There is nothing especial to describe concerning the condylo- mata which are found in the anal region and which are rare in compari- son with the lesions of the mouth. They begin as rounded papules, which sometimes coalesce, and there is more or less infiltration of their edges and breaking down of their centres. Mouth. — The syphilitic lesions of the mouth are found so commonly, and are of so important a character, that an especial description should be given of them. There is no syphilitic lesion of the mouth which is represented by a characteristic stomatitis. The mucous membrane in the course of hereditary syphilis may at any time be in so sensitive a condi- tion that the various forms of stomatitis may be engrafted on it, and we thus may have different lesions of the lips, tongue, buccal cavity, and tonsils, which, while simply representing the lesions of certain non-syphi- litic affections, may, by their peculiar grouping in combination with other symptoms, represent the hereditary form of syphilis. The lesions most commonly appear around the lips and on the mucous membrane lining the cheeks. On the lips fissures are exceedingly frequent ; on the upper lip they commonly appear on either side of the median lobule, while on the lower lip they are usually single and in the median line. The angle of the mouth is often the seat of condylomata, and these are frequently covered with crusts and at times are deeply ulcerated. A peculiar appear- ance is in some cases seen at the commissures of the mouth, caused by cutaneous ulcerations, which make it look larger than normal, and at times produce a number of lines radiating from the mouth to the cheeks. Ulcerations may occur on the tongue, the lips, and the fauces. Forch- heimer considers that the fissures which occur in syphilitic infants 1 mouths w T hen they are present, leave no doubt as to the diagnosis, since they are infiltrated. The most common place for them to appear is at the corner of the mouth. In this place, as a rule, the most striking feature of the 528 PEDIATRICS. fissure is that it is a papule which has been split in or about its middle, and that it has an infiltrated edge. The fissures sometimes disappear in the mucous membrane, sometimes stop belore reaching it, and sometimes run into it. The fissures may or may not be covered by a crust, and, unlike most syphilitic efflorescences, produce more or less pain when the mouth is opened. These fissures are called rhagades. They are charac- terized by their persistency and by their lack of tendency to spontaneous healing. Ulcers and plaques muqueuses may be found upon the mucous membrane of the lips and cheeks and on the sides and under surface of the tongue. They are superficial, but cover more space than the fissures. The infiltration is not so well marked, but is present to a greater or less degree. The most common lesions which are found on the tongue are these plaques muqueuses and ulcers. Both have infiltrated edges, but the plaque in this situation rises above the level of the tongue, while the ulcerations are considerably depressed. They are both characteristic of syphilis. Their locality is determined somewhat by the presence of such irritants as sharp teeth pressing against a portion of the tongue. The secretion of all these lesions of the mouth and lips is highly infec- tious. Bones. — One of the striking symptoms of this early stage of heredi- tary syphilis results from osteochondritis. According to Post, the form of lesion is usually that of a tumor at the junction of the diaphysis and epiphysis at the distal end of the long bones, although any part of the osseous system may be involved. These swellings are difficult to recog- nize in fat children. The tumors rise abruptly from the bones ; they are small and globular, and in some cases form a ring at the junction of the shaft and epiphysis ; in others the whole epiphysis is enlarged. At times only a part of the cartilage is affected, and the external swelling is corre- spondingly circumscribed. The lesions appear soon after birth, and their development is completed either slowly or rapidly. The termination varies widely. The swelling may be absorbed under appropriate treat- ment, or suppuration may take place and the skin break down ; the dis- ease may end in the separation and destruction of the epiphysis. The result upon the final growth of the bone varies, of course, with the severity of the local disease. When the morbid process is arrested before the destruction of either cartilage or epiphysis, there is no deformity, but the destruction of cartilage puts an end to growth at that point, and a more or less shortened and useless limb results. When the disease takes such a course as to separate the epiphysis while the integuments remain sound, the limb becomes useless for a time and appears to be paralyzed. The disease was first fully described by Parrot, and is known as Parrot's disease, or syphilitic pseudo-paralysis of the new-born. The joints in immediate connection with the diseased bones are sometimes in- volved. There may be simply an effusion, but, where the bone is de- stroyed, serious disorganization of the joint must follow. The pain and SPECIFIC INFECTIOUS DISEASES. 529 sensitiveness in these eases of pseudo-paralysis are probably caused by a low grade of periostitis. The bones of the fingers and of the toes present at times the pecu- liar lesion which is known as dactylitis syphilitica. The phalanx may be enlarged to two or three times its natural size, giving the fingers a pyri- form shape. One or several fingers or toes may be involved, and some- times the metacarpal bones are diseased. The proximal phalanx is more frequently affected than the distal phalanx. In the early stages the integu- ment is unchanged ; later, the overlying parts become involved and abscesses form. If the case is submitted to early treatment the deformity usually subsides, but if untreated the disease may result in permanent deformity and uselessness. Dactylitis, however, is not characteristic of syphilis alone, as it occurs also as a result of tubercular disease of the bone. One of the more uncommon symptoms of hereditary syphilis is cranio- tabes, but in rare cases it may be found. These softened spots, nearly circular in form and about 1.2 cm. (J inch), more or less, in diameter, may be recognized by the finger during life. Formerly craniotabes was considered to be exclusively a symptom of rhachitis. It is found especially in the occiput. It is present in rhachitis where no trace of syphilis can be discovered, but it seems to be most common in cases in which there is a distinct syphilitic taint. Out of one hundred cases of craniotabes collected by Drs. Barlow and Lees, in forty-seven there was satisfactory proof of syphilis. Diagnosis. — The diagnosis of hereditary syphilis in its more advanced forms, such as has just been described, is not difficult, as no other disease represents such serious lesions of the skin with such a combination of general symptoms and lesions of the mucous membranes. The milder forms of the disease are frequently mistaken for other diseases of the skin, such as papular erythema, which simulate the syphi- litic lesions but which are of a benign character. Occlusion of the nares caused by swelling of the Schneiderian mem- brane, if persistent during the early weeks and months of life without rise of temperature, should always make us suspicious of the presence of hereditary syphilis, for a syphilitic efflorescence is often so slight and eva- nescent as to be frequently overlooked. Marked improvement following the administration of mercury is also usually considered of diagnostic value, and, although not by any means conclusive, is at least significant. Periostitis, especially of the lower end of the humerus or the anterior border of the tibia, is met with in children. It should make us suspicious that syphilis is causing this condition, especially if there is periostitis of a number of bones at once. A great deal has been written and much discussion has taken place regarding the relationship between syphilis and rhachitis. The two dis- 34 530 PEDIATRICS. eases are so distinctly separated that it seems scarcely necessary to dwell except very briefly, on the differential diagnosis between them. Rha- chitis is so largely dependent in its osseous changes on a profound dis- turbance of nutrition that it can fairly be said to result from any disease which from its debilitating nature may interfere Avith the nutrition of the bones. In this way individuals whose nutrition has been seriously af- fected by hereditary syphilitis may develop rhachitis. In regard to the actual lesions of the bones present in syphilis and rhachitis, there seems to be a concurrence of opinion that the pathologi- cal conditions are quite different. Thus, syphilitic bones very rarely present the spongy tissue peculiar to rhachitis, and rhachitic bones never show the osteophytes of syphilis. Prognosis. — The prognosis in any case of hereditary syphilis is a se- rious one. In addition to the results which we are likely to have from the syphilis of the parents being early or late in regard to the impregna- tion, and from their having been thoroughly treated or not, there are certain facts to be remembered concerning the infant itself. The prognosis is grave inversely to the number of weeks after birth when the disease first shows itself. The milder forms of the efflorescence justify us in giving a better prognosis than the more severe ones. In addition to these conditions which render the prognosis more favorable are the possibility of the infant being fed with good breast-milk or with a carefully prepared substitute food, and good hygienic surroundings. The cases in which the spleen is much enlarged are evidently so pro- foundly affected by the secondary anaemia by which the enlargement is caused that the prognosis is almost invariably bad, and the degree of splenic enlargement may almost be taken as an index of the severity of the disease. The opinion which we give to the parents should, however, always be very guarded, as, even though the disease may for the time apparently be entirely cured, it is always liable to appear again in later childhood and at puberty. When the disease is amenable to treatment these sec- ondary symptoms almost always disappear by the second year, and in quite a large number of cases, where proper treatment has been thor- oughly carried out, the infant recovers entirely and is as well and strong as though it had never had syphilis. In another set of cases, however, although the disease is apparently eradicated, in later years it is found to have left its marks in disturbances of the different functions and in the general lack of vigor of the various tissues. Treatment. — The treatment of hereditary syphilis is first to adapt at once as nourishing a food as is possible to the infant's digestion. A healthy mother with plenty of good breast-milk will, as a rule, provide the best food for her infant. If the mother's nutrition is reduced by syphilis or by any other chronic disease, the infant should be fed on a properly adjusted substitute food, SPECIFIC INFECTIOUS DISEASES. 531 while the general hygiene, such as fresh air, sunlight, and warmth, should be carefully regulated. A wet-nurse should not be employed unless she has herself had syphilis, in which case the same rules will apply to her nursing as to that of the syphilitic mother. It should be remembered that the secretions from a syphilitic infant's mouth are very infectious, whether the disease is of the hereditary or of the acquired form. If, therefore, the mother is not syphilitic and the infant has acquired in any way a syphilitic lesion, the nursing must be discontinued and the infant fed on a substitute food. The only drug which can be depended upon in the treatment of the early lesions of hereditary syphilis is mercury. This drug naturally would be employed from our experience with it in acquired syphilis, where it is more valuable in the early stage of the disease than at any other period. In like manner iodide of potash is of little use in the early stages of hereditary syphilis, while it becomes useful in the retarded form, which corresponds to the later stage of acquired syphilis. It is important carefully to adapt the form, of mercury which is given to the syphilitic infant according to its special idiosyncrasy for the drug, and also to regulate the means of its administration according to the ne- cessity of having it act quickly, as is indicated in the more severe forms of the disease, and according to the sensitiveness of the individual's stomach or skin. Thus, mercury may be administered either through the mouth or through the skin. In the latter case it may be applied directly in the form of liquid or ointment or by means of subcutaneous injections. The last method should be used in very urgent cases only, for the tissues and skin of the syphilitic infant are especially liable to be irritated to such an extent that sloughing may take place, and the tissues under these circum- stances are readily destroyed. When used, it should be in the form ot corrosive sublimate. The corrosive sublimate should never be given subcutaneously in larger doses than 0.0006 gramme (jfo grain). Where the mercury is to be applied directly to the skin it may be in the form of corrosive subli- mate baths, 0.3 to 0.6 gramme (5 to 10 grains) to each bath once daily, but practically it is found better to introduce it into the system by means of an ointment. This ointment may be the official mercurial ointment, either in full strength or diluted with some simple ointment, and this may be applied by means of inunction, as is the custom in the acquired syphilis of adults. After the infant's skin has been thoroughly washed, a small portion of the ointment should be applied to its back and rubbed carefully and gently into the skin for ten minutes. On the next day the same procedure can be carried out on the front of the chest ; on the third day in the axillary regions ; and on the following days respectively on the outer surfaces of the arms and thighs. I have found that the most practical way of applying inunctions to these infants is. after having thoroughly washed the abdomen, to spread the ointment thickly on a 532 PEDIATRICS. piece of thin soft flannel cut so as to reach from the ensiform cartilage to the pubes and to extend around the entire abdomen. This ointment is made in the following way : Prescription 78. Metric. Apothecary. Gramma. Ii Unguenti oleati hydrargyri, R Unguenti oleati hydrargyri, Unguenti lanolini aa 60J00 Unguenti lanolini aa ^ ii. M. M. The band should be allowed to remain in place for forty-eight hours. It should then be removed, and, after the skin has been thoroughly washed with warm water and soap and dried with a soft towel, the flannel should again be spread with the ointment and reapplied. In giving mercury by the mouth I am in the habit of using the official hydrargyrum cum creta. I usually begin with 0.06 gramme (1 grain) of the drug, administered three times in the twenty-four hours. Within a few days the dose is increased to four times in the twenty-four hours, and if no unfavorable symptoms appear it is again raised to 0.12 gramme (2 grains) three or four times in the twenty-four hours. The unfavorable symptoms which have just been referred to as pos- sibly being caused by the drug are represented by diarrhoea. We must remember that the infants whom we are treating for hereditary syphilis are so young that the salivary secretion has been very slightly developed, and that therefore we naturally do not salivate an infant of this age so readily as we would a child or an adult. We must not, however, think that we can be guided as to the amount of mercury we are introducing into the infant's stomach by salivation, which is usually relied upon to indicate the physiological action of mercury. I have found it a safe rule to continue with the mercury until diarrhoea is caused, when the drug can be reduced in quantity, or even be omitted for a few days. When the intestine has become less sensitive we can again begin with a smaller dose, and one which by experiment has been shown not to cause diar- rhoea in the especial infant. Other forms of mercury, such as calomel in doses of 0.006 gramme ( T V grain) three or four times daily, may be given by the mouth in these cases. These various forms of mercury should be tried when for any reason one of them is found not to suit the case. For the treatment of the fissures which occur around the lips and the lesions of the mouth, as well as those which occur at the anal orifice, I am in the habit of using a simple powder of calomel, which is dusted on the part affected. The mouth should be carefully cleansed several times during the day and a wash of chlorate of potash used at least twice a day. In some cases, although rarely, nitrate of silver is needed as an application to the ulcers when they are intractable. When there are crusts around the lips and in the neighborhood of the fissures, or where anal condylo- SPECIFIC INFECTIOUS DISEASES. 533 mata are present, the mercurial ointment just spoken of is of much benefit. The crusts should be carefully removed from the nose and this same ointment gently applied to the lesions. The application of this oint- ment to the abdomen is at times followed by an eczematous irritation of the skin of the abdomen. Under these circumstances any simple emol- lient should be applied in place of the mercurial for a few days until the skin has recovered, and the mercury can then be further diluted with lanoline or some simple ointment and reapplied, thus finally adjusting the strength of the mercurial to the vulnerability of the infant's skin. In addition to the mercurial treatment, tonics in some form, especially iron, are at times required. It is usually in the later stages of the disease that they are indicated, and in cases in which the persistence of the splenic enlargement shows the presence of profound secondary anaemia. After all the symptoms of syphilis have disappeared and the infant is entirely well, the mercurial treatment should be continued for some months, and also later during the first three or four years of its life, at intervals of three or four months, even when there is no return of the syphilitic symptoms. It should likewise be given at intervals during the period of the second dentition, and again at puberty. This treat- ment is especially important whether the infant appears to be in good health or not, as it tends to prevent a recurrence of the disease, and we should remember that a recurrence often proves very intractable to treatment. The following cases illustrate the different phases of hereditary syphilis and the different conditions which are liable to be met with in this disease. The first infant was three weeks old. Its mother looked well and strong, denied having had any miscarriages or disease of any kind, and asserted that the father was also healthy. Both of these statements were probably untrue, but an excellent oppor- tunity for making a diagnosis simply by inspection and by a physical examination was given. At birth the infant was puny and atrophic. It soon began to have occlusion of the nares. When one week old, an efflorescence of papules appeared on its arms, legs, and feet, with pustules on the palms of the hands and the soles of the feet. It did not vomit. The faecal movements were of a good color and fairly well digested. The heart and lungs were normal. The splenic area of dulness was slightly increased, but the spleen could not be felt. There were marked fissures at the angles of the mouth, a muco-purulent discharge from the nose, and crusts forming on the eyebrows. The mouth and throat showed nothing beyond a pronounced erythema. There were papules and pustules on the body, and a squamous as well as a pustular efflorescence on the palms of the hands and the soles of the feet. There were maculae on the buttocks. The anus showed nothing abnormal. The temperature was normal. The infant looked fairly well nourished. There could be no question about the diagnosis in a case like this, and the state- ments of the mother regarding herself and her husband were entirely ignored, for by simple inspection it was clear that it was a case of hereditary syphilis. The next infant was six months old. The mother, a healthy-looking woman with plenty of breast-milk, nursed the infant. She had had one miscarriage, in the third month, and this was her first child. The father denied having had any venereal disease. 534 PEDIATRICS. At birth the infant was rather atrophied and had a general papular efflorescence all over it, and later a squamous efflorescence on the palms of the hands and the soles of the feet. It always had marked occlusion of the nares (snuffles). The infant was immediately placed under treatment, and at six months looked well nourished. It was a case of hereditary syphilis, and showed the beneficial results of good breast-milk and mercury, for it was very large for its age and was fat and strong-looking. It had, however, certain lesions of the bones which were the result of the syphilitic manifes- tations which it presented at birth. One of these lesions was represented in the marked prominences , on either side of the frontal bone, with a somewhat depressed sulcus between them. The first phalanx of the left little finger and that of the left third finger were swollen and somewhat reddened, and the tissues had a tendency to break down. This is the condition which has already been described as syphilitic dactylitis. Cases of tuberculosis of the bone often simulate this condition, and, in fact, so nearly approach it in appearance that the two diseases cannot be distinguished by simple inspection. The diagnosis must be made by considering the other symptoms. The syphilitic infant is described essentially as atrophic ; this is, as a rule, the case only when it is deprived of good breast-milk or of a properly proportioned substitute food, the atrophy being usually a fault in diet, provided that the intra-uterine nutrition has been good. Syphilis is so prolific a source of miscarriage that a history of miscar- riage in the mother justifies us in looking with suspicion on a doubtful lesion of the skin in her infant. A woman may have a number of mis- carriages caused by syphilis, and may then, if she has been treated with mercury, give birth to a living syphilitic infant, or to one that is healthy. These facts are important for us to remember when we are considering the prognosis in a case of hereditary syphilis. The next infant illustrates one of the many unusual forms of syphilis which may manifest itself in infancy. A male, four months old, was brought to my clinic with syphilis of a rather aggra- vated type, and among other lesions with condylomata at the anal orifice. It had a general papular efflorescence on the face, body, and limbs, including the palms of the hands and the soles of the feet. The left arm hung helpless by its side. The left leg was also somewhat affected. On examining the arm there was found a small, hard, painful, circumscribed swelling at the lower end of the humerus. No crep- itation was detected. The condition was one of the osseous lesions of syphilis, an osteochondritis ac- companied by periostitis, which caused so much pain on movement as to disable the limbs and simulate both paralysis and fracture. Mercury was given and the infant recovered. The next case is of remarkable interest, owing to the form and appearance of the efflorescence, which, although unusual, is so characteristic that it could represent no other disease than syphilis. The infant was six weeks old. The mother stated that she had been married about three years, had had two children, and had had no miscarriages. She said that the father was well and strong, and that neither of them had had any efflorescence on their skin. The older infant was fourteen months old, and was healthy. The younger infant was being nursed by its mother. At birth it was apparently healthy and well nourished. Its skin was clear, its body fat, and there was no occlusion of the nares. This condition continued until it was eight days old. It then began to have occlusion of the nares (snuffles), a slightly hoarse voice, and an efflorescence on SPECIFIC INFECTIOUS DISEASES. 535 various parts of the body and limbs. This efflorescence consisted mostly of maculae, many of which were circumscribed by healthy skin. They varied in size from 0.6 to 1.25 cm. (\ to i inch). Plate X., facing page 610, shows a number of lesions represented in this case. In addition to the macula?, which varied from a delicate pink to a yellowish-white color, there was a pustule on the outer side of the leg just below the knee. On the inner edge and almost on the back of the foot were the remains of a bleb which had broken down and had been emptied of its contents. There was also on the inner side of the foot, nearer to the heel, a small ulcer. The entire skin of the heel was reddened and had a shining appearance. The erythematous lesions in places on the leg were surrounded by normal skin, presenting a mottled appearance, and there were white spots on the skin. These latter, however, were caused merely by the peculiar distri- bution of the syphilitic macula 3 . In addition to these lesions on the leg there were a few ulcers on the buttocks, and in addition to the maculae on the soles of the feet there were some on the palms of the hands. A few scales showing a squamous condition could be seen on the left leg, but this lesion was not a prominent one. The eyes were not affected. There were a few fissures about the mouth, but no lesions of the buccal mucous membrane, and there were no gummata around the anus. The treatment of this case was by inunction with the oleate of mercury ointment and by the administration of hydrargyrum cum creta. Fig. 120 represents the lesions of syphilis on the soles of the feet in a male. The lesions consisted of a number of bulla?, some of which had burst, and the tissue Fig. 120. ■■•. JSE-..--'-.- -JRte-* Syphilitic maculre, ulcers, and bullse on the soles of the feet. Male, 2% months old. beneath having broken down, ulcerations were formed. There were also a few papules, some smaller bulla?, and some pigmented areas. This same case had the "waxen 11 pallor of the skin, so characteristic of the higher grades of grave anaemias. There was moderate enlargement of the liver, which on palpation was found to be hard and somewhat tender. The inguinal glands were slightly enlarged. The post-aural glands were enlarged. The spleen was much enlarged and extended, as indicated in Fig 121 by the black line, from the fifth rib to the left inguinal region. It was hard, but was not tender. There were no other glandular enlargements. The examination of the blood was as follows : Nov. 17. Nov. 20. Erythrocytes 3,387,000 3,300,000 Haemoglobin 47 per cent. 45 per cent. Leucocytes 20,000 20,000 536 PEDIATRICS. There was a considerable variation in the size of the erythrocytes, which were pale in color. There was poikilocytosis in a moderate degree ; there were also some micro- cytes and megalocytes. The mononuclear elements predominated (about three-quar- ters). The eosinophiles were not numerous. Era. 121. Male, 2>2 months old. Congenital syphilis. Grave secondary antenna. Lower border of ribs, fifth rib, and enlarged spleen marked in black. Late Manifestations of Hereditary Syphilis. — Symptoms. — The mani- festations of hereditary syphilis which appear at birth usually develop in the first three or four months of the infant's life. In certain cases of syphilis which are without doubt of the hereditary form, either no symp- toms w T hatever are noticed in the early years of life, or they are so slight, or so lacking in the characteristics of syphilis, that it is sometimes impossi- ble to recognize them as syphilitic lesions. The lesions of this late heredi- tary form correspond to the tertiary lesions of the acquired form. They appear in different periods of childhood or at puberty. These periods correspond to the time when a fresh outbreak of an attack of syphilis which has occurred in the early months of life is apt to take place. This is significant as leading us to suspect that the early symptoms of the disease have been overlooked rather than to believe that they did not occur. Bones. — The lesions of the bones hold a prominent place in these later manifestations of hereditary syphilis. These lesions may be in the form of a periostitis, or an actual necrosis of the bone may take place either in connection with a dactylitis or with a simple lesion of the osseous tissue in any of the bones. As these later forms of hereditary syphilis merely represent the same conditions which are met with in tertiary acquired syphilis, we should expect the most varied lesions. In this late form of hereditary syphilis the bones of the nose are frequently involved, and a flattening of the bridge of the nose is not uncommon. The cranial bones show certain alterations which at times are quite characteristic. The frontal bone may present a promi- nence on either side, which, with a depression more or less deep between SPECIFIC INFECTIOUS DISEASES. 537 the prominences, causes such a peculiar conformation of the head as to be almost characteristic of syphilis. This is well represented in Fig. 124, on page 541. In addition to these frontal prominences, at times there is a prominence of the centre of the frontal bone, which, with the apparent flattening on either side, causes a peculiar shape simulating the keel of a ship. Sometimes protuberances similar to those which have been de- scribed of the frontal bone may appear on the parietal bones. When they are bilateral the sagittal suture appears as a depressed sulcus between them, and this deformity of the skull, from its resemblance to the shape of the nates, has been designated by Parrot as the natiform skull. These tuberosities on the skull may also appear upon the long bones, either in the diaphysis or in the epiphysis. When the tibia is affected there is often so marked an increase in parts of the shaft of the bone, especially its middle third, that, as the enlargement is chiefly in the ante- rior portion, the swelling when prominent gives an appearance of curva- ture to the bone. This is, however, only a seeming curvature, as the posterior portion of the bone is not affected. Mental Development. — An interference with the growth of children who are affected by these various osseous lesions of syphilis is not un- common. There is frequently a lack of development, which shows itself usually in a failure of the individual to attain the ordinary height. The mental development is retarded, the children often appearing to be a number of years younger than they really are. This condition Fournier has designated as infantilism. Teeth. — The first set of teeth in infants with hereditary syphilis have nothing characteristic about them ; they show a lack of nutrition, a con- dition which may arise from many other morbid processes. The second set of teeth, however, present certain characteristics. These characteristics are shown especially in the two middle upper in- cisors, in which the cutting edge of the tooth is worn away, leaving a convex sur- FlG - 122- face with the convexity upward. The teeth are also apt to be somewhat far apart, and, as the child grows older, to assume a peg shape. The especial char- acteristics of syphilitic teeth were first described by Hutchinson. This peculiar shape of the teeth is not always present in Syphilis, but When it appears it is Cer- Syphilitic teeth of the second dentition. tainly very suggestive of the disease. As was pointed out by Coleman, the dentist who examined Hutchinson's cases, in nearly every one of them there was a deficiency in the superior alveolar arch at the anterior portion, so great in some cases that when the jaws were closed the upper and the lower incisiors did not come together. 538 PEDIATRICS. Fig. 122 represents twelve syphilitic teeth of the second dentition. They are all more or less disorganized in a way which might occur from any cause which would interfere with the normal development of the teeth and cause their early decay. The middle two and the left lateral upper incisors show the notched and somewhat peg-shaped condition which is supposed to be characteristic of syphilis. Nails. — The onychia which occurs as one of the earlier manifestations of hereditary syphilis has already been described. In the late form of syphilis another form of onychia is met with, characterized, according to Post, by a swelling at the base or the side of the nail, which becomes thickened, fissured, and brittle, with more or less deformity of the phalanx. Eye. — In the late form of syphilis a peculiar inflammation of the cornea at times appears. It usually begins with a cloudiness of the sub- stance of the cornea, with ciliary congestion. The entire cornea in this way becomes clouded. The affection is not accompanied usually by pain, and does not show any special congestion of the conjunctivae. Hutchin- son says that it is always symmetrical, although at first it is apt to begin with one eye and later to attack the other. The interval between the two attacks may extend over several years. This disease is called inter- stitial keratitis, and may for a few weeks seriously interfere with the sight. It usually disappears under treatment without leaving any trace of the disease behind it. On the other hand, opacities are sometimes left which interfere with vision. The total duration of the disease varies from six to eighteen months. Interstitial keratitis, according to Post, occurs most frequently in female subjects, and is most common between the ages of ten and fifteen, although it may occur much earlier, and, according to Fournier, may even be met with at birth. Complications may arise in the shape of iritis, choroiditis, and retinitis. Ear. — Disturbances of hearing may occur from a number of causes, especially from those secondary to diseases of the pharynx. An especial form of deafness, however, without any special lesions to explain it, occurs in the syphilis of childhood, is usually intractable to treatment, and per- sists into later life. Extensive ulcerations produced by syphilis may occur in the nose and pharynx at any time during childhood. Nervous System. — Syphilis of the nervous system may be congenital or acquired, involving either the brain or cord. It is very rare in children. It may occur as a diffuse inflammation of the meninges, as localized gummata, or as an endarteritis. Syphilitic meningitis and endarteritis present essentially the same symptoms as in adults. Gummata of the brain or cord present no symptoms in themselves to distinguish them from other cerebral tumors (see page 978). The lesions in the cord are, however, apt to be widely distributed, involving the cervical, dorsal, and lumbar regions, with preservation of some of the functions and complete loss of others. The rapid diminution of some symptoms and SPECIFIC INFECTIOUS DISEASES. 539 the persistence of others are characteristic. The presence of syphilis elsewhere and the marked improvement under antisyphilitic treatment are important points in the diagnosis. Syphilitic endarteritis and multiple gummata of the base have been observed in infants as early as fifteen months. Treatment. — The treatment of the lesions which usually occur in the retarded form of syphilis is essentially with iodide of potash, either alone or in combination with some mercurial. The iodide of potash should be given at first in doses of 0.12 or 0.18 gramme (2 or 3 grains), and this dose should be gradually increased to 0.36 or 0.6 gramme (6 or 10 grains), or even more, as children often tolerate this drug remarkably well, and large doses are usually indicated. When iodide of potash is given in combination with mercury, it is well to begin with corrosive sublimate in doses of 0.0006 gramme ( T -^-g- grain) and gradually to increase the dose. Corrosive sublimate is, how- ever, so apt to cause disturbance of digestion that I prefer to treat these cases by giving the iodide of potash uncombined with any other drug, by the mouth, and by applying the mercurial ointment to the skin. The treatment of these later manifestations of syphilis must often be continued for long periods. The following case illustrates the retarded form of syphilis, and shows the importance of carefully reviewing the previous history not only of the child, but also of its parents. The child was a girl, thirteen years of age. The mother had had no other children nor any miscarriages. She had always been well, and had never shown any manifesta- tions of syphilis. The father, so far as could be ascertained, until recently had always been well and strong, and had shown no signs of syphilis. About one year previous he began to have cerebral symptoms, which rapidly increased, were accompanied by paralysis, and were undoubtedly of syphilitic origin. I was first called to see this child when she was suffering from a mild attack of appendicitis, which did not come to operation. At that time I noticed a peculiar con- formation of the upper incisors, which made me at once suspect a case of hereditary syphilis. On further inquiry I learned that she had been treated some years earlier by an oculist for keratitis. The upper incisors were abnormally far apart and stunted in their growth. They were notched, as was also the left lateral incisor, which was peg-shaped and by its clearly cut notch represented more nearly than the others the characteristic syphilitic teeth. The right upper lateral incisor had a peculiar shape, the crown of the tooth coming down almost to a point. The other teeth were in many places deprived of their dentine, and were in various stages of disorganization. On recovering from the appendicitis the child remained in a weak condition during the following year, looked sallow, and had continual headaches, which did not improve under the usual remedies. Treatment with iodide of potash was not only followed by the disappearance of the headaches, but also resulted in a healthy appearance of the child, who became perfectly well. The following case is an illustration of the various tertiary lesions of syphilis. 540 PEDIATRICS. A girl, three and one-half years old, had certain lesions on the face, arms, hands, and feet, which were the result of congenital syphilis. When this child was born she was apparently healthy. When she was three months old she was noticed to have occlusion of the nares, and at that time she had an attack of bronchitis lasting for three weeks. It was said that no efflorescence was ever noticed on her skin. When she was seven months old her hands began to swell, and at fourteen months the tissues around the metacarpal bones of the little fingers of both hands became reddened and ulcerated and the fingers assumed the pyriform shape characteristic of syphilitic dactylitis. Fig. 123. Late manifestations of syphilis. Female, 3% years old. When the child was about sixteen months old the feet began to swell, and in certain parts, especially the metatarsal bones of the right foot, the skin became red- dened. When the child was three years old pieces of dead bone began to come away from the hands, and this continued for some time. At the same age, swellings began to appear over the upper maxillary bones, and an extensive reddened and swollen condition of the tissues existed under the right eye. The fontanelles were closed. There were evidently a periostitis and an osteochondritis of the right arm, and there was also an enlargement of the left ankle, accompanied by ulceration on the outer side of the malleolus. The child was treated with the combination of mercury and iodide of potash shown in the following prescription : SPECIFIC INFECTIOUS DISEASES. 541 Prescription 79. Metric. R Hydrarg. chloridi corrosivi Potassii iodidi 3 Aq. destil 60 M. Gramma. 03 75 00 Apothecary. Hydrarg. chloridi corrosivi gr. ss Potassii iodidi 3 i ; Aq. destil. ^ ii. M. S. — 2 c.c. (^ drachm) 3 or 4 times in 24 hours. While it was taking this medicine all its symptoms ahated, it seemed better and brighter, and the lesions showed a tendency to heal. Whenever the medicine was omitted all the previous symptoms returned. The following case illustrates, among other interesting points, this same lesion of the bones. The boy was six years old. He was rather pale, and had a somewhat peculiar frontal development, which well illustrates one form of syphilitic head. There was a slight depression of the bridge of the nose and the bulging of the fore- head on either side just above the orbital ridges. These prominences were accentuated Hereditary syphilis. Male, 6 years old. Abnormal prominences of frontal bone. by the deep sulcus between them, extending from the depressed nasal bones upward almost to the margin of the hair. This condition represents the typical syphilitic head. The boy was in fair health, and had nothing abnormal about him on careful physi- cal examination. His mother brought him to the clinic to receive a course of treatment for a few months in order to prevent a recurrence of his infantile syphilis. The boy had been treated at the Children's Hospital when he was six weeks old. The mother had been well and strong, and had never had any other children nor any miscarriages. The father had had a primary syphilitic lesion one year previous to the birth of the child, which was followed by secondary manifestations. The mother had plenty of good breast-milk, and nursed her infant until he was nineteen months old. He was never atrophic, and although pale was apparently well nourished. At birth 542 PEDIATRICS. he showed a bullous efflorescence of medium grade. During the early weeks of his life he did not receive any medical treatment, although he had a general efflorescence of macules, pustules, and bullae. At about the fifth week he lost the use of his left arm. When seen at the sixth week he showed a number of lesions besides those described, and it was doubtful if he would live. These lesions consisted of fissures at the corners of the mouth, mucous patches in the mouth, condylomata of the anus, and occluded nares. There was not at that time the peculiarly formed head which is now present. The left arm was helpless and was supposed to be broken ; in fact, there was some crepitation, and probably there was a slight separation of the epiphysis of the distal end of the humerus. There seemed to be considerable pain in the arm, which made the infant restless and fretful. Insomnia was a prominent symptom. The arm was put in a light splint, and the oleate of mercury ointment (Prescription 78, page 532) was ordered. The infant was not seen for a week. When he was brought back to the hospital the right arm was found to be helpless, and the mother stated that the ointment had been discontinued, as it caused excoriation of the skin. The ointment was then re- duced one-half with lanoline, and hydrargyrum cum creta was given three times daily in doses of 0.06 gramme (1 grain). In three days he was much better, the paralysis soon disappeared, and nothing abnormal was detected about the arms. The hydrargyrum cum creta was increased to 0.24 gramme (4 grains), but as this caused diarrhoea the dose in a few days had to be reduced to 0.18 gramme (3 grains). In the course of the next month the nasal symptoms and the efflorescence had disappeared, and the infant seemed perfectly well. Six months later he was brought back to the hospital with a return of the condylo- mata and a slight papular efflorescence. The same treatment as before was carried out. The syphilitic manifestations disappeared, and did not return. He was kept under observation and treated from time to time for three or four years. The first teeth were cut at nine months, and were in fair condition. THE EXANTHEMATA. In contradistinction to the various diseases of the skin which derma- tologists are accustomed to designate as exanthems of local origin are certain acute, specific, infectious diseases which are called the exanthe- mata. This group of infectious diseases is of especial interest in con- nection with children, as it is among children that they most frequently occur. They can, however, attack individuals of any age. Although none of these diseases are entirely self-protective, yet the instances in which they develop in an individual more than once are rare. The exanthemata comprise five diseases, — scarlet fever, measles, rubella, varicella (chicken-pox), and variola (small-pox). Each of these diseases is characterized by certain conditions common to all. Besides being infec- tious, each disease runs a definite course and is self-limited, facts which should be remembered when we are studying its diagnosis and treatment. The course of these exanthemata from the time when the infection takes place up to the appearance of their later manifestations may be divided into distinct stages. In the first of these certain micro-organisms are supposed to enter the system, and, so far as external appearances and general symptoms are concerned, to remain dormant for a time, constituting what is called the stage of incubation^ This stage of incuba- SPECIFIC INFECTIOUS DISEASES. 543 tion is followed by certain general symptoms resulting from the supposed development of the special organisms and constituting the prodromal stage. These prodromal symptoms are, after intervals varying according to the special disease, followed by an efflorescence on the skin, which marks the third stage of the disease, called the stage of efflorescence. The efflores- cence in its turn is followed by what is called the stage of desquamation, this desquamation being more or less pronounced in proportion to the intensity of the lesions of the skin which have occurred during the stage of efflorescence. Although in a large number of cases the diagnosis of these diseases can be determined by the appearance of the efflorescence and its location, yet instances occur not infrequently in which the efflorescence is very misleading. We should, therefore, be familiar with the characteristics of the other stages, for it is by carefully considering the pictures which they present to us as a whole that we are enabled to make a correct differen- tial diagnosis of the especial case. Thus, a papular efflorescence, although significant in most cases of measles, may also be present in other members of the group, while an erythema closely resembling scarlet fever may occur in variola, measles, or rubella. SCARLET FEVER. Scarlet fever is an acute infectious disease, characterized by a short incubation, short prodromal stage, erythematous efflorescence, pronounced desquamation, and long course. The micro-organism which produces it has not yet been determined. With the exception of variola, it is the most dangerous of the group, and is therefore the most important of all the exanthemata. The complications of scarlet fever are so much more serious and its sequelae so much more common and grave than those of varicella and measles, that its immediate diagnosis and prompt treatment are of vital necessity in every community where numbers of children are liable to be attacked by the disease. Etiology. — Scarlet fever is the most irregular of all the exanthemata in its virulence and in the manifestations which it presents in different individuals. It is usually epidemic, returning to the same localities after a period of years. It is at times sporadic, and is commonly endemic in large cities. The epidemics of scarlet fever vary in severity, so that we cannot ascribe the virulence of the disease in certain years to individual susceptibility. The sporadic cases may be of the most malignant or of the mildest type. A mild case may give rise to a malignant case in another child, and a malignant case may give rise to a mild one. The epidemics of scarlet fever spread slowly, in contradistinction to those of measles, which spread rapidly. Scarlet fever may occur more than once in the same individual, but this is rare. Instances have occurred in which a child has had scarlet fever, and, on returning after several weeks 544 PEDIATRICS. to the same room, even after it had been disinfected, has again con- tracted the disease in its typical form. The source and identity of the contagium have not been definitely determined. The bacterial infection is secondary, and is mostly from the streptococcus pyogenes. The skin appears to be the chief vehicle of transmission. It has, however, been shown that the discharge from the nose and throat, both in the early stages of the disease and when they are prolonged even after the stage of desquamation, may be a source of infection. The contagium has a great tenacity for clothing and other articles, and may be capable for many months of reproducing the disease. In reference to what has been said concerning the slow spread of scarlet fever during epidemics in comparison with the rapid spread of measles, certain clinical facts are significant. The disease does not seem to be very infectious in its early stages. We are thus led to believe that it is during the stage of desquamation that the contagium is most likely to be disseminated. Measles, on the other hand, is known to be highly infectious in its early stages, and for this reason to spread more quickly. Although the contagium of both diseases may be active through their whole course, yet the general rule is early infection in measles, late in scarlet fever. The following cases illustrate this conclusion : A boy six years old and a girl four years old slept in the same room, with their beds touching each other. The boy was taken sick May 1, but remained in the same room with his sister during that day and the following night. He was seen by me early on the morning of May 3, and was then found to have scarlet fever. His sister was taken to the country, and the boy was left in charge of a trained nurse. There was absolutely no communication between the town-house and the country-house, either by people, clothes, or letter. I myself did not again see the boy during his sickness, having placed him under the charge of another physician. On June 1 I was called to see the girl, and found that she had scarlet fever. There were no other cases of scarlet fever in the vicinity of the country-house where she had remained since leaving the city. The boy at this time was desquamating freely, and four days previous to the girl's being taken sick a letter written by him had been sent to her, and she, after having had it read to her, had been allowed to keep it under her pillow. A careful study of this case led to but one conclusion, — that the boy during the period of his desquamation had infected his sister at a distance of twenty miles by en- closing the contagium of scarlet fever in an envelope. The girl, although she had been in the same room with the boy for thirty-six hours at the beginning of the disease, and although susceptible to the disease, had not contracted it at that time, owing to its very slightly infectious nature in its early stages. On the other hand, the stage of incubation of scarlet fever being only a few days, and many instances having proved that the dis- ease is very infectious during its period of desquamation, it was evident that the girl had been infected by means of the letter. In the following year, on May 20, I was again called to see the same boy. He had been well in the morning, but in the afternoon was found to have a high pulse and tem- perature, with coryza and lachrymation, so that it was deemed best to send the sister, who had been in the nursery only a few hours with her brother after he had been taken sick, to another house, while the boy was absolutely isolated. Three days later the boy was found to have measles. Ten days later the girl was attacked by measles. This SPECIFIC INFECTIOUS DISEASES. 545 case merely emphasizes the now commonly accepted belief that measles, in contradis- tinction to scarlet fever, is highly infectious in the early hours of the disease. "Whether the contagium of scarlet fever can be carried by the breath is somewhat doubtful, but it is probable that any of the excretions may contain it, and that it is especially liable to be transmitted by milk, cloth- ing, toys, books, carpets, and other articles. Scarlet fever may occur in certain animals, and the contagium may be transmitted by others, such as dogs and cats. An instance which leads me to believe that scarlet fever may be trans- mitted at a very early stage of the disease is the following : A child who had contracted scarlet fever a few days previously came to a party given in a small and practically isolated community. At this time the child was begin- ning to feel sick and to complain of a sore throat. A spoon which had been used by her was also used, before it was washed, by one of the other children. Six or seven days later this second child was attacked by scarlet fever. A careful and critical investigation of the possible origin of the second case re- sulted in the evidence strongly pointing towards a direct transmission of the contagium from the mouth of one child to that of the other by means of the spoon. Scarlet fever may occur at all ages, but is rare during the first year of life. It has been met with in young infants who were nursing, and who have proved to be the focus of infection for a whole household. The following table was compiled by McCollom. It represents the age and the number of deaths in one thousand cases of scarlet fever treated in the contagious wards of the Boston City Hospital : TABLE 65. One Thousand Cases of Scarlet Fever, by Ages, with the Deaths. Years. Under 1 year. 1 year .... 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years Cases. 24 66 115 99 124 106 64 62 58 53 21 20 23 10 12 10 Deaths. 20 21 Years. years , years . years . years . years . years . years . years . years . years . years . years . years . years . years . years . years . years . vears . Cases. 10 15 3 2 3 1 1 1 1000 Deaths. 1 3 1 1 98 35 546 PEDIATRICS. Pathology. — The organs primarily affected in scarlet fever are the skin and the throat. The principal complications which arise in the course of the disease are connected with the ear and the cervical glands. The chief sequela, and the only one which is at all common, is nephritis. Cardiac disease may occur, but is commonly secondary to the nephritis. Lesions of the other organs are somewhat unusual and have no defi- nite connection with the scarlet fever. They are generally due partly to the fever, partly to the septic processes which have arisen in the course of the disease, and are essentially those of acute inflammation with cellu- lar exudation, and with focal necrosis of the liver and kidneys. The changes are a marked infiltration of leucocytes in the tongue and in the desquamating skin. The internal organs show an infiltration with plasma- cells, and this is especially noticeable in the kidney in the acute interstitial form of nephritis. A proliferation of cells is found in the follicles of the lymph-nodes, and these cells are also often found infiltrating the coats of the veins, seeming in many places only to penetrate the endothelium and forming plugs in some of the smaller vessels. Hyperplasia of the lymph- nodes is a constant and marked characteristic. As a rule, the spleen is enlarged and shows marked follicular hyperplasia. (Pearce.) Skin. — Macroscopically the morbid conditions of the skin in scarlet fever, although varying in their manifestations, are usually represented by an intense general erythema covered thickly with minute macules, which are of a darker red than the accompanying hyperemia. Minute white spots may also appear thickly scattered over the reddened surface, prob- ably arising from areas of unaffected skin existing in the midst of the general hypersemia. An appearance like that of milium is also at times noticed to be scattered on the areas of skin affected by the erythema. No evidence of this hypersemic condition, which is so pronounced during life, is found after death. According to Neumann, microscopic examinations of the skin by means of hardened sections of specimens from cases of scarlet fever and measles in the stage of desquamation explain in a measure why the former is so much more likely to be infectious during its stage of desqua- mation than is the latter. In contradistinction to the pathological pro- cesses which are found in the skin in measles, and which affect chiefly the blood-vessels and glands, a very different picture is presented on examination of sections of skin taken from cases of scarlet fever. In the latter we find the pathological process represented especially by exudative cells, which are very numerous and closely packed together, reaching even up to the horny layer of the epidermis. Occasionally these exudative cells may finally take the place of the epidermal cells, appearing on the free surface of the skin, and are gathered thickly among the excretory ducts of the cutaneous follicles. It is thus readily understood why the tissue proper of the skin and its epidermis present no marked changes in measles, and why the epidermal cells are far less likely to carry the contagium than SPECIFIC INFECTIOUS DISEASES. 547 in scarlet fever, in which the possibility of contagium exists until the des- quamation has entirely ceased. Throat. — The earliest lesions of scarlet fever appear on the mucous membrane of the hard and the soft palate. This appearance is very similar to the efflorescence which is seen on the skin, except that the minute white spots do not appear on the congested mucous membrane. Forchheimer states that the exanthem of scarlet fever appears from twelve to twenty-four hours before the efflorescence ; it appears upon the pillars of the fauces in the form of the characteristic puncta, then rapidly spreads over the mouth in the form of a scarlet-red coalescing efflorescence, which finally ends in desquamation, producing the strawberry tongue, and lasting well into the second week of the disease. These pathological conditions which occur in the throat in scarlet fever may either be simply catarrhal, or result in one of the more severe inflammatory conditions affecting the tonsils, the pharynx, and the larynx. The tonsils are uniformly and extremely bright red, and are thus to be differentiated from their dusky red color in cases of diphtheria before the membrane has appeared. On the hard and soft palate a punctate efflorescence is seen, and this appearance in from twenty-four to forty- eight hours may assume a yellowish color not ordinarily seen in catarrhal conditions of the throat or in diphtheria. When a membrane is seen it is impossible without a culture to differ- entiate conclusively from diphtheria. In many cases, however, we can make a fair diagnosis by the color of the membrane in scarlet fever being whiter and the thickness less, as a rule, than in diphtheria. As is stated by Delafleld and Prudden, one of the most marked features of scarlet fever is the predisposition which it entails to the incur- sion of pathogenic germs other than those which we believe to cause this disease. Thus, in addition to the inflammatory lesions produced by the scarlet fever organism an acute exudative inflammation of the mucous membrane may occur, and may be associated with them. This is appa- rently caused by the growth of a streptococcus which, according to Welch, in morphological and biological character seems to be identical with the streptococcus pyogenes. In these cases there may be much or little fibrinous exudate, and there may be none at all in the early stages, or even through the whole course of the affection. The pellicle when formed may be more or less adherent, and sharply circumscribed, or it may tend to spread. The submucous tissue may show little change, or much congestion and oedema, or it may be the seat of suppurative inflammation. The entire process may be confined to the tonsils. While under these varying con- ditions the inflammatory process is usually a local one and runs its course, with or without the symptoms of septicaemia, occasionally the streptococcus finds access to the blood and may induce the lesions of pyaemia. On the other hand, it may by inhalation gain access to the lungs and induce varying phases of complicating broncho-pneumonia. 548 PEDIATRICS. The staphylococcus pyogenes is not infrequently associated with the strep- tococcus in these lesions, but it is not apparently of great significance. Simulating very closely as it does in many cases both the local and the general phenomena of diphtheria, this pseudo-membranous condition was formerly confounded with it, but it is now recognized as a distinct disease. There have been a number of extended investigations made on what are called the pseudo-membranous inflammations of the throat in scarlet fever. Booker has reported eleven cases of pseudo-membranous angina (two fatal) complicating scarlet fever, and one case of simple angina with- out exanthem in a family three members of which had scarlet fever. In all these cases, as well as in four scarlatinal anginas without pseudo-mem- branes, Booker found streptococci as the predominant organism, and in none was the Klebs-Loeffler bacillus present. The staphylococcus aureus was found in eleven cases without apparent influence on the severity of the disease. No difference was observed between the early and the late pseudo-membranous anginas in regard to the bacteria present. Booker describes with much detail the morphological and bacteriological charac- teristics of the streptococci found, and divides them into groups. Park, in a series of one hundred and fifty-nine cases, reports nineteen cases of pseudo-membranous inflammation of the throat complicating scarlet fever. In seventeen of these cases streptococci predominated, and in only two was the Klebs-Loeffler bacillus present. Staphylococci were found in only a few cases. Williams has also reported cases of this kind, and Morse has reported ninety-nine cases of pseudo-membranous inflammation of the throat complicating scarlet fever. The Klebs-Loeffler bacillus was found in twenty-three, with a mortality of forty-three per cent., and was not found in seventy-six, Avith a mortality of twenty-one per cent. Finally, we may conclude that in scarlet fever the mucous membrane of the throat is rendered peculiarly vulnerable to the invasion of patho- genic germs. When the morbid condition in the throat is represented by a pseudo-membrane it will be found that in the great majority of cases the process, as stated by Welch, is due to streptococci ; but when diph- theria is prevalent and the opportunities are favorable for exposure, a large portion of the pseudo-membranous cases may be due to the Klebs- Loeffler bacillus. In addition to the lesions of the throat just described, the micro- organism of scarlet fever may attack the nasopharynx. In this way, and by direct extension through the Eustachian tubes, secondary aural lesions may be produced. The morbid changes in the mucous membrane of the nasopharynx which thus take place may result in a thickening of the tissues, which in some cases lasts for many months after the scarlet fever has run its course. Ear. — The pathological condition of the ear which is most commonly SPECIFIC INFECTIOUS DISEASES. 549 met with in scarlet fever is an acute inflammation of the middle ear. This inflammation is likely to result in destruction of tissue, the formation of adhesions, the establishment of a long-continued suppurative process, and an accompanying necrosis. Cervical Li/mph-Xodes. — -There may be hyperplasia of the cervical lymph-nodes. This condition is sometimes accompanied by inflammatory oedema of the tissues of the neck, which may go on to suppuration and even to gangrene. In these cases streptococci are found in the glands and in the areas of suppuration. The infection is supposed to originate in the throat. The enlarged glands are, as a rule, indicative of secondary or mixed infection, although it is possible that the slighter forms of enlarge- ment may be due to reflex irritation with resulting hyperplasia from the scarlet fever contagium. In the severe form the glands are at times very much enlarged, and when a gangrenous process results the blood-vessels may be affected to such an extent as to be ruptured. Kidney. — In scarlet fever, as in a number of other infectious diseases, there are certain poisons produced in the course of the disease which are probably soluble in character. The results of bacteriological cultures in scarlet fever have shown that in a number of cases there is a general strep- tococcus infection, the infection probably coming from the lesions in the pharynx. In these cases of general infection streptococci may be cul- tivated from most of the organs of the body, there being a general septi- caemia. In a number of these cases extensive lesions may be found in the kidneys, and yet these lesions may bear no relation whatever to the presence or absence of streptococci. In like manner, streptococci may be found in the kidney without any lesion of the kidney. These lesions are diffuse, and affect both kidneys and all parts of the kidney. From the best evidence which we have it would seem that the virus, or whatever it is which produces the lesions in the kidney, is not a living organism, but is a soluble chemical poison produced by the organisms of scarlet fever, or by other organisms located in some other part of the body. This soluble poison when produced elsewhere is taken locally into the blood and affects various parts of the economy. In post-mortem examinations of scarlet fever certain lesions will usually be found in the kidneys. These lesions, according to Councilman, may be divided into two classes, (1) represented by simple degeneration of the epithelium, and (2) represented by marked changes in the tissues of the kidney. In the first class of cases the soluble poison may only affect the integ- rity of the capsular epithelial cells of the glomeruli. The poison may produce certain degenerative changes in these, but need not be accompa- nied by any proliferation of cells, or by any condition which would be characterized as inflammatory. It is more than probable that these sim- ple degenerative lesions are accompanied during life by evidence of albu- minuria, and in case death takes place there may be no macroscopic evidence of any lesions in the kidneys. Careful microscopic examination, 550 PEDIATRICS. however, will show a condition of degeneration in the capsular epithelium of the glomeruli. Associated with this there will usually be found cloudy swelling of various degrees of intensity in the cells of the convoluted and the smaller collecting tubules. The degeneration here is rarely of a fatty character. Clinically, in the purely degenerative changes there may be only albuminuria with the presence of faint hyaline casts, and here and there a few leucocytes. In the second class, owing to a greater intensity in the action of the poison, or to some possible difference in its character, more marked changes may take place in the kidney, and may be accompanied by the degenera- tive lesions which are distinctive of the first class. Different forms of lesions may occur in the second class, and, according to the predominance of one form over the other, may characterize a special form of renal dis- ease. These lesions may be divided according to their anatomical distri- bution into interstitial, in which there is marked proliferation of the inter- stitial tissue of the kidney, and glomerular, in which the lesions are chiefly confined to the glomerulus and its capsule. In the interstitial form there will be found in the interstitial tissue be-, tween the tubules accumulations of cells, the source of which is not clear, although they probably come from the blood. Most of these cells have the character of plasma-cells, but among them are a few lymphoid cells and polynuclear leucocytes. This form of nephritis should be considered as purely interstitial, since its lesions are in no way related to those of the epithelial tissue. There is both a general and a focal infiltration of cells in the interstitial tissue. The focal infiltration is found principally in the cortex of the kidney and about the glomeruli, the glomerulus frequently appearing as a centre from which the infiltration extends into the intersti- tial tissue between it and the surrounding tubules. This form of nephritis was first described by Wagner as the lymphoid kidney. The kidney, macroscopically, is swollen ; the capsule is easily stripped from the cortex, and is moist, whitish, and opaque. Usually there is no evidence of hemorrhage, although in some cases points of punctiform hemorrhage may be found in the cortex and in the intermediate zone. Clinically, in this form there may be little evidence of the severity of the lesions. There may be, however, albuminuria corresponding to what is seen in the purely degenerative class. The quantity of the urine may be very little diminished, and casts may be present, as well as a certain number of desquamative epithelial cells and leucocytes. These lesions are not confined to scarlet fever, but may be found in diphtheria, in measles, and in other infectious diseases of children, but they are not common in the infectious diseases of adults. Fig. 125 represents a microscopic section, made by Councilman, and is a good example of these interstitial lesions in scarlatinal nephritis. The section was taken from a case of pure scarlet fever. There was no anuria and no dropsy. The kidneys were enlarged, whitish, and without SPECIFIC INFECTIOUS DISEASES. 551 hemorrhage. Cultures from this case gave a general infection with strep- tococci in all the organs except the kidney, and yet the kidneys, notwith- standing the extent of their lesions, were found to be free from strepto- cocci. The epithelium of the tubules was somewhat swollen. The tubules Fig. 125. 7 "-W#!^^o'-— •oTfe^'N- Interstitial nephritis. Section of kidney from child with scarlet fever. (Hartnack, ocular No. II., objective No. VIII. Tube closed.) themselves were slightly dilated, and the epithelium was more granular than normal. The interstitial tissue was much more extensive than normal. The spaces between the tubules were increased both by oedema and by cellular infiltration. In the interstitial tissue blood-vessels were seen filled with cells of the same character as those outside. It is probable that most of the cells outside the vessels came from proliferation of the cells of the blood-vessels. The round spaces in the interstitial tissue represent blood- vessels. Another form of nephritis, called the glomerular, is much more fre- quently found in scarlet fever than in any other of the acute infectious dis- eases of children, but is not so common as the acute interstitial form. In this glomerular form the chief lesion of the disease consists essentially in a proliferation of the capsular epithelium combined with hyperplasia of the connective tissue. The proliferation of the capsular epithelium leads to the formation of masses of cells within the capsule between the glomerular capillaries and the capsule. These cells evidently result from the proliferation of the capsular epithelium. As a result of this there may be greatly increased pressure on the vessels of the glomerulus, possibly with an obliteration 552 PEDIATRICS. of these vessels. The cellular infiltration in the interstitial tissue is not so extensive as in the other form. Accompanying these changes in the glomerulus there is almost always more or less hemorrhage both in the tubules and in the interstitial tissue. Fig. 126 represents a section made by Councilman of glomerular ne- phritis. This section was taken from a case of scarlet fever complicated by glomerulo-nephritis. In the centre of the field a glomerulus is seen, Fig. 126. Capsular glomerulo-nephritis. Section of kidney from child with scarlet fever. (Hartnack. ocular No. II., objective No. VIII. Tube closed.) with an infiltration of cells in the capsular space. The capsular cells are oval and distinctly epithelial in character. Cellular proliferation of the cells having generally the character of those in the section of interstitial nephritis (Fig. 125) is to be seen in the interstitial tissue. In the tubule at the left upper corner there is evidence of hemorrhage, and some hemor- rhage is also to be noticed in the interstitial tissue on the right of the specimen. In this case the anuria and dropsy were extreme. This form of nephritis may be best designated as capsular glomerulo- nephritis. The kidney is swollen and much more hyperaemic than in the interstitial form. The markings of the cortex either are obscured or can- not be made out at all, and there are numerous areas of hemorrhage and hyperemia, giving the kidney a mottled appearance. It is this capsular glomerulo-nephritis which gives the most marked SPECIFIC INFECTIOUS DISEASES. 553 clinical evidence of the extent of the lesions in the kidney. In this form dropsy is almost always present, the amount of urine is greatly dimin- ished, and in the more severe cases there may be complete anuria. Blood-casts are found more frequently in the urine than in the interstitial form The diminution in the amount of the urine points to involvement of the glomerulus. Even severe cases of this form may be recovered from. The process of cell-proliferation may cease, the cells formed in the capsular space may disappear and pass out, and the kidney in after- years may show few or no evidences of the process through which it has passed. In a certain number of cases, however, from this form of nephritis a chronic nephritis is developed. Cases of this kind have been reported, notably one by Aufrecht. In both the interstitial and the capsular glomerulo-nephritis fatty de- generation of the epithelium is not found to any degree. The epithelium is frequently swollen and granular, and may be hyaline. These two forms of nephritis should be separated from each other, although transitions between their lesions are found. Usually they can be distinguished microscopically. We can, therefore, recognize three pathological conditions of the kid- ney in scarlet fever : first, the purely degenerative ; second, the acute inter- stitial ; and third, the capsular glomerular. Heart. — The pathological conditions of the heart which are at times found in scarlet fever do not differ in their macroscopic appearances from those met with in other diseases. Cardiac disease occurring in the course of scarlet fever may arise in two ways : (1) from the general septic con- dition existing during the period of the height of the temperature and general efflorescence, and represented usually by an endocarditis ; (2) at a much later period from a nephritis which has arisen as a complication, and following which, from the resulting increased blood-pressure, en- largement of the heart has been produced, which may be represented by hypertrophy or by dilatation, or by both. In connection with this subject, Silbermann has found on examining a large number of cases of nephritis during attacks of scarlet fever a decided hypertrophy of the heart combined with dilatation. In some cases both sides of the heart were equally affected, but usually only the left side was involved. In only a few cases was there found a partial fatty degeneration of the muscular fibres ; the endocardium, pericardium, and blood-vessels were normal. According to Silbermann's observations, the cardiac affection was related to the post-scarlatinal nephritis, and not to the scarlet fever process itself, as the hypertrophy was never found when the child died in the early weeks of the scarlet fever. He calls atten- tion to the short period which intervened between the first appearance of the nephritis and the consecutive heart hypertrophy, in many cases the time not being much longer than a week. He also noticed that in the cases in which hypertrophy and rapid dilatation followed the acute ne- 554 PEDIATRICS. phritis of scarlet fever the ages of the children were three and a half, four, five, and six years, and the post-scarlatinal cardiac enlargement corresponded to the physiological hypertrophy referred to on page 91. Incubation. — The stage of incubation of scarlet fever is uncertain and irregular, but, as a rule, it is shorter than that of any of the other ex- anthemata. It is usually less than seven days, and quite frequently it is only from two to four days. Variations in the Type of Disease. — Scarlet fever may be divided into two forms, the benign form and the malignant form. The difference in the symptoms of the common, or benign, form of the disease from those of the rare, or malignant, form is very striking. They could well be classified as entirely separate diseases, were it not that the contagium has been proved to be the same in each, by the fact that one form of the dis- ease may give rise to the other in different individuals. It seems as though it were more the susceptibility of the individual to the scarlet fever contagium than the contagium itself which produces a greater or less severity of the symptoms. BENIGN FORM OF SCARLET FEVER. The benign form of scarlet fever either runs a simple typical course or is accompanied by variations and complications, which makes its course irregular. Symptoms. — Prodromata. — The invasion of the disease is usually sud- den and, as a rule, active. The child feels very sick, looks dull, com- plains of sore throat and nausea, and in a large number of cases vomits continuously. The vomiting usually ceases in the stage of efflorescence and often before the prodromal stage has ended. The pulse is rapid. The temperature is high,— 39.4°, 40°, 40.5° C. (103°. 104°, 105° P.). In infants and very young children if the temperature rises to 40° or 41.1° C. (104° or 106° F.) convulsions are very likely to occur. The higher the temperature at the beginning of the disease the more active the symptoms, and the shorter the prodromal period the more severe will be the case. An initial temperature of 40° C. (104° F.) points towards a severe case. Young children seem to show a less sensitive condition of the throat than is met with in older children and in adults. The appearance of the mucous membrane of the throat, although perhaps not characteristic, as at times a simple non-infectious pharyngitis may simulate it quite closely, is, in connection with the general symptoms, at least suggestive. The mucous membrane of the hard and the soft palate and of the pharynx is much congested. On the hard and the soft palate thickly scattered over the reddened surface are minute macules the color of which is a little darker red than that of the intervening mucous membrane. This condi- tion represents the earliest stage of the efflorescence which later appears on the skin. SPECIFIC INFECTIOUS DISEASES. 555 The length of the prodromal stage varies, as a rule, from twelve to thirty-six hours. During this stage the temperature continues to rise somewhat, and at its end the efflorescence appears on the skin.. Efflorescence. — The efflorescence of scarlet fever is of an erythematous and punctate character, sometimes looking as though minute macules had been sprinkled over the general redness of the skin. It starts on the front of the neck and the upper part of the chest, and rapidly extends all over the body and extremities, and upward to the face. This charac- teristic order of invasion of the skin aids us in distinguishing the efflores- cence of scarlet fever from that of the common erythema which occurs in such diseases as pneumonia, and in cases in which certain drugs, such as belladonna, have affected the skin and the efflorescence comes ' out everywhere at once and has an irregular distribution. It also enables us to distinguish the disease from measles, in which the efflorescence begins on the sides of the neck and on the face and extends downward. On gently drawing the finger over the efflorescence of scarlet fever the result- ing white mark remains longer than is the case with a common erythema. The efflorescence of scarlet fever continues to extend over the body for two or three days after its first appearance. Daring this period the tongue is much reddened and its papillae appear very prominent, consti- tuting what has been called the " strawberry tongue." This condition is to be distinguished from the enlarged papillae seen at an earlier stage of the disease on the tip and sides of the tongue. McCollom, in a study of one thousand cases, describes this latter condition as diagnostic of scarlet fever. There is at times in this stage great irritation of the skin. There may be slight delirium even in mild cases during the stage of efflorescence. This delirium may be very active and yet not be of serious import, provided the temperature remains moderate. The temperature rises when the efflorescence appears, and reaches its maximum at the end of the outbreak, in uncomplicated cases, but there is no decided rise just before or fall after the height of the efflorescence as is the case in measles ; on the contrary, the temperature slowly di- minishes until the ninth or tenth day from the beginning of the prodro- mal symptoms, when it becomes about normal, showing no decided crisis such as is seen in measles, but representing a defervescence by lysis. Chart 20 represents the temperature as it commonly occurs in cases of scarlet fever of the benign and regular form. The pulse is accelerated during the period when the temperature is elevated, and corresponds to it. It varies from 120 to 160. Desquamation. — The stage of desquamation begins at about the seventh day from the time when the efflorescence first appears, and in the parts of the skin first attacked. The desquamation, however, is not always proportionate to the intensity of the efflorescence. It is at first composed of small particles of cutis, but these soon become larger, and early in the third week from the beginning of the disease 556 PEDIATRICS. they fall from the body in large flakes. This form of desquamation is called lamellar. Here, again, we have an important means of dis- tinguishing scarlet fever from measles, for in measles the desquamation is almost universally of a furfuraceous character throughout the whole ( 3HAKT 20. Dai/s o/l/?z'sem V, an oe IU Di se 2 St J ' Varicella gangrenosa. , abnormal was found in connection with the lungs, heart, or kidneys. Until the child was attacked with varicella the temperature was usually normal, but sometimes rose to 37.7° C. (100° F.), and occasionally as high as 38.3° C. (101° F.). About one month before entering the hospital the child became restless, and his temperature rose somewhat. On the following day the symptoms became more marked, and the temperature was found in the evening to be 39.4° C. (103° F.) On this day an efflorescence of varicella appeared on his skin. During the third day of 612 PEDIATRICS. his sickness his face swelled, and in the evening his temperature was found tc be 41.1° C. (106° F.). The vesicular efflorescence was well developed on his trunk and face by this time. Somewhat later it became universal and assumed a purulent char- acter, especially about the face. During the fourth, fifth, and sixth days of the dis- ease his temperature varied in the evening from 39° C. (102.2° F.) to 39.4° C. (103° F.). On the seventh day of the disease all the symptoms increased in severity, and the temperature was found to be 41.1° C. (106° F.) On this day some of the vesicles on the face had become ulcers. Nothing abnormal was found in the lungs, and no albumin or casts in the urine. A psoas abscess developed during the progress of the varicella. The ulcers on the face extended to such a degree that the child lost the sight of one of its eyes. The child sank rapidly. The treatment, which was essentially with stimulants, failed to keep up its strength, and the local treatment in connection with the eye proved entirely unsuccessful. The child continued to grow weaker, and died on the thirtieth day from the time when the first symptoms of the varicella were noticed. No autopsy was obtained. DIFFERENTIAL DIAGNOSIS OF THE EXANTHEMATA. The characteristics of this group of exanthemata are as follows. In none of these diseases has the specific organism been determined. When it shall have been, its detection will enable us to state definitely what disease we have to deal with, and even in the atypical cases of measles we shall be able to decide whether it is a case of true measles or some disease such as rubella, which closely simulates its irregular forms. The following table presents the chief points of differential diag- nosis in the exanthemata : TABLE 68. Scarlet Fever. Measles. Rubella. Variola. ! ■ i Varicella. Incubation 4 davs. 10 davs. 21 days. 12 days. 17 days. Prodromata . . . . 2 da vs. 3 days. A few hours. 3 days. A few hours. Efflorescence ... Erythema. Macules. Papule, Papules. *$£ Pustules. Vesicles. Desquamation . . ; Lamellar. Furfuraceous. Large crusts. Small crusts. Complications Kidney. Eye. Lung. Tuberculosis. Larynx. Lungs. and sequelae . . Heart. In addition to the leading points which are indicated in the table, the general symptoms, the topography, and the temperature of these diseases distinguish them from each other. The slow progressive development of variola is very distinct from the acute, rapid course of all the others. The vomiting and sore throat of scarlet fever are usually quite distinct from the coryza, lachrymation, and SPECIFIC INFECTIOUS DISEASES. 613 cough of measles. In variola the rise of temperature during the pro- dromal stage, its decided lessening at the time of the appearance of the efflorescence, and its gradual rise again during the stage of suppuration, are very distinct from the sudden rise of temperature in scarlet fever during the prodromal stage and up to the height of the efflorescence. In like manner the temperature in measles differs from that of the other diseases in its sudden rise on the first day of the prodromal stage, in its- lessening on the second day, and in its rise on the third day and up to the height of the efflorescence. The manner of the decline of the tem- perature differs in variola, in scarlet fever, and in measles. While in variola it is slow and prolonged, in scarlet fever it is rather rapid, although it declines by lysis, and in measles the fall is often by crisis. In contradis- tinction to variola, scarlet fever, and measles, varicella and rubella differ markedly in the absence of a prodromal stage, in their short duration, and in their evanescent and moderate temperature. PAROTITIS. Etiology. — Parotitis (mumps) is a highly infectious disease which attacks the parotid gland. No specific organism has been determined. Its period of incubation is usually from two to three weeks, but cases in which the period was only three or four days have been reported. Symptoms. — The onset of the attack is usually accompanied by a sense of chilliness, a rise of temperature, and a sensation of stiffness and tenderness about the jaws. This is succeeded by a swelling in the region of the parotid gland, which becomes enlarged and tender, rendering deg- lutition difficult and often very painful. The disease begins on one side, but the other gland is usually involved in a day or two. The infection is sometimes confined to the submaxillary glands on one or both sides. The duration of an attack of parotitis is from a few days to a week, but the infection may last for two or three weeks, and it has been stated in some cases to antedate the appearance of the glandular enlargement. In boys at the age of puberty the complication of orchitis at times arises. Although the symptoms of parotitis are commonly very mild, un- usual cases sometimes occur in which the children are quite sick, and there have been instances in which the orchitis was of so high a grade that acute delirium supervened, and in one case reported by Dukes the boy fainted when the orchitis began. Exceptionally, some cases of parotitis are marked by general malaise with little or no pain. Diagnosis. — It is sometimes difficult to differentiate parotitis from a simple non-infectious enlargement of the parotid gland or of the glands in its neighborhood. When the parotid gland is enlarged it usually shows a characteristic swelling under and behind the lobe of the ear, so that the lobe is pushed somewhat upward and forward. This swelling increases rapidly, is very tender, is not especially reddened, does not fluctuate, and 614 PEDIATRICS. Fig. 129. is accompanied by constitutional symptoms. The diagnosis is readily made if after a few days the unilateral swelling is followed by correspond- ing symptoms on the opposite side. Treatment. — There is no especial treatment for the disease, as it is self-limited and runs a definite course. The children should be carefully isolated, in order that there may be no further spread of the affection. As deglutition is painful, their diet is usually milk and soups. They should be carefully protected from exposure, and should be confined to their rooms. Older children should be confined to bed, as orchitis in boys and trouble with the mammae in adolescent girls are less likely to arise under these conditions. It is usually better to apply some soft cotton-wool to the painful swelling, and to protect it from any irritation. Submaxillary Mumps. — The submaxillary glands are enlarged in children from various causes. At times the enlargement of the glands is accompanied by pain and tenderness, constituting a disease which has been called submaxillary mumps. In the beginning, however, we should not at once make this diagnosis, as the glands may become enlarged and tender from various causes which have no connec- tion with the specific disease mumps. Fig. 129 represents a probable case of submaxillary mumps. The child, a girl two years and four months old, was suddenly attacked with a swelling of the submaxillary glands, accom- panied by pain and a slight amount of tender- ness over the swollen region. She had a his- tory of exposure to parotitis. On the follow- ing day the swelling had extended under the entire chin and up the left side of the neck to the face and ear. The swelling, pain, and tenderness lasted for a number of days and then gradually sub- sided. Nothing more definite was discovered regarding the case. The diagnosis in a case of this kind must be held in abeyance for a few days, and strict isolation should be enforced, as, if the cause of the glandular enlargement proves to be infectious, other children should be protected. Submaxillary mumps. DIVISION IX. DISEASES OF THE MOUTH, NOSE, EAR, NASO- PHARYNX, AND PHARYNX. DISEASES OF THE MOUTH. Nomenclature. — Much confusion exists as to the nomenclature of dis- eases of the mouth. A great variety of names has been used by different authors to describe the same disease, so that at times it is quite difficult for one investigator to compare his work with that of another. Such terms as " canker" and " aphthae" are so commonly used for almost any morbid condition of the mucous membrane of the mouth that they have ceased to convey any definite idea. In order to obviate this difficulty the American Pediatric Society has adopted a provisional nomenclature of the diseases of the mouth which was prepared by Dr. Forchheimer, of Cincinnati, and myself. To Dr. Forchheimer's extended investigations on this subject I am much indebted. Diseases of the mouth occur more frequently and in much greater variety in infancy and in early childhood than at any later period of life. This depends partly on the anatomical conditions at different periods of development and partly on the external influences which are brought to bear upon the buccal mucous membrane. During the first three or four months of life the function of the salivary glands is not developed, and the flow of saliva is insignificant. This lack of saliva allows the mucous membrane of the mouth to be dry in comparison with that of the older subject. Even after the saliva is secreted the infant is more apt under certain conditions to let it flow from the mouth than to swallow it, so that the mucous membrane of the lips and mouth may present a different appearance in young infants, when they are attacked by various morbid processes, from that seen at a later period of development. We must also remember that the salivary glands in addition to their especial func- tion are excretory organs, and that substances which are absorbed by the stomach may be eliminated by the mouth and in this way become sources of irritation and disease in the latter. The mucous membrane of the mouth during almost the whole period of infancy is subject to external sources of irritation to which older children, as a rule, are not liable. Thus, during the first year the mucous membrane is subjected to more or less mechanical irritation through the mechanism of sucking. At this 615 616 PEDIATRICS. period, also, it is very common for foreign organisms to be introduced into the mouth by means of the fingers either of the infant itself or of its at- tendant. It is not surprising, therefore, that we should meet with a great variety of pathological conditions in the mouth in infancy. The organisms which occur in the mouth are so numerous that very few of them have as yet been differentiated in such a way that they can be known as the cause of the specific disease in which they are often found. We cannot, therefore, at the present time describe the various diseases of the mouth under their proper etiological headings, and we are forced to adopt provisionally the name of the pathological lesion which exists in them. In almost every disease of the mouth which occurs in infants and in young children there is a coexisting inflammation of the mucous mem- brane. This inflammation may at times be very mild and often difficult to detect as such, but it still presents a recognizable pathological condi- tion. This inflammatory condition, although not necessarily preceding the various diseases, yet in a large number of cases either exists as a basis on which the disease develops, or so closely accompanies it that the general name stomatitis (inflammation of the mucous membrane of the mouth) seems to be a proper term to use in connection with all these diseases. Under the general heading stomatitis we can speak of most of the important diseases which affect the mucous membrane of the mouth in infancy and early childhood. These diseases may be divided into four general headings, according to the character of the lesions which occur in them. The following table represents the provisional nomenclature of dis- eases of the mouth adopted by the American Pediatric Society : TABLE 69. f Simplex. Stomatitis Catarrhalis. Herpetica Ulcerosa. . Mvcetosrenetica. Exanthematica Traumatica. Secondary to the Exanthemata. [ Mechanical. J Thermal. I Chemical. Aphthosa. Scorbutus. f Arsenic. Mineral Poisons J Lead. .-,-,-,. I Mercurv And other diseases. - Hyphomycetica Pseudo-Membranosa. I ^ Gangrenosa . .Thrush. f Diphtheria. I Tuberculosis. j Syphilis, [ and like diseases - . .Noma DISEASES OF THE MOUTH. 617 In accordance with this table the four general names which cover all these diseases are stomatitis eatarrhalis, stomatitis herpetica, stomatitis ulcer- osa, and stomatitis mijectogenetiea. STOMATITIS CATARRHALIS. Stomatitis Simplex. — The form of stomatitis eatarrhalis which is called the simple or erythematous form is commonly seen in young infants as a hypersemie condition of the blood-vessels, causing diffuse redness of the whole buccal mucous membrane. This erythematous form is so common and so entirely without clinical significance that it may be con- sidered as physiological and need only be referred to. Stomatitis Exanthematica. — The second form, which is called ex- anthematica, is the condition of the mucous membrane which occurs secondarily to the exanthemata, and has already been described in con- nection with these diseases. It therefore need not be spoken of again. Stomatitis Traumatica. — The third form, which is called traumatica, is the one which represents the characteristic stomatitis eatarrhalis. The causes of the traumatic form of stomatitis eatarrhalis are very numerous. They may be mechanical, thermal, or chemical. Mechanical. — Among the most common mechanical causes may be cited the irritation produced by rubber nipples, too vigorous cleansing of the mouth, injudicious rubbing of the gums during dentition, and local irritation from a tooth. Thermal. — The thermal form of traumatism may result from the admin- istration of food which is too hot. Chemical. — The chemical irritation may arise in various ways, as from lack of cleanliness in the mouth, with its resulting fermentation, and from the elimination of irritating products from the glands apparently con- nected in some way with disturbance in the gastro-enteric tract. It is probable also that various forms of bacteria or their products may cause both mechanical and chemical irritation of the buccal mucous membrane. Our knowledge of the bacteriology of the mouth is as yet, however, so limited that we can scarcely undertake to describe the relation between special forms of bacteria and special lesions of the mucous membrane. Pathology and Symptoms. — As the lesions which are seen in the mouth of an infant with stomatitis eatarrhalis during life almost entirely dis- appear at death, and as very few post-mortem examinations have been made of these lesions, we can speak of the pathology and symptoms of this disease together. The lesion is essentially an inflammatory one, and occurs in different grades. On examining the mucous membrane in these eases it is seen that the entire lining of the mouth is intensely reddened, that the tem- perature of the mouth is increased, that there is usually a certain amount of swelling, and that, although the mucous membrane may be dry under 618 PEDIATRICS. certain circumstances, especially at first, yet. as a rule, there is later a hypersecretion of mucus and saliva. The blood-vessels are so dis- tended and their walls so weak that the slightest traumatism may cause their rupture, and the saliva is frequently mixed with a little blood. In older children the mucous membrane may be considerably swollen, espe- cially behind the incisor teeth. In addition to this general condition of the mucous membrane of the mouth, at times the lips are found to be swollen and much reddened. The surface of the mucous membrane shows a number of small round prominences, which are the muciparous follicles. If complete occlusion of the ducts of these follicles occurs, great dilatation of the gland will take place, and a cyst may be formed. This, however, is a comparatively rare complication. In connection with the disturbance of the glands in the mouth the lymphatic glands are usually involved secondarily. When the catarrhal condition is at its height the mucous membrane is so vulnerable that even slight traumatisms may cause abrasions. The most marked symptom of stomatitis is pain. The infant is restless, usually has a heightened temperature, and refuses to take its nourish- ment. The saliva is acid in its reaction, and when secreted in large quantities flows out of the mouth upon the chin and neck, sometimes causing considerable irritation. The tongue is dry and white at first, then becomes of a grayish color, and as the secretion of saliva increases the coating of the tongue is washed off and its surface becomes red. Prognosis. — The prognosis of stomatitis catarrhalis is, as a rule, good. Although the disease does not run a definite course, yet in most cases after a few days the pathological condition improves and the symptoms grow less severe. The course of the disease is. however, often lengthened by the secondary conditions which arise from the gastric disturbances, which may be caused by swallowing the irritating secretions of the mouth. In weak, poorly nourished infants who refuse to nurse or to take the food which is given them, serious results may arise from a lack of sufficient nourishment, so that in these cases the prognosis is always grave. In older children the prognosis is very good. Treatment. — Although stomatitis catarrhalis may run a favorable course without any treatment whatever, yet there are so many causes which may prolong its course or give rise to secondary affections that it is exceedingly important to treat the disease at once. The indications for treatment are to relieve the pain and to allay the irritation of the mucous membrane so that a sufficient amount of nourishment may be taken by the infant to prevent it from being harmed by a lack of nourish- ment or by a secondary disturbance of the gastro-enteric tract. If the cause can be ascertained, it should be removed at once. The local appli- cation of a one to two per cent, cold solution of bicarbonate or borate of sodium in distilled water is indicated. This solution should be used very gently every half-hour when the infant is awake, by means of a dropper. DISEASES OF THE MOUTH. 619 and occasionally on a clean swab of absorbent cotton. The infant should be systematically fed at regular intervals, whether it resists or not ; and if it is not being nursed or will not suck from the nipple, a carefully modified milk at a temperature of about 32.2° C. (90° F.) should be ad- ministered with a spoon or dropper. There is no necessity for giving any drug internally in this disease. When the stomatitis proves to be intractable and lasts for more than three or four days, the mouth can be gently touched with a cotton swab wet with a one per cent, solution of nitrate of silver. This should be done once a day, and the mouth washed carefully with cold sterilized water after the application. When there are any abrasions which show a tendency to extend or to form an ulcer, they should be touched with a little nitrate of silver melted on the end of a silver probe. These abrasions are often so painful that in themselves they may prevent the child from taking its food, and after they have been treated with the nitrate of silver the child will often again take its nourishment readily. The following case represents stomatitis catarrhalis : An infant, six months old, was reported to have been always healthy, and to have been nursed by its mother. It cut its first tooth, a middle lower incisor, when it was five months old. Nothing abnormal was noticed about the infant until it became fret- ful, restless, had a heightened temperature of about 38.8° C. (102° F.), and vomited occasionally. Although it did not cry a great deal, it frequently whimpered, as though in pain, and kept putting its fingers to its mouth. A few days later it refused to nurse. When it was put to the breast it appeared to be hungry and would take hold of the nipple vigorously, but immediately afterwards would draw its head away, as though sucking the nipple caused pain. A physical examination showed nothing abnormal except in the mouth. The mucous membrane of the month, tongue, and gums was reddened, and small raised spots were seen corresponding to the positions of the muciparous glands. The mucous membrane of the tongue and lips was somewhat swollen and hot, and evidently sensi- tive to the touch. Where the tooth touched the tongue the inflammatory condition was especially marked, and it was possible that the sharp edge of the tooth was the original starting-point of the general inflammation. In the above case the indications were for active treatment, as the infant was losing in weight from lack of sufficient nourishment. When the mouth is in this condition there is also a great liability to other diseases being implanted upon it, as the mucous membrane is very vulnerable when a pronounced stomatitis catarrhalis is present. The saliva flows from the mouth in such quantities and is so irritating that an eczematous condition is likely to be produced on the chin. The following prescription will be found useful in such cases : Prescription 82. Metric. Apothecary. Gramma. R Sodii boratis 1 Glycerini 7 Aq. destil ad 120 8 R Sodii boratis gr. xxx 5 Glycerini ~ ii ; 00 M. M. 620 PEDIATRICS. This should be applied every hour while the child is awake. The chin should frequently be dried gently and a little vaseline applied if there is any eczema. If the infant is unwilling to nurse because of the stoma- titis, the milk should be given by means of a dropper regularly every two hours until it will again take the breast. Improvement should be ex- pected within four or five days. STOMATITIS HERPETICA. The name herpetica has been adopted for the next form of stomatitis, because it seems to represent most nearly the lesion which is seen on the mucous membrane, although it is not definitely settled that it is a true herpes. The disease consists of a catarrhal stomatitis in the course of which certain lesions resembling sub-epithelial vesicles surrounded by areolae occur irregularly and in different parts of the entire buccal cavity. This form of stomatitis has usually been known as stomatitis aphthosa (aC? ko-f ne:n ioni [ 3 \ y / \ ■£. ^v / \ j - | / / / 1 1 ^ / / I / f S b' r 1 JL. 1 \zt / ~r / y / 150 140 130 120 110 100 90 80 70 60 | / / / 1 J / / / J 1 ~7 s / 1 / N t / =£ 50 45 40 35 30 25 20 15 10 r \ I .o 1 ! \ 1 / / / ! \ / / / 1 / / J s v^ Bronchopneumonia following crisis of measles. 2 rears old. Child. Chronic Broncho-Pneumonia. — In a certain number of cases, after a child has had an attack of acute broncho-pneumonia the physical signs of consolidation may persist, although apparent recovery has taken place so far as the general symptoms are concerned. When this occurs the fever may return after a variable period, and the child, after having become still more emaciated, may die after a number of months of exhaustion. DISEASES OF THE BRONCHI AND LUNGS. 705 These cases are Aery apt to be associated with a tubercular broncho- pneumonia which may eventually heal by the production of fibroid cica- trices, but the most common termination of these cases is in acute general miliary tuberculosis. Instead of this fatal issue, the child, as has been shown by Delafield, may be left with a chronic form of the disease, which may last for many years and be accompanied by symptoms of cough, dyspnoea, and at times periods of fever. Broncho-pneumonia of a sub- acute or of a chronic type is so apt to develop in the lungs of young children during the course of any disease of a prolonged nature that frequent examinations of the lungs should be made, in order that the insidious development of these pulmonary lesions may not be overlooked. Treatment. — The treatment of these chronic cases of broncho-pneu- monia is essentially symptomatic and climatic. The child should be taken to a warm, dry climate of high altitude, where it can live in the open air and where it will not be subjected to frequent atmospheric changes. HYPOSTATIC PNEUMONIA. Hypostatic pneumonia is an extreme degree of passive congestion which occurs in the course of many long-continued diseases, such as typhoid fever. The dependent portions of the lungs become engorged with blood and the alveoli partially filled with accumulated alveolar cells, so that the condition resembles a consolidation. It occurs especially in patients whose vitality has been greatly lowered by a prolonged illness, and who are kept too long in one position without being turned. The physical signs are those of slight dulness on percussion, generally at the base of the posterior lobes, diminished tactile fremitus, and feeble respirations and voice-sounds. Moist rales, generally bilateral, are heard over the areas of dulness, but fever, pain, and cough are absent. The condition is recognized by the presence of the primary disease and by the gradual development of the physical signs without the characteristic features of pneumonia or pleurisy. It may, however, give no evidence of its presence during life, and may be discovered only at the autopsy. Treatment. — The treatment is chiefly prophylactic during the course of the primary disease. The nurse should see that the child is not allowed to lie in one position for more than two hours. The condition calls for active stimulation. ATELECTASIS. Atelectasis is a collapsed and unaerated condition of the air-vesicles. It may be congenital or acquired. Congenital Atelectasis. — Congenital atelectasis arises because the infant has not sufficient general vitality and respiratory power at birth to inflate fully all parts of its lungs. There may be an obstruction by mucus. There are in all these cases areas of uninflated pulmonary vesicles of varying extent. These vesicles at the post-mortem exami- 45 706 PEDIATRICS. nation can easily be artificially distended and then cannot be distinguished from those which have been normally inflated. Symptoms. — The symptoms of congenital atelectasis are cyanosis, dyspnoea, rapid respiration, rapid, feeble, and often intermittent pulse, a temperature usually lowered, and dulness on percussion with lessened respiration over the area of atelectasis. These are the typical physical signs, but in many cases some or all of these signs are absent and the condition is detected only at the post-mortem examination. Acquired Atelectasis. — Acquired atelectasis is a symptom of a num- ber of diseases, and occurs especially in severe cases of bronchitis in which the smaller bronchi are involved, also in broncho-pneumonia and in pertussis. Acquired atelectasis undetected during life is frequently found at the post-mortem examination of infants and young children dying of almost any disease. Prognosis. — The prognosis in these cases varies according to the ex- tent of the pulmonary tissue involved and the vitality of the infant. As a rule, the prognosis is very unfavorable. Treatment. — The treatment of atelectasis is to stimulate the infant, and to endeavor v to raise its temperature by means of a warm pack. In a num- ber of cases I have found the administration of small quantities of oxygen to be of benefit. Artificial inflation of the air-vesicles has not proved to be an especially valuable form of treatment. Many cases of atelectasis may be avoided if the physician appreciates the importance of making an infant, in the first few minutes after birth, thoroughly expand its lungs by vigorous crying. EMPHYSEMA. Emphysema is an over-distention of the alveoli and infunclibula of the lungs. It is always a secondary process. Various descriptive terms have been used to denote differences in the type of the disease. Compensatory emphysema consists in a dilatation of the alveoli in certain portions of the lung as a result of obliteration of the function of other parts by consolidation, adhesions, or pressure of deformed bones. This condition is likely to occur in connection with pneumonia, tuber- culosis, chronic adhesive pleurisy, or rhachitis. Obstructive emphysema represents the same pathological lesions, but the cause lies in some obstruction to expiration, as in stenosis of the larynx, asthma, and pertussis. Interstitial emphysema occurs rarely as a result of a rupture of the walls of the alveoli, by which the air works through the interstitial tissue of the lung into the subcutaneous tissue. Symptoms. — Hyperresonance on percussion, feeble breathing, pro- longed expiration, diminution in tactile fremitus and voice-sounds are the physical signs of emphysema. The normal area of cardiac dulness may be much diminished by the overlapping emphysematous lung ; in the same way the upper border of the liver dulness may be considerably DISEASES OF THE PLEURA. 707 lowered. The symptoms are those of the disease in which the emphy- sema occurs. Treatment. — The treatment should be adapted to the underlying con- dition. GANGRENE AND ABSCESS OF THE LUNG. Gangrene and abscess of the lungs are represented essentially by the same clinical symptoms, and may occur in connection with lobar or broncho-pneumonias. They are caused by the action of suppurative and putrefactive bacteria which invade the affected portions of the lung with the production of small or large abscesses. Gangrene is diagnosticated chiefly by the presence of putrid, purulent sputum containing elastic fibres. It is to be distinguished from fetid bronchitis, which does not contain the elastic fibres of the lung-tissue. The rupture of an empyema into a bronchus, with the resulting ex- pectoration of purulent sputum, simulates the condition of abscess, but the diagnosis should be made by the physical signs of empyema. The treatment is that of the primary disease. DISEASES OF THE PLEURA. Inflammations of the pleura may be primary or secondary, acute or chronic, and with or without an exudation. ACUTE PLEURISY. Etiology. — Acute pleurisy, either with a simple exudation of fibrin or accompanied by fluid, is not infrequent in children in the winter and early spring. Primary forms occur, but are very rare, and are attributed to exposure to cold or to injury, as from penetrating wounds and fractured ribs. Secondary forms are the rule ; they occur by direct extension in con- nection with lobar pneumonia, broncho-pneumonia, tuberculosis of the lungs, pulmonary embolism, pericarditis, peritonitis, or some neighboring local inflammation. They may also be caused by metastatic infections from distant inflammatory processes, by means of the blood-vessels or lymphatics, or in the course of acute infectious fevers. Pleurisy may also occasionally be associated with nephritis and syphilis. The bacteriology of inflammations of the pleura includes many varie- ties of organisms. The pneumococcus is found in the great majority of cases of pleurisy in early life and is generally accompanied by a purulent exudation ; these cases are apt to arise in connection with pneumonia and run a favorable course. The streptococcus pyogenes causes a much more serious, and often fatal, purulent infection, but is less common in children than in adults. Tubercular pleurisy is rare in infancy, but occurs more frequently in the later years of childhood. Eichhorst has shown in one series of serous 708 PEDIATRICS. exudations that nearly sixty-five per cent, of the cases were tubercular, but the pneumococcus, cliplococcus, and staphylococcus are sometimes found in these non-purulent exudations. The staphylococcus, gono- coccus, Friecllanders bacillus, colon bacillus, and typhoid bacillus have occasionally been cultivated from the purulent exudations. In acute inflammations of the pleurae we can make a clinical dis- tinction between three types of the disease, based upon differences in the pathological lesions : (a) acute dry or plastic pleurisy, (6) acute pleurisy with sero-fibrinous exudation, and (c) acute pleurisy with puru- lent exudation (empyema). Acute Dry or Plastic Pleurisy. — Pathology. — The pleura is injected and without lustre. At first it is covered with a thin layer of lymph, which becomes opaque and thickened by the deposition of fibrin and leucocytes. The sub-pleural fibrous tissue is also thickened by the exuda- tion of serum and by cellular infiltration. The roughened surfaces of the visceral and parietal layers may adhere, forming loose connections which may subsequently undergo organization without producing an exudation and end in a chronic adhesive pleurisy. The areas of inflamed pleura may be large or small and diffusely located. They may rarely occur at the apices of the lungs in connection with an early tubercular process. On the other hand, they may be limited to the base and give rise to diaphragmatic pleurisy. The term i^leuro-pneumonia has been applied to those cases of dry pleurisy in which there has been an excessive exudation and deposition of pus-cells in the layer of fibrin without the formation of free fluid in the pleural cavity. Symptoms. — Although localized areas characterized by -the production of fibrin are quite frequently found at the post-mortem examination, the diagnosis of this form of disease in infants and in young children is not often made during life. The symptoms are of acute onset, characterized by a sharp pain or stitch in the side, slight fever, and a short, dry cough. The pain is usually referred to the lower part of the axilla, where the largest excursions of the two layers of the pleura take place in the act of breathing, or to the abdomen. On auscultation a friction-rub may be heard at the site of the pain or remote from it. In infants and young children, however, friction-sounds and pleuritic pain are much less pro- nounced than in adults, and a pleurisy is often not even suspected until the advent of the exudation. Probably in the great majority of cases of dry pleurisy in early life the condition is secondary to lobar or broncho- pneumonia, and its signs and symptoms may be masked by those of the primary disease. Acute Pleurisy with Sero-Fibrinous Exudation. — Pathology. — The pathological exudate of a dry or plastic pleurisy may be directly absorbed or the inflammation may result in an exudation of serum and fibrin into the pleural cavities. DISEASES OF THE PLEURA. 709 The fluid is of a clear, pale-yellow color, coagulates spontaneously, and contains flocculi of fibrin and a few leucocytes and endothelial cells. The amount of fibrin varies, and, according as it is small or large in relation to the serum, we speak of the exudate as sero-fibrinous or fibrino-serous. A greater proportion of fibrin is likely to be present in the exudation in children than in adults. The quantity of fluid may be small and encysted, and accompanied by areas of atelectasis in the adjacent lung, or it may fill the whole cavity, compressing the lung against the spine, and thus practically depriving it of its functions. In a similar manner when the exudation is on the right side the liver is depressed. Displacements of the heart and pericardium very commonly occur when the exudation is either on the right or the left side. Symptoms. — The onset of acute pleurisy with serous exudation is in many cases violent, and attended by a high temperature, increased respirations, rapid pulse, restlessness, and even pain, which in young children is usually referred to the abdomen. In infants and in young children convulsions are quite common, while in older children the symptoms are more like those which occur in adults. There is a short, painful cough, with loss of appetite, and frequently vomiting and diarrhoea. The white blood count is rarely increased in serous exudations, except in the febrile stages, and even then is not often over thirteen thousand. Uncomplicated cases of tubercular pleurisy probably never have a leuco- cytosis (Cabot). These early symptoms are usually followed in two or three days by an exudation and by a decided lessening of the pain and dyspnoea. At the same time the temperature begins to have a decided morning re- mission. When the exudation is large, the children lie more comfortably on the affected side, and when they are nursing they nurse most easily from the right breast if the left pleura is affected, and from the left breast if the right pleura is affected. After the serous exudation has remained for a few days it ordinarily begins to lessen in amount, absorption takes place, and by the end of a week or ten days it is entirely absorbed and the child recovers. In other cases it becomes chronic unless its absorption is furthered by aspiration. Physical Signs. — The physical signs of fluid in the pleural cavity differ in certain respects from the usual signs in adults. Inspection. — On inspection we find diminished movement of the affected side on inspiration, and if the fluid is large in amount, a decided bulging. The impulse of the apex beat is often displaced, depending on the quantity of the exudation and the side affected. The displace- ment of the heart is most marked in left-sided effusions, in which the impulse may be seen in the third and fourth right intercostal spates, and sometimes as far out as the mammillary line. In right-sided effusions the degree of displacement is less, but the impulse may be seen in the fourth interspace and between the mammillary and midaxillary lines. 710 PEDIATRICS. Palpation. — By palpation the intensity of the apex beat and the amount of displacement of the heart and of the liver (in right-sided affections) may be determined. The information to be obtained by tactile fremitus is not of much value in infancy and early childhood ; its diminu- tion is not marked, and occasionally it is quite distinct over an exudation. Thus one of the most valuable of differential signs from consolidation fails in the doubtful cases in children. Percussion. — The percussion-note varies from slight dulness to flat- ness, according to the quantity of the fluid, and there is a sense of in- creased resistance to the fingers. Above this level of dulness the note is normal or tympanitic (Skoda's resonance), and may be most pronounced in front below the clavicles. On the right side the dulness may be con- tinuous with that of the liver, on the left it may obliterate the semilunar space of Traube. The upper border of a fluid exudate has certain peculiar character- istics, as shown by Ellis and Garland, if not complicated by pleural adhe- sions, and is often of aid in the differential diagnosis from consolidation of the lung. When the fluid is small in amount it can usually first be detected in the back. In these small exudations the upper border of dulness begins at the vertebral column, extends outward horizontally for a distance which varies according to the size of the exudation, and drops in the neighborhood of the posterior axillary line, by a curve more or less abrupt, to the base of the thorax. As the fluid increases in size the line of dulness drops more anteriorly. When it is moderate, the lower half of the pleura only being filled, the upper border of the area of dulness is found to extend at first outward and then upward over the angle of the scapula, reaching its highest point in the axillary region. The line may then drop abruptly from the upper axilla to the base of the thorax near the apex of the heart or to the corresponding point on the right side. This line, which has been called the "letter S curve," is characterized by having its highest point in the axillary line. When the quantity of fluid is still larger and exceeds a certain amount, the t; letter S curve" is obliterated, and the resonance over the compressed lung becomes less marked. This curve can only be determined by very light percussion. If the line of dulness is altered by a change in position of the body, it is a positive sign of fluid. An encysted exudation or a large amount of fluid will not give this sign. The displacement of the heart is a most valuable indication of effusion in young children, and with careful, light percussion the gradual increase and decrease of the effusion, when it is of any great extent, can be de- termined by the variations in the position of the heart. The physio- logical dulness of the heart which has been described as occurring in early childhood (page 90) under the lower third of the sternum, becomes much more marked when the heart is displaced. Auscultation. — The sounds obtained by auscultation are variable, and DISEASES OF THE PLEURA. 711 in some respects are very different from those which are heard over a pleural exudation in an adult. Bronchial breathing is the rule rather than the exception. It is, however, less intense and more distant than that which we ordinarily hear over an area of consolidation. Vocal reso- nance, moreover, is generally increased (bronchophony), and is sometimes as pronounced as in pneumonia. Occasionally it will give the same nasal quality (egophony) as over a consolidation. Friction-sounds above the level of the fluid, or after absorption, are rare in early life. Moist rales are sometimes heard over an exudation, and are probably of bronchial origin. Even friction-sounds are sometimes said to be heard over the fluid, but are probably transmitted from points above the level of the exudation. Diagxosis. — The principal physical signs of pleural effusion in infancy and early childhood are flatness which does not correspond to the ana- tomical divisions of the lobes of the lung, bronchial or distant tubular breathing, bronchophony, displacement of the heart, and changes in the outline of dulness on shifting the position of the body. The differential diagnosis can best be described in connection with purulent exudations (page 713). Prognosis. — The prognosis of a serous effusion, as a rule, is very favor- able in infants and in young children unless the streptococcus or one of the more virulent forms of the pyogenic cocci is present, or unless the disease is secondary to tuberculosis elsewhere and is caused by the tubercle bacillus. If the serous exudation tends to become purulent, the prognosis is not so good, but still, provided appropriate treatment is carried out, it is favorable. If, as in rare cases, the pleuritic exudation occurs on both sides, the prognosis becomes grave. The possibility of the presence of the tubercle bacillus should be considered in these latter cases. I had in my service at the Boston City Hospital a boy, thirteen years old, who was attacked with pleurisy and a serous exudation on the left side with displacement of the heart to the right. After one aspiration the fluid was quickly absorbed, but three weeks later he was attacked with pleurisy on the right side, followed by an exudation and displacement of the heart to the left. This effusion was absorbed without aspira- tion, and the boy was discharged from the hospital well and strong, with both lungs apparently in a normal condition. When the effusion is very large and the heart is much displaced, there is always the danger of a fatal issue from asphyxia, and the prognosis de- pends upon whether the exudation can be controlled by aspiration and the heart thus be kept in normal position. The following case illustrates the danger w T hich may arise when these large quantities of fluid are accompanied by displacement of the heart. A boy, four or five years old, entered the hospital with a large exudation in the left chest. The heart was displaced to the right and upward as far as the second interspace to the right of the sternum. He was cyanotic and gasping. On aspirating 712 PEDIATRICS. the chest and removing a large quantity of fluid, the heart reassumed its normal posi- tion under the sternum. On the following night the hoy died suddenly, the fluid having rapidly reaecumulated and again displaced the heart. Cases of this kind should warn us that a pleuritic exudation of any extent in a young child should be watched carefully, and that aspiration should be performed when there is indication of an increase in the intra- thoracic pressure. AVhen the pleurisy is secondary to other diseases, such as rheumatism and scarlet fever, the prognosis is not so favorable ; the fluid is not apt to be absorbed so readily, and is more likely to become purulent. The prognosis is also rendered more unfavorable in these cases by the pro- longed pressure upon the lung, with its corresponding ill effects upon the general condition of the child. The clangers which arise from the de- velopment of tuberculosis must also be borne in mind. Treatment. — The treatment of acute pleurisy during the early days of the attack, before an exudation of any considerable extent has appeared, should be directed to the relief of the pain by a flannel bandage closely applied to the thorax, so as to allow the ribs to move as little as possible in respiration. Sometimes an occasional dose of tinctura opii campho- rata will also be needed to make the child comfortable. After the fluid has increased, the child should, if possible, be kept in bed. There are some cases, however, in which a child with considerable exudation in its pleura will feel well and bright, and will play about its nursery without showing any especial symptoms of discomfort. I have met with instances of this kind where, except for pallor and a poor appetite, the child seemed bright and active, and yet had a pleuritic exudation large enough to dis- place the heart. The child should be examined each day in reference to an increase in the quantity of fluid and to a displacement of the heart. If neither oc- curs, and if the respiration and circulation show no evidence of disturbance, an expectant treatment is all that is required. If, on the contrary, the fluid is increasing and the heart is displaced to any considerable degree, or if absorption of the fluid is delayed for two or three weeks, the chest should be aspirated. The point of aspiration should usually be in the fourth or fifth interspace in the midaxillary or posterior axillary line, but in deciding where to enter we should always be guided by the indi- cations given by the physical signs. A bacteriological examination of the fluid removed should then be made, to determine which form of organism is present in the exudate. If one of the more benign forms of bacteria is present, such as the pneumococcus, or if the fluid is found to be serous, no further treatment will be required, unless there be a reaccumulation of the fluid, in which case a second aspiration will be indicated. If, how- ever, streptococci are found in the exudate, the case must be watched very carefully, as it is more likely to become purulent and to need radical surgical treatment. DISEASES OF THE PLEURA. 713 As the unfavorable symptoms in a pleuritic effusion arise mostly from intra-thoracic pressure, relief from the pressure by aspiration is indicated rather than by the use of drugs, which cannot be depended upon. Acute Pleurisy with Purulent Exudation. — Empyema. — In the first three or four years of life purulent exudations into the pleura are much more common than serous or sero-fibrinous exudations. Nearly all the cases which are secondary to lobar or broncho-pneumonia, repre- senting the largest group in children, are caused by the pneumococcus. The presence of other organisms has already been referred to. Pathology. — The inflammatory process begins with an exudation of fibrin upon the surface of the pleura, accompanied by an excessive migra- tion of leucocytes and a rapid accumulation of pus. The exudation may occasionally be sero-fibrinous at first and subsequently become purulent. In cases of streptococcus and staphylococcus infections, the inflammation may be purulent from the beginning, but the pus is not so thick and contains less fibrin than in pneumococcus infections. The pus may be encysted, but this rarely occurs in an empyema following pneumonia. When no bacteria are found in the fluid, when there is no history of a preceding acute pneumonia or a neoplasm of any kind, when there is little tendency to absorption of the exudate, and when the exudate is found to contain blood, the signs point strongly towards a tubercular origin. Symptoms. — The disease when primary may be acute in its onset, and may simulate closely the initial stage of lobar pneumonia. When second- ary to pneumonia or some other acute infectious disease it is slow and somewhat insidious in its development. The pulse and respirations may be increased, but after the early days of the disease they are often very little raised. There is nothing characteristic in the temperature of an em- pyema, and the diagnosis usually can be made only from the knowledge that the younger the individual the more likely is pus to be present. Cachexia, anaemia, and prostration soon become prominent. A pro- nounced leucocytosis is present from the onset and is the most important symptom in the differential diagnosis from a purely sero-iibrinous exuda- tion, which rarely shows more than a moderate increase in the white cells. Leucocytosis may at times be absent when aspiration shows pus to be present, but this is unusual and may be only temporary. The physical signs are the same as in sero-fibrinous exudations and have been described on page 709. The absorption of a purulent exudate without surgical interference is very rare. I have occasionally met with cases in which one or two aspirations were all that were necessary and in which complete absorp- tion seemingly took place„ When cases of empyema are left untreated, a spontaneous opening usually takes place through some portion of the thoracic walls, but the exudate may also find its exit through the lungs by opening into one of 714 PEDIATRICS. the bronchi or perforating in other directions. I have met with cases in which the diaphragm was perforated and the point of exit of the pus was in the region of the umbilicus. When perforation does not occur, the pus is partially absorbed, adhesions are formed, and sometimes great deformity of the chest follows, which may result in a marked degree of lateral curvature of the spine as well as in great contraction of the chest. Diagnosis. — The diagnosis of empyema rests upon the signs of fluid in the pleural cavity associated with a pronounced leucocytosis, but it cannot be made definitely without the aid of the aspirator. In all doubtful cases the aspirator should be freely used, for the consequences of a neglected empyema are very serious. The differential diagnosis of empyema is to be made from a number of different lesions. From Pneumonia. — The conditions which are most likely to be con- founded with a pleural exudation are acute and unresolved pneumonias. The difficulty arises from the frequency of bronchial breathing and bron- chophony and normal tactile fremitus over a pleural exudation in early life. When the physical signs are those both of fluid and of consolida- tion, the diagnosis must rest upon the results of exploratory aspiration. It is to be borne in mind, however, that aspiration frequently yields a negative result even when fluid is present, and several punctures may be necessary before the diagnosis can be settled. The possibility of pneumonia and pleurisy with exudation being combined should not be forgotten in making the differential diagnosis. From Atelectasis. — A simple bronchitis in children may cause an occlu- sion of the bronchi and produce atelectasis of the lungs, the signs of which may simulate closely a small effusion. Coughing and deep inspira- tion will, however, often remove the mucous plugs and allow the air to enter, so that the condition is readily determined. If the atelectasis per- sists, the signs may suggest an encapsulated empyema, and aspiration must be resorted to. From Sero- Fibrinous Exudations. — The diagnosis from sero-fibrinous exudations is very difficult, but the younger the individual the more likely is the fluid to be purulent. After the first week or ten days of the dis- ease, however, when the fluid is purulent, the usual signs of absorption which so commonly occur in a serous exudation are not ordinarily found, and aspiration of the pleural cavity will then determine which form of the disease is present. Marked leucocytosis favors the diagnosis of empyema. From Chronic Adhesive Pleurisy. — The signs of chronic adhesive pleurisy may exactly resemble those of fluid. If the diagnosis is doubt- ful aspiration will make it clear. Prognosis. — The prognosis in empyema is good if the diagnosis is made early, if the pneumococcus is the cause, and if the case is properly treated. If the infection is from the streptococcus pyogenes or the tubercle bacillus the prognosis is very unfavorable. If the pus has been allowed DISEASES OF THE PLEURA. 715 to remain in the chest for a long period, the chances of recovery are proportionately diminished. Spontaneous recovery rarely occurs. In infants under one year the mortality is usually much higher than in later periods, especially in hospital practice. Treatment. — The treatment of empyema is essentially surgical, and I shall not enter into its details. After the first aspiration, if absorption does not occur within a week and if the infection is due to the pneu- mococcus, it is well to wait a week before deciding on a second aspira- tion or operation. If one of the more virulent forms of bacteria is found in the exudate, a radical operation is the best method of treatment and should be performed at once. Sometimes one aspiration of the pus will be followed by permanent and entire recovery. This, probably, only occurs in infections due to the pneumococcus, and I have seen such a case in an infant seven weeks old. I have also seen recovery follow after two and even three aspirations. The pleural cavity should be thoroughly drained by means of drainage-tubes. In many cases, especially in chil- dren over two or three years of age, resection of one or two ribs gives the best results. Although in some cases a rapid cure in two or three weeks follows the operation, yet the recovery is often prolonged for many months, even when strict antiseptic precautions have been taken at the time of the operation. The following cases illustrate pleurisy with sero-fibrinous exudation : A girl, eleven years old, was attacked with a chill followed by vomiting and a short, dry cough. Later she complained of pain in the lower part of the right chest. She was feverish, lost in weight and in appetite, and her respirations were painful. She lay most comfortably on her back and on her left side. A pleuritic friction-rub was heard in the right axillary region. Her lips and cheeks were slightly cyanotic. Her tongue was somewhat coated. The alae nasi were working and orthopricea was marked. The percussion and auscultation of the left lung showed nothing abnormal. The resonance was fair over the upper part of the right front and back. There was flatness from about the fifth dorsal vertebra in the right back to the base of the lung. The flatness extended into the axillary region, where it reached its highest point, and then gradually descended to the right parasternal line on a level with the fourth costal cartilage. Over this area of flatness respiration was markedly diminished. No friction- rub was heard. The vocal and the tactile fremitus were diminished. The impulse of the heart was found in the fourth interspace, 1 cm. (f inch) to the left of the mam- miliary line. The heart-sounds were normal. There was no displacement of the liver. An examination of the urine showed it to be acid, to have a specific gravity of 1022, to be of normal color, and to contain no albumin. The chlorides were normal. The temperature was 38.3° to 40° C. (103° to 104° F.) for the first two days and then gradually declined to normal in the course of three weeks. The pulse and respirations were irregular, the former ranging between 80 and 120, and the latter between 25 and 50. The physical signs were those of a pleuritic effusion of the right side with dis- placement of the heart to the left. The area of flatness gradually decreased, and an exploratory aspiration showed the fluid to be serous. Nine weeks from the beginning of the attack, the dulness on percussion gradually disappeared, auscultation showed the respiration to be normal, and the heart resumed its normal position. 716 PEDIATRICS. In another case of serous effusion in the pleura, the temperature ranged between 37.2° and 38.8° C. (99° and 102° F.) for three weeks and suddenly dropped to normal. In the beginning 165 c.c. (5 \ ounces) of fluid were withdrawn from the chest. The fluid reaccumulated, so that absolute dulness was found over the whole right side of the chest in front and behind, but aspiration did not have to be resorted to again, and complete absorption took place thirty days from the beginning of the attack. Another case which illustrates the difficulty in diagnosticating a purulent effusion in the pleura in the early days of the disease is the following : A girl, four years old, was suddenly attacked with cough, and pain in the right side. The temperature was 40.5° C. (105° F.). The respirations were quickened, and the pulse was rapid. Nothing abnormal was detected on physical examination. On the following day the general symptoms disappeared, and the temperature fell to 38.8° C. (102° F.). In another day the temperature fell to 37° C. (98.6° F.), and the child seemed bright and well. On the following day, however, the temperature rose to 40° C. (104° F.), flatness and the other signs of fluid were detected in the right axillary region, and an exploratory aspiration showed the presence of pus. CHRONIC PLEURISY. Chronic pleurisy results from previous attacks of acute inflammations of the pleura, either with or without the formation of fluid. The result is essentially the same, differing chiefly in degree. The lesions are repre- sented by adhesions between the thickened layers of parietal and visceral pleura. Large or small areas of the cavity may thus be obliterated. The physical signs are represented chiefly by dulness and diminution in the intensity of the breathing, voice-sounds, and tactile fremitus. Litten's phenomenon is absent. On the other hand, adhesions are often found at the autopsy, where during life both lungs seemed perfectly normal. The diagnosis is aided by the use of an aspirating needle, by which we can often determine by the sense of touch whether the needle is in a thick- ened pleura, the lung, or a free cavity. If the adhesions are extensive, retraction of the chest with certain compensatory changes occur as illus- trated in the following case. A little girl, three years old, had an attack two years previously of some pulmo- nary disease accompanied by fever. From that time until she was first seen she was delicate and coughed a great deal. Her cough had increased, but she did not lose in weight nor have any other abnormal symptoms. She was pale, and the cervical, axillary, and inguinal glands were enlarged. Her fingers were markedly clubbed. She showed a peculiar lateral curvature of the spine, which could not be made to dis- appear by traction. The right side of the thorax expanded normally, the left side scarcely at all. There were hyperresonance, no rales, and compensatory respiration over the right lung. The left lung was apparently atelectatic and showed dulness everywhere except in a small triangular area at the inferior angle of the scapula. This deformity of the thorax was probably the result of an empyema which occurred when she was one year old and was not properly treated. Treatment. — The treatment consists entirely of general hygiene and systematic exercises of the chest. DISEASES OF THE PLEURA. 717 HYDROTHORAX. Hydrothorax is a non-inflammatory affection, characterized by the transudation of a simple fluid into the pleural cavities. It is a rare affec- tion in children. The effusion is the result of mechanical obstruction to the flow of the subpleural blood and lymph. The principal causes for this obstruction are found in diseases of the heart and kidneys. The fluid is generally bilateral ; in some cardiac cases it may be unilateral. It is apt to be greater in amount on one side than on the other. The transudation is watery in character, of low specific gravity, under 1015, and contains less albumin than inflammatory exudations, generally from one to two per cent. It does not coagulate spontaneously unless complicated with the exudation of an inflamed pleura. A few leucocytes, red blood-corpuscles, and endothelial cells may be found when the sedi- ment obtained by the centrifuge is examined microscopically. Symptoms. — The symptoms are in most cases simply those of the con- dition to which the hydrothorax is secondary. If the fluid is excessive there is a sense of constriction beneath the sternum, dyspnoea, and short, rapid respirations, weak pulse, and sometimes cyanosis. Any of these symptoms may be due to the primary disease alone, and it is therefore of much importance to watch the lungs carefully in all advanced and serious cases of cardiac and renal disease associated with dropsy. The physical signs are those of pleurisy with exudation. There is no friction-rub, as the pleurae are not inflamed, and the fluid shifts more readily on change in position, because of the absence of inflammatory adhesions. Diagnosis. — The diagnosis can be made from inflammatory exudations by the chemical examination of the fluid obtained by aspiration. Treatment. — The treatment is that of the primary disease to which the hydrothorax is secondary. If the symptoms of pressure are serious, repeated aspiration is generally necessary. PNEUMOTHORAX. Pneumothorax, or air in the pleural cavity, rarely occurs alone. It is generally associated with serous or sero-fibrinous fluid, and is then called hydropneumoihorax ; or with pus, when we speak of it as pyopneumothorax. Etiology. — Air may enter the pleural cavity from penetrating wounds from without, such as may result from aspiration. The most frequent cause, however, is due to perforation of the visceral pleura in the course of pulmonary tuberculosis, gangrene, or abscess. Nine-tenths of the cases, according to Fraentzel, are due to pulmonary tuberculosis. The condition is of rare occurrence in children. Pathology. — As a result of the entrance of air into the pleural cavity, the lung collapses and is withdrawn into the upper and posterior part of the pleural cavity. The amount of retraction depends upon the extent of the pleural adhesions or consolidation present. The entrance of air 718 PEDIATRICS. is generally accompanied by micro-organisms, and by the conditions which follow a sero-fibrinous or purulent inflammation of the pleura. Symptoms.— The onset when sudden is characterized by severe pain in the side, dyspnoea, a weak, rapid pulse, and great prostration. Some- times the pneumothorax develops insidiously without giving rise to these symptoms of distress. The physical signs are distinctive. Inspection. — Respiration is diminished on the affected side and Litten's sign is absent. The heart may be displaced in the same way as by a pleuritic effusion. Palpation. — Tactile fremitus is absent over the lower part of the chest, but may be normal or even increased at the upper posterior por- tion over the retracted lung. The liver is generally displaced if the pneumothorax is on the right side. The apex of the heart will also be found to be displaced as in effusions. Percussion. — Tympanitic resonance is pronounced throughout the affected side, and may be so marked as to mask the presence of small effusions. When the air within the pleural cavity is very tense, the per- cussion-note may be muffled, simulating dulness. Auscultation. — The respirations and voice-sounds are very faintly heard or are absent in the lower portions of the chest, whereas at the top a faint amphoric or metallic breathing may be heard. If one coin is tapped against another coin placed on the back over the tympanitic area, the metallic echo is readily transmitted to the stethoscope on the front of the chest, and is quite characteristic. When the pneumothorax is accom- panied by fluid, as is generally the case, the signs of pneumothorax and fluid are combined and vary in their character according to the relative predominance of fluid or air. The sound of splashing obtained by suc- cussion is very distinctive of air and fluid, but must not be confused with similar sounds transmitted from the stomach. The difference can be made out by attention to the position of the intensity of the sound. Diagnosis. — Only when the air is very tense, and gives a muffled or dull note, will the physical signs resemble those of fluid. If the diagnosis is doubtful, aspiration will make it clear. Very large tubercular cavities may give rise to the signs of pneumothorax, but they are rare in children, and even when present are not associated with succussion or displace- ment of organs. Pneumothorax and emphysema resemble each other in the signs of feeble breathing and hyperresonance, but emphysema is almost always bilateral, with the coarse moist rales of an associated bronchitis, and does not displace the heart or liver, although it may alter the cardiac and hepatic areas of dulness. Prognosis. — The prognosis of pneumothorax depends largely upon the primary condition to which it is secondary. Treatment. — The treatment is essentially the same as that of pleurisy with effusion. DIVISION XL DISEASES OF THE HEART AND PERICARDIUM. DISEASES OF THE HEART. Cardiac disease in infancy and early childhood may be divided into congenital or acquired, developmental or inflammatory, organic or func- tional, acute or chronic. In this early period of life cardiac disease has certain characteristics in which it differs essentially from those which are met with in later life. One of these characteristics is that there is a more decided tendency to recovery than at a later period. Another is that, owing to the undeveloped condition of the infant and young child, inter- ference with the growth of other organs and parts of the body may more easily result from diseases connected with the circulation than is possible in the case of the fully developed adult. Thus, there are certain ana- tomical facts connected with the ossification of the sternum which be- come of great importance in connection with cardiac disease. Deformi- ties of the thorax may result from the continued pressure of the enlarged heart on the soft and pliant sternum and costal cartilages of the young subject. These deformities do not arise merely when the individual is rhachitic, but may also depend upon the stage of development at which the cardiac disease begins. The deformity is more or less pronounced in inverse ratio to the age and in direct ratio to the time during which the cardiac disease has existed. The shape and extent of the deformity are also dependent upon the degree of ossification which has taken place in the sternum. In young infants, in whom the entire sternum is in a cartilaginous con- dition, the intra-thoracic pressure from an enlarged heart may cause a bulging of the whole front of the thorax. This may occur during the first year, and even up to the third year. As the child grows older, the manu- brium and the second piece of the sternum become ossified and offer more resistance, while the third piece of the sternum, still remaining in a semi- cartilaginous condition, may be tilted. This latter displacement may occur in children in whom the cardiac disease has not developed until the fourth, fifth, or sixth year. I have had under my care a child seven years old who at the age of five years had articular rheumatism with resulting cardiac hypertrophy, and who presented this displacement of 719 720 PEDIATRICS. the third piece of the sternum. Xo other signs of rhachitis were de- tected. The middle period of childhood is also a peculiarly unfortunate one for the occurrence of cardiac disease, because the heart grows so rapidly at this period that it requires a proportionately greater amount of intra-thoracic space for the normal performance of its function than it does later. In addition to the injury which may be done to the thoracic Avails by an enlarged heart, we must consider the interference with the normal uniform expansion so necessary for the growing pulmonary tissue and the consequent loss of the elasticity which plays so prominent a part in the establishment of the equipoise which should exist in a perfected respiratory apparatus. The occurrence of diseases of the blood-vessels is rare in infancy and early childhood in comparison with later life. Aneurism' is rare. A narrowing of the isthmus aorta' is more common, and is one of the most marked of the congenital defects of the blood-vessels. It may result in increased blood-tension, followed by hypertrophy of the left ventricle and subsequent dilatation. Sometimes there is an absence of the isthmus aorke during foetal life. The compensation for this defect takes place by an increased action of the left ventricle and the establishment of a col- lateral circulation between the subclavian artery and the thoracic and the abdominal aorta. These malformations exert in varying degrees an in- fluence on the heart, as the infant grows older, from increased blood- pressure. CONGENITAL DISEASES OF THE HEART. Congenital diseases of the heart are somewhat obscure in their etiology, but usually result either from an interference with the normal development of the organ or from endocarditis, or from a combination of both. The parts of the foetal circulation at birth which are of most importance in reference to diseased conditions of the heart and great blood- vessels are the foramen ovale and the ductus arteriosus. When these remains of the foetal circulation, which are normal during infra-uterine life and for a short period afterwards, continue as the infant grows older, they become abnormal and interfere with the equilibrium of the circu- lation. When the development of the heart has been interfered with in intra- uterine life, there results another set of malformations, the chief of which are an open ventricular septum, a transposition of the great vessels con- nected with the heart, and various malformations of the valves, such as atresia of the orifice, absence of one or more cusps, or supernumerary segments. There may also be absence of one of the large vessels. When, again, an inflammatory condition has taken place in intra-uterine life (foetal endocarditis), various other morbid conditions result, usually located in the right side of the heart, the most common of which are CONGENITAL DISEASES OF THE HEART. 721 connected with the pulmonary artery, causing stenosis or atresia, a nar- rowing of the conus arteriosus, and various malformations of the tricuspid valve and other orifices of the heart. These inflammatory lesions of the valves result in dilatation and hypertrophy of the heart and prevent its normal development by keeping open, for the purpose of compensation, the foramen ovale, the ventricular septum, and the ductus arteriosus. The valvular lesions vary greatly in their extent and pathology. It is sometimes very difficult to distinguish between the lesions re- sulting from foetal endocarditis and errors of development. The nodules of Albini and the small hemorrhages which are so commonly found on the cardiac valves in children, must not be mistaken for endocar- ditis. The form of inflammation of the endocardium which occurs in infra-uterine life is the chronic or sclerotic variety. Verrucose endo- carditis is rare. A deficient filling of the left side of the heart in early life, such as occurs in cases of atelectasis, foetal pneumonia, or foetal endocarditis, especially when stenosis of the pulmonary artery has resulted, may delay the closure of the foramen ovale and of the ductus arteriosus, which under these circumstances act as safety-valves. This is true also of the delay in the closing of the intra-ventricular septum, which is often of great aid in preserving the equilibrium of the circulation. The most common congenital cardiac lesions are an affection of the pulmonary artery, an open foramen ovale, an open ventricular septum, and an open ductus ateriosus. Transpositions of the aorta and pulmonary artery are very com- monly met with in connection with other congenital defects, such as spina bifida or hydrocephalus, but may occur in infants who are otherwise normally developed. In these cases the duration of life is almost in- variably short. Although these various abnormal conditions may be found alone, yet they generally occur in combination with each other, and all kinds of transpositions and malformations of the vessels are at times met with. There are various other malformations of the heart which occur at an early period of foetal development, and which are of pathological rather than clinical interest. Of these can be mentioned cases in which there are one auricle and one ventricle (cor bilocidare), or one ventricle and two auri- cles (cor triloculare), as well as a case which has come under my notice, in which the heart had a double apex, the right apex lying in the fourth interspace to the right of the sternum, and the left apex lying in the fourth interspace to the left of the sternum. At times there may be a double heart, absence of heart (acardia), heart on the right side (dextro- cardia), or the heart may be in various parts of the thorax or abdomen. General Symptoms. — Although in some cases the symptoms of con- genital cardiac disease are very indefinite, and the disease may be masked for a number of months, yet in a large number of cases they soon be- 46 722 PEDIATRICS. come evident. The typical symptoms of congenital cardiac disease are cyanosis and attacks of dyspnoea, amounting at times to suffocation, and atrophy. As the disease progresses, the fingers and toes often become club-shaped, the nails blue, and the skin cool. In connection with these rational signs there is usually an evident pulsation in the cardiac region, with bulging of the precordia. When the obstruction caused by the lesions is sufficient to produce hypertrophy and dilatation of the heart, an increase in the area of cardiac clulness is found. Diffuse cardiac murmurs are heard often over the whole chest, but usually have their maximum intensity towards the upper part of the sternum, are commonly systolic in time, and in some cases are accompanied by a thrill. The most common symptom is cyanosis. Cyanosis may arise from incomplete oxygenation of the blood, and not merely from a mixture of the venous and arterial currents. When cyanosis is present to any extent there is usually some malformation of the pulmonary artery or its valves. Well-marked congenital malformations may be present with no symptoms whatever. There may be an entire absence of cyanosis ; there may be no increased area of dulness and no murmurs ; and I have met with instances in which the infants seemed to be thriving, and showed neither labored breathing nor physical signs of disease up to within a few hours of death, and yet a number of cardiac malformations were found at the autopsy. Although, as a rule, the symptoms occur at a very early period of extra-uterine life, yet quite frequently they are so mild in character that they are not especially noticed, as they may appear only when the infant is much excited or crying. The cardiac symptoms may not be prominent enough to attract attention until the infant is old enough to exert itself sufficiently, as by creeping or walking, to interfere with the equilibrium of its circulation. At times another disease, especially bron- chitis or pneumonia, may precipitate the cardiac symptoms. It is quite common for endocarditis to develop in a heart in which a congenital malformation is present The diagnosis between a congenital and an ac- quired cardiac affection then becomes necessary and is accompanied by many difficulties. The following case illustrates how congenital cardiac disease can be masked for a number of weeks : The infant was apparently healthy at birth, and a careful physical examination showed nothing abnormal in the thorax. There was no cynosis noticed, the skin being of a normal color. When it was sixteen days old it refused to take the breast, and in the afternoon seemed somewhat cold, was slightly cyanotic, and had a tem- perature of 35.2° C. (95.5° F.). An examination of the heart detected nothing abnormal. A few drops of brandy were given to it, and after several hours the skin became warm, the respirations normal, and it took its food as usual. Early in the following morning the quickened respiration returned, the temperature rose to 37.7° C. (100° F.). it refused to take its food, failed rapidly, and died in the afternoon. The examination of the heart showed a large open foramen ovale and an absence cf the upper part of the intra-ventricular septum below the aortic valve. The be- CONGENITAL DISEASES OF THE HEART. 723 ginning of the aorta for a distance of 1 cm. (f inch) was dilated into a spherical pouch, from which were given off (1) the aorta without any branches before the inter- costals, thus supplying only the lower part of the body, (2) a large vessel to the right lung, and (3) a large vessel to the left lung. From the upper part of the right ven- tricle was given off a large vessel which divided 1.4 cm. (J inch) above the pulmonary- valve into a large vessel on the right side and two' smaller ones on the left. The large vessel apparently corresponded to the innominate, and the other two vessels to the subclavian and common carotid of the left side. By these vessels blood was supplied to the head and upper extremities. There was no communication between the arterial and pulmonary vessels, as the ductus arteriosus was absent. The cause of the dila- tation of the beginning of the aorta was a thickening and narrowing of the vessel for 8 mm. (\ inch) just beyond the dilatation. The heart was enlarged, but not especially hypertrophied. There was a general streptococcus invasion, for which no source could be found. The cord had come away at the usual time without leaving any abnormal condition in the neighborhood of the umbilicus. General Diagnosis. — Although it is usually possible to make a diagnosis of congenital cardiac disease, yet when we consider the variety of lesions which may occur, and the combination of different lesions which may be present, with the same symptoms or a marked lack of symptoms, it will be understood that a diagnosis of the especial lesion is often impossible. Bearing in mind the mechanism of the fcetal circulation and the con- nection which an enlargement of the heart has with especial lesions, we can sometimes arrive at an approximately correct diagnosis. Too much reliance, however, must not be placed upon the locality or sound of the cardiac murmurs, as such murmurs may be produced by very trivial lesions, and may be absent when the lesions are most pronounced. The following characteristics may, however, be considered to represent the more common congenital anomalies. OPEN FORAMEN OVALE. One of the most common congenital malformations of the heart is represented by a defect in development of the auricular septum by an open foramen ovale. The failure of the foramen ovale to close is usually caused by an interference with the pulmonary circulation, such as may occur in atelectasis. Premature closure of the foramen ovale has been met with, but is extremely rare. So long as the patent foramen ovale is not associated with other de- fects it does not, as a rule, produce a murmur or give rise to any symp- toms. The reason for this is supposed to be that the blood can only flow from the right auricle into the left when the pressure is greater in the former, and it is not greater unless there is some obstruction either at the tricuspid valve or in the pulmonary valve or artery, by which the flow of the blood-current into the right ventricle is interfered with. When symptoms such as cyanosis or murmurs are met with in connec- tion with an open foramen ovale, they almost always depend on asso- ciated lesions, the most common of Which are stenosis of the pulmonary 724 PEDIATRICS. artery and a defect in the ventricular septum. The prognosis in uncom- plicated cases of patent foramen ovale is good, as the lesion is one which need not cause much embarrassment of the circulation. DEFECT OF THE VENTRICULAR SEPTUM. A defect in the ventricular septum is a very frequent congenital lesion. It may be complete, but is usually partial, and is most common in the upper part. This defect rarely occurs alone, but is associated with other lesions, especially stenosis of the pulmonary artery, and in such cases acts as a safety-valve. An abnormal origin of the great vessels is also frequently found with this defect. As the lesion is so frequently associated with other anomalies, there are no sharply marked and distinctive symptoms. In most cases, however, a loud systolic murmur is heard over the whole front of the chest, with its maximum intensity hardly ever near the apex, and with a notable absence of a palpable thrill. In uncomplicated cases hypertrophy of the ventricles is not marked. When the right ventricle is strong enough to resist the increased blood-pressure from the left ventricle, the circulation is carried on nor- mally without compensatory hypertrophy and without cyanosis or dropsy. When, however, great expiratory efforts occur, as in bronchitis and per- tussis, or when the blood-pressure is increased from any other cause, dilatation of the right ventricle may set in acutely with symptoms of broken compensation, especially those of cyanosis and dropsy. These symptoms may, for a tune, be delayed by a compensatory hypertrophy of the right ventricle. The prognosis must necessarily be uncertain and unsatisfactory, as in so many instances the defective septum is accompanied by other lesions. In most instances the infants die early, but cases have been reported in which they have lived for many years. LESIONS OF THE PULMONARY ORIFICE. There are three lesions of the pulmonary orifice which play a very important role in congenital cardiac disease. These are stenosis or atresia of the pulmonary orifice and stenosis of the conus arteriosus of the right ventricle. These lesions may occur alone, but most commonly are asso- ciated with a defect in the septa and with a patent ductus arteriosus. They may be the result of a fault in development or of a fcetal endocar- ditis. Pulmonary Stenosis. — This lesion is characterized by extreme cyano- sis, cold, livid extremities, clubbing of the fingers, rapid respirations, and a tendency to dyspnoea. The physical, like the rational, signs are more characteristic than in the other forms of cardiac anomalies. They consist chiefly of a loud systolic murmur heard most distinctly in the pulmonary region and transmitted in all directions. There is, according to the extent of the stenosis, a weak or absent pulmonic second sound ; if. hoAvever, CONGENITAL DISEASES OF THE HEART. 725 the ductus arteriosus happens to be patent there may be no diminution in the intensity of the pulmonic second sound. In some cases a palpable systolic thrill may be felt in the pulmonary region. In many cases, how- ever, the murmur obscures and dominates all other sounds. Generally there is an increased area of cardiac dulness extending to the right of the sternum and representing hypertrophy of the right ventricle. Notwithstanding the apparent gravity of the lesion, pulmonary stenosis permits the infant to live, often for many years, but there is always in these cases a special tendency to tuberculosis and to pneumonia. Pulmonary Atresia. — This lesion is less common but much more serious than stenosis. It is so commonly combined with other anomalies, such as defects in the septa and patent ductus arteriosus, that it cannot be said to have any distinctive physical signs of its own, while its general symptoms are the same as those of pulmonary stenosis. Stenosis of the Conus Arteriosus. — This is an anomaly of develop- ment, is usually associated with other lesions of the orifice, and tends to accentuate the symptoms and results of such lesions. Pulmonary insuffi- ciency has been observed in certain cases, but is very rare. PERSISTENCE OF THE DUCTUS ARTERIOSUS This lesion when existing alone may, as in a case which has come under my observation, present no symptoms except slight and evanescent cyanosis. The sign which, in addition to a light grade of cyanosis and a cadaverous color, is most characteristic of this condition is a loud vibra- tory systolic murmur, with its greatest intensity at the base of the heart. If the lesion is unassociated with other anomalies, there is no hyper- trophy of the ventricles, but if, as so often occurs, there is obstruction at the pulmonary orifice, there is usually also hypertrophy of the right ventricle, and a diagnosis cannot be made, as the murmur cannot be dis- tinguished from that of pulmonary stenosis. The ductus arteriosus should gradually be obliterated within the first two weeks of extra-uterine life. Interference with this normal involution is not very uncommon, rarely occurs alone, and is usually found in con- nection with lesions of the pulmonary artery or narrowing of the isthmus aortae. Sometimes the process of obliterative endarteritis extends to the aorta and causes stenosis of the isthmus aortae. Again, the duct, in closing and retracting, pulls the aorta and tends to narrow that vessel, thus increasing the arterial tension. During fcetal life stenosis of the isth- mus aortae does not produce much disturbance in cases in which the ductus arteriosus can carry the blood to the descending aorta. At birth, however, in these cases, unless the ductus arteriosus remains pervious, serious symptoms arise. If life is prolonged, hypertrophy of the left ven- tricle takes place, and the arterial blood has to be conveyed to the de- scending aorta by means of a collateral circulation which is established between the branches of the subclavian arteries and the branches of the 726 PEDIATRICS. thoracic arid abdominal arteries. Premature closure of the ductus arterio- sus during foetal life has been met with, but is a rare condition. Very rarely the ductus arteriosus may be entirely absent. TRANSPOSITION OF THE LARGE ARTERIES. A transposition of the aorta and pulmonary arteries sometimes occurs when the former arises from the right and the latter from the left ventricle. Both arteries may arise from a common trunk, and a number of other anomalies which are very rare may exist. Transposition of the arteries is not an uncommon anomaly, but there are no symptoms by which the condition can be diagnosticated, as there may be an entire ab- sence of cyanosis, cardiac hypertrophy, and murmurs. The anomaly is, however, at times accompanied by intense cyanosis, asphyxia, cool skin and extremities, and apathy, but as it is always associated with other lesions, there are no distinctive symptoms by which a diagnosis can be made. When this transposition of the main arterial trunks occurs the infant usually lives but a short time. LESIONS OF THE TRICUSPID ORIFICE. Tricuspid Stenosis. — This lesion is usually the result of a foetal endocarditis. It is very rare and is often associated with deficient de- velopment of the right ventricle and hypertrophy and dilatation of the left ventricle. Tricuspid Insufficiency. — This also is very rare, and results in hypertrophy of the right ventricle and dilatation of the right auricle. Both of these lesions are accompanied usually by a number of other anomalies, so that there are no distinct symptoms by which to make a diagnosis, but, as a rule, the cyanosis is pronounced, the heart impulse is unusually strong, there are extensive systolic and diastolic murmurs, thrills, venous pulsation in the neck, epigastric pulsation, and a tendency to hemorrhage. LESIONS OF THE MITRAL AND AORTIC ORIFICES. Although lesions of the left side of the heart may be produced by foetal endocarditis, they are exceedingly rare, in comparison with lesions of the right side of the heart, and are generally associated with a number of other congenital cardiac anomalies. Their symptomatic significance is the same as when they occur in extra-uterine endocarditis, and will be described under acquired diseases of the heart. It may be said, how- ever, that the signs of tricuspid, mitral, and aortic lesions do not differ materially from those met with in adults. The duration of life when the lesions are at the aortic orifice is not nearly so long as when the pulmonary orifice is affected. Differential Diagnosis of Congenital Disease of the Heart. — The differential diagnosis of congenital from acquired organic disease, and of the different varieties of congenital lesions, is exceedingly difficult at times, CONGENITAL DISEASES OF THE HEART. 727 and often cannot be made. Certain facts, however, which seem to be generally accepted, may be stated, and will sometimes aid in the diagnosis. Lond murmurs without much increase of cardiac dulness point towards congenital disease, while with increase of dulness they maybe from either congenital or acquired disease. If there are loud precordial murmurs without thrill and without hypertrophy, which are heard with greatest intensity about in the centre of the area of cardiac dulness, the lesion is probably a congenital defect of the ventricular septum. If there is a thrill but no hypertrophy, the lesion is probably a con- genital patent ductus arteriosus. Fig 149. S, unclosed ventricular septum. Female, 10 months old. Warren Museum, Harvard University. If there is a loud murmur at the base, with a weak pulmonic second sound, a thrill, and hypertrophy of the right ventricle, especially if there is marked and continued cyanosis, the lesion is probably pulmonary stenosis. Murmurs of congenital origin must be distinguished from those of a functional or hsemic source. In congenital disease the murmurs are loud, often accompanied by a thrill, except in defect of the ventricular septum, are associated with cyanosis, dyspnoea, and cardiac hypertrophy, and are permanent. Functional murmurs, on the other hand, are seldom so loud, are evanescent, are unaccompanied by other marked signs, excepting often pronounced anaemia and a venous hum, and usually can be traced to definite etiological conditions such as are described on page 748. Fig. 149 shows a small opening in the ventricular septum. 728 PEDIATRICS. In this case there was also an open foramen ovale, but no other malformation. The infant, after showing the usual progressive signs of congenital cardiac disease, died suddenly. There was no history of cyanosis. Fig. 150. Congenital cardiac disease. Male, 4% years old. Right and left ventricles laid open by two cuts. Stenosis of pulmonary orifice. Incomplete septum ventriculorum. 1 and V, septum ventriculorum cut across ; 2, aortic valves ; 3, probe passing through narrowed pulmonary orifice ; 4, bent probe, passing through right ventricle to left through opening in septum ventriculorum. Fig. 150 represents a specimen taken from a boy four and a half years old, who during life had shown cyanosis, clubbed fingers, and at times severe dyspnoea. The physical signs in connection with the heart were a fine wave perceptible to the eye at the left third interspace, a soft, purring thrill over the base of the heart, cardiac pul- sation 1.4 cm. (J inch) outside of the left mammillary line, and cardiac dulness from the right sternal margin to the left mammillary line, with no dulness to the right of the sternum. A loud, harsh systolic murmur was heard over the left margin of the sternum, most marked at the second left interspace and third rib, and not transmitted to the left or along the aorta. Fig. 151. Transverse section of heart near apex. 1, right ventricle ; 2, left ventricle. The pulmonary artery was abnormally small, the aorta was abnormally large, the conus arteriosus was practically obliterated at the pulmonary orifice, and the ventricu- lar side formed a ring of white cicatricial tissue ^ cm. Q inch) in diameter. Fig. 151 represents the same heart Avith the apex cut away so as to show the rela- tive thickness of the ventricular walls and the greatly thickened septum ventriculorum. The right ventricle was markedly hypertrophied. The left ventricle was normal. The ventricular septum was greatly hypertrophied. In this case the ductus arteriosus CONGENITAL DISEASES OF THE HEART. 729 was impervious and the foramen ovale practically closed. A foetal endocarditis had taken place before the septum ventriculorum had closed. The endocarditis caused contraction of the conus, and the blood being forced from the right ventricle through the imperfect septum prevented the latter from closing. This provided a safety-valve, which, as usually happens in this form of malformation, allowed the child to live longer than is common in other congenital cardiac malformations. The aorta, receiving a direct stream from both ventricles, was distended ; the pulmonary artery, receiving but little, remained small. It is interesting to note in this case that the child passed through an attack of pertussis and measles without serious results. It died ultimately of abscess of the brain. Fig. 152 shows an open ductus arteriosus. Fig. 152. % D, open ductus arteriosus. Male, 16 days old. Warren Museum, Harvard University. This heart, which was left attached to the lung, was taken from an infant, sixteen days old, who was apparently healthy at birth and presented no symptoms of cardiac disease. When the infant was five days old it was noticed that it would sometimes become slightly cyanotic. At this time its temperature rose to 39.4° C. (103° F.). A physical examination showed nothing abnormal, and nothing unusual was seen on inspection. The area of cardiac dulness was normal, and no murmurs were detected. A day or two later the temperature became normal ; the cyanosis increased somewhat, but was intermittent and of a very slight degree. At times the skin would become cool. A few days later there was slight intestinal disturbance. When sixteen days old. without any other symptoms having developed, the infant died suddenly. The post-mortem examination showed this widely open ductus arteriosus. The foramen ovale was also open. There were no other lesions, such as stenosis of the pulmonary artery, open ventricular septum, or lesions of the valves. The heart was of normal size. There were no signs of the obliterative endocarditis usually found at this age in the ductus arteriosus. 730 PEDIATRICS. General Treatment. — The treatment of congenital disease of the heart is essentially hygienic and symptomatic. The infants should be carefully protected from atmospheric changes which would be likely to produce bronchial irritation, as in many cases bronchitis appears to play an important part in interfering with the maintenance of the equilibrium of the circulation and in destroying compensation. In a number of cases I have found that the administration of digitalis in small doses and with the greatest caution is valuable when hypertrophy has begun to fail and dilatation to increase. When the dyspnoea is distressing, a few drops of aromatic spirits of ammonia will often give relief. Stimulants are usually indicated. Freedom from excitement and over-exertion should be constantly en- forced, but the child should be kept in the open air, when it is warm and dry. as much as possible. Finally, infants and children with congenital cardiac disease should be closely watched, even when they seemingly are doing well, for they are apt to die suddenly. ACQUIRED DISEASES OF THE HEART. In studying acquired diseases of the heart it is important to recog- nize the relative size and position of the heart at different ages. These have been described on page 90. Acquired diseases of the heart are more apt to attack the left side of the heart than the right ; when the right heart is affected it is generally secondary to the lesions on the left side. There are certain differences between the symptoms of cardiac disease in infancy and early life and those in later life. In young children mur- murs are more apt to be diffuse than in adults, often being heard over the entire chest ; and the rate and rhythm of the heart are so easily disturbed by nervous influences as to be of little diagnostic value. Progressive emaciation is a symptom which is apt to be pronounced and to appear early in the disease, especially if the child is young. An enlarged heart dependent on adhesions from a preceding pericar- ditis is more common in early life than in adults, while compensation is much more readily acquired. I have had children with cardiac disease at my children's clinic one year with cardiac symptoms so severe that they had to be carried ; they were emaciated and cyanotic, the area of cardiac dulness was increased, and souffles were present : yet these same children would return and be shown to the next class of students in the following year, walking up-stairs without dyspnoea, looking well nourished, of good color, with much less enlargement of the area of cardiac dulness, and with the cardiac souffles scarcely perceptible, showing that the cardiac compensation was complete. Cardiac symptoms dependent on organic lesions may arise and yet no physical signs of such lesions be detected during life. ACQUIRED DISEASES OF THE HEART. 731 CARDIAC HYPERTROPHY. Hypertrophy of the heart consists of an increase in thickness of the cardiac walls. It may be of one or both sides of the heart and is usually most marked in the ventricles. The hypertrophy may be of the walls without an accompanying dilatation of the cardiac cavities (eccentric), or dilatation of the cavities may be present, thus increasing the entire size of the heart. Cardiac hypertrophy is always an effort of nature to counter- act various morbid influences by maintaining the equilibrium of the circu- lation, — that is, it is compensatory. Etiology. — Hypertrophy of the heart is not in itself a disease, *but may occur in many diseases whether of the Avails or of the valves. It is closely related to increased blood-pressure, which may arise from disease or circulatory disturbance outside of the heart or from imperfect valvular conditions within the heart. In the former case the most common causes in children are pericardial adhesions, prolonged pertussis, narrowing of the aorta, and nephritis, espe- cially that which follows scarlet fever. Mechanical interference with the action of the heart arising from adhesions of the pericardium is often latent in its symptoms in infancy, and its occurrence should be especially borne in mind. In the valvular lesions the increased demand for cardiac work beyond what is normally called for acts as an immediate cause for cardiac hypertrophy. Pathology. — The chief morbid conditions of cardiac hypertrophy are an increase in weight and an increase in size and number of the muscular fibres which is found not only in the cardiac walls but in the papillae and trabecular. If the left side of the heart is conspicuously enlarged, as in obstruction at the aortic orifice or in the general arterial system, the heart is elongated ; if the hypertrophy is of the right side, as in obstruction of the pulmonary circulation, the heart is widened. Symptoms. — So long as the compensation is complete, cardiac hyper- trophy does not produce in young subjects any marked symptoms, even the dyspnoea on exertion not being especially noticeable. Hypertrophy of the Left Ventricle. — In hypertrophy of the left ventricle the cardiac impulse is perceptible over an abnormally large area and the impulse is lower and further to the left than normal, the degree varying according to the extent of the hypertrophy. Palpation shows the impulse to be increased in force. Percussion shows the cardiac dulness to be markedly increased in extent downward and to the left. Auscultation shows the first sound at the apex to be long and low in comparison with the second sound, which is loud and sharp. There is accentuation of the aortic second sound. The pulse is full and strong. Hypjertrophy of the Right Ventricle. — In hypertrophy of the right ven- tricle the cardiac impulse is especially marked further to the let! than 732 PEDIATRICS. normal and somewhat downward. There is nothing characteristic in the pulse. The area of superficial cardiac dulness is increased in width, notably to the right and often beyond the right sternal line. There is accentuation of the pulmonic second sound, but- this accentuation, al- though almost always present in hypertrophy of the right ventricle, is not peculiar to this condition, as it may be present in varying degrees in young children normally and from such causes as pneumonia and certain nervous conditions. Prognosis. — So long as full compensation is present the prognosis is favorable. It becomes proportionately unfavorable as the compensation lessens. Treatment. — The treatment is described on page 746. CARDIAC DILATATION. Cardiac dilatation occurs when the cavities of the heart are abnor- mally increased in volume. In many cases there is a thinning of the Avails of the heart, as in acute dilatation, but when hypertrophy is present, as in certain chronic cases, the walls may be thicker than normal. Etiology. — Acute dilatation may occur from a weakening of the cardiac muscle caused by degeneration of the myocardium, as in certain infec- tious diseases and from poor nutrition. Chronic dilatation occurs slowly as the result of valvular lesions or in the progress of the circulatory disturbances spoken of as causing hyper- trophy. Pathology. — In simple dilatation, without hypertrophy, the weight of the heart is not increased, although there is increase in its size. The papillae are flattened, when the dilatation is marked, in comparison with the accompanying hypertrophy, and the endocardium is thickened and opaque. Symptoms. — The symptoms of cardiac dilatation are essentially those of a failure of compensation characterized by dyspnoea on exertion, pal- pitation, cough, and, later, cyanosis and oedema. In both acute and chronic dilatation there are a weak, fluttering apex-beat and pulse, an increased area of cardiac dulness, and valvular murmurs varving accord- ing to the especial lesions. Dilatation of the Left Ventricle. — There is an increased area of cardiac dulness to the left and downward. The first heart-sounds are sharp and short. The aortic second sound is feeble both at the apex and in the aortic area. Dilatation of the Right Ventricle. — The chief signs of dilatation of the right ventricle are increase of the area of cardiac dulness to the right, corresponding to the region of the right auricle, and a weak pulmonic second sound. In all the conditions which cause dilatation there is a greater liability that acute dilatation may take place in early life than at a later period. ACQUIRED DISEASES OF THE HEART. 733 The processes which suddenly cause great increase of the blood-pressure in the lungs may lead io acute dilatation of the right ventricle. When there is a diffuse renal disease, such as may develop in the course of scarlet fever, acute dilatation of the left ventricle may take place, and be followed by hypertrophy. In all these diseases this acute dilatation may take place rapidly and disappear almost as rapidly, a phenomenon which is somewhat characteristic of cardiac disease in early life. The great changes which take place in the heart and its rapid growth at the time of puberty have already been referred to. At this period the general growth of the child is apt to be very rapid, and symptoms of car- diac weakness commonly occur, especially in girls. These symptoms are debility, lack of energy, palpitation, and dyspnoea on exertion. There may also be signs of slight cardiac dilatation, and murmurs, probably hsemic in their nature. This period, therefore, is one in which cardiac disease from any cause, such as rheumatism, is of more serious import than at a later period, when the heart is not taxed by too rapid growth. Prognosis. — The prognosis of cardiac dilatation depends on whether the cause is a temporary one or whether, in case it is not, compensatory hypertrophy can be obtained by treatment. Whether the prognosis is favorable or unfavorable must, then, be determined by the evidence of re- action which is presented by the individual case. Treatment. — The treatment is described onjoage 746. MYOCARDITIS. Primary disease of the myocardium is very rare in children, in whom disease of the myocardium is almost ahvays a secondary process resulting from one of the infectious diseases. It may be acute or chronic. Etiology. — The most common causes in children are endocarditis, pericarditis, and the infectious diseases, especially scarlet fever and diph- theria. The other causes which may produce an affection of the myo- cardium in later life may occur at any age, but are too rare in children to be considered. They are found in lesions of the coronary arteries (anaemic necrosis), an excess of food, alcohol, physical strain, and arterio- sclerosis. Pathology. — The lesions may be parenchymatous or interstitial, de- generative or inflammatory. They are essentially of the septum and left ventricle. In the parenchymatous form the anatomical changes are in the muscle-cells, the cells being degenerated in various ways (granular, fatty, hyaline), and the muscular fibres often separated, a condition known as fragmentation and segmentation. This form is usually met with in fevers, intoxications, infectious conditions, and in connection with endocarditis and pericarditis. It is always acute, usually diffuse, and is especially characterized by softness of the heart. The interstitial form may be acute or chronic, and occurs in small areas. In the acute variety, such as occurs in certain infectious diseases, most 734 PEDIATRICS. commonly in diphtheria and typhoid fever, and especially in acute pericar- ditis, which is an important local cause in childhood, there is an infiltra- tion of round cells between the fibres, and in some cases small abscesses are formed. In the chronic variety there are opaque, white or yellow spots which later may soften (Ziegier s myomalacia), and, as has occurred in rare cases in children, cardiac aneurism and rupture may result. The parenchymatous and interstitial lesions of the myocardium may develop alone or in combination. The other pathological lesions of the myocar- dium are so rare in children that they need merely be mentioned. They are fatty degeneration and infiltration, brown atrophy, amyloid degeneration, hyaline transformation (Zenker), and calcareous degenercdion. Symptoms. — The symptoms are essentially those of a weak heart, but as to whether such symptoms are indicative of an affection of the myo- cardium, or of nervous conditions of the heart, or of some other cardiac disease is usually very uncertain. In acute cases there may be palpitation, pallor, dyspnoea on slight exertion, a rapid, irregular, weak pulse, disturbance of digestion, and on auscultation feeble heart-sounds, especially the aortic second, and in the beginning absence of murmurs. Usually there is no increase in cardiac dulness. It must, however, be remembered that these same symptoms may be present and yet no lesion of the myocardium be found at the autopsy, while, on the other hand, without any especial symptoms referable to the heart, sudden death may occur and marked lesions of the myocardium be present. In chronic cases the weakening of the heart is slow and progressive and the area of cardiac dulness is increased, corresponding usually to the left side of the heart. The impulse is feeble and murmurs may eventually appear as the valves of the heart become incompetent. Symptoms of venous stasis gradually supervene. The pulse is irregular and small ; it is sometimes slow, but becomes rapid under even slight nervous ex- citement. All these symptoms may become intensified, but it must be borne in mind that other diseases may cause these same cardiac symptoms and that the autopsy may disclose serious chronic lesions of the cardiac walls where during life no cardiac symptoms had appeared. Diagnosis. — The diagnosis depends upon symptoms of cardiac weak- ness, with a rapid, irregular, feeble pulse, without murmurs, with or with- out increased cardiac dulness, upon the progressive character of the symp- toms, and upon the comparatively slight improvement under treatment. The etiological factor in the diagnosis is important. When a previously healthy child has been attacked by one of the infectious diseases, such as scarlet fever, diphtheria, or typhoid, and when cardiac symptoms not re- ferable to an endocarditis or pericarditis arise, we may suspect a lesion of the myocardium. Prognosis. — The prognosis in affections of the myocardium depends ACQUIRED DISEASES OF THE HEART. 735 upon the cause of the condition and also, if it is secondary to one of the infectious diseases, upon the degree and virulence of the infection. It is, therefore, very uncertain in the acute cases, although always serious, while in the chronic cases it is very grave. Treatment. — The treatment is essentially rest and freedom from ner- vous excitement and sudden exertion, as from sitting up in bed. After such diseases as diphtheria a recumbent position is often indicated for weeks when marked signs of cardiac weakness have arisen ; and this may be said also when these symptoms supervene on any of the infectious diseases. Stimulants such as aromatic spirits of ammonia and alcohol should be freely used. Strychnine is, of all drugs, perhaps the most valu- able, while digitalis, if used at all, should be given with great caution and in small doses. When there is much precordial distress and the symp- toms of cardiac failure are imminent, small doses of morphia given subcu- taneously are indicated. Anaemia and other symptoms, if present, should receive appropriate symptomatic treatment. ENDOCARDITIS. Endocarditis is an inflammation of the endocardium which is usually confined to the valves. It may be acute or chronic. Acute Endocarditis. — The acute form of endocarditis may occur in fcetal life, and in these cases almost invariably affects the right side of the heart, while if the disease is acquired in extra-uterine life it is the left side of the heart which is most frequently attacked. Etiology. — Acute endocarditis may, in rare instances, be a primary disease, but in most cases is caused by some one of various infectious processes. In some cases bacteria have been found, but not in all. There is no one variety of bacteria exclusively concerned in the production of acute endocarditis. The streptococcus, staphylococcus, pneumococcus, and gonococcus are the forms which have been most frequently found. Less frequently, especially in the simple form of acute endocarditis, the tubercle bacillus, the typhoid bacillus, and the anthrax bacillus have been met with. The colon bacillus, diphtheria bacillus, bacillus pyocyaneus, and bacillus of influenza have also been reported. There is no difference in the endo- carditis arising from these various organisms except in the degree of the malignant nature of the especial organism which has produced the disease, or in the vulnerability to infection of the individual. The frequent occurrence of acute endocarditis in children has been attributed to the greater vulnerability to bacterial action in early life. Acute endocarditis may be of the simple or verrucose or of the septic or malignant form ; this distinction, however, is based on the intensity of the endocarditis rather than on marked etiological differences. The malignant form is very rare in childhood. The most frequent etiological factor in simple acute endocarditis is acute articular rheumatism. It may also occur in chorea either with oi 736 PEDIATRICS. without a rheumatic complication. While it may occur in the course of any of the infectious diseases, such as influenza and diphtheria, it is most common in scarlet fever, pneumonia, and pleurisy, while it is not common in measles and varicella. The malignant form of endocarditis seems to occur more frequently in pneumonia than in any of the other acute in- fectious diseases. Pathology. — While the same lesions of endocarditis may be found in children as in adults, yet in infancy, although marked acute cardiac symp- toms and murmurs frequently arise, the autopsy almost invariably fails to show any endocardial lesions or growths. In two thousand autopsies at the New York Foundling Asylum, Dr. Northrup and Dr. O'Dwyer never found an acute inflammatory lesion, except in one case, which showed the lesions of acute malignant endocarditis. When the lesions of endocarditis are found in children, the connective tissue and the basement substance are principally concerned in the inflammatory process. The endocardium which forms the valves is that which is most frequently inflamed, but other portions of it are by no means exempt. In some cases there is swelling of the valves, which are thickened, their surfaces remaining smooth, the basement substance is swollen, and there is a moderate pro- duction of new connective-tissue cells. In other cases the growth of connective-tissue cells is very much more marked, the basement substance is broken up, and little cellular fungus-masses, called vegetations, project from the free surface of the endocardium (verrucous endocarditis). On the surface of these vegetations thrombi may be formed, and bacteria are sometimes present. In still other cases the cellular growth in some places forms vegetations, and in others degenerates, and thus portions of the valves are destroyed. This is acute ulcerative endocarditis, also called malignant endocarditis. In these cases the diseased valve and the thrombi contain bacteria much more frequently and in far greater numbers than are found in the simple benign form. This malignant form is evidently secondary in the course of a septic infection, and the previous disease of the valves favors the invasion of the infectious bacteria. In the simple form of acute endocarditis emboli may occur, which from their size usually produce mechanical disturbances alone, while in the malignant form the emboli are usually smaller, and, being septic, produce inflamma- tory rather than mechanical disturbance, giving rise to miliary abscesses in various parts of the body, such as the liver, kidneys, spleen, stomach, intestine, brain, eye, joints, and skin. Acute endocarditis may also be secondary to old cardiac malformations or lesions (endocarditis recurrens). In some cases the children recover, and the valves seem to return to their normal condition, while in others the valves are left permanently damaged. Simple Acute Endocarditis. — Symptoms. — The symptoms of simple acute endocarditis are often obscure, and in infants and young children in the beginning are apt to be latent. When the disease arises in connection ACQUIRED DISEASES OF THE HEART. 737 with some other disease, the symptoms are especially likely to be masked by those of the disease which it complicates. In some cases the endocar- ditis develops insidiously without any additional symptoms, such as pain or precordial distress, and its presence is not recognized until a careful ex- amination of the heart detects a murmur ; in others, pronounced and even violent cardiac symptoms are present from the beginning. Again, the first evidence of an endocarditis may come from symptoms of embolism such as hemiplegia, haematuria, dyspncea, cough, or localized pain, as in the thorax or abdomen. If the muscular tissue is involved as well as the endocardium, the general cardiac symptoms of dyspncea, cyanosis, and palpitation are still more marked. When endocarditis arises in the course of acute rheumatism there may be nothing which would draw especial attention to the heart, but there are usually general symptoms of increased rapidity of the heart's action, with perhaps slight irregularity, restlessness, prostration, and a rise in the temperature, which is especially suspicious if, with this in- crease in the fever, there is no exacerbation of the trouble in the joints. Palpitation and dyspncea are also quite frequently present. There may at first be no murmur, but usually after a few days a soft systolic murmur at the apex transmitted to the left, and later a slightly accentuated pul- monic second sound, may be heard. Endocarditis may with these same symptoms occur in the course of chorea. When endocarditis does not arise as a complication of some other disease, the symptoms at the onset, when prominent, are usually a rise of temperature, an accelerated and sometimes weak and irregular pulse, dyspncea, palpitation, and more or less precordial distress. All these symptoms vary according to the extent of the lesions. Later they depend upon whether or not compensation has been established. In connection with these early symptoms, cardiac dilatation and cyanosis are very apt to occur. When the disease has advanced so far as to interfere with com- pensation, the physical signs of dilatation appear. The symptoms differ somewhat according as the inflammatory condition has begun in the valves or in the cardiac walls (Steffen). In the former case the signs of dilatation accompany those of valvular weakness, while in the latter the symptoms of dilatation come first, and are followed by the mechanical results of valvular insufficiency. In a first attack of acute endocarditis the serious symptoms connected with great lack of compensation which are met with when the attack supervenes on a previous cardiac lesion are not likely to arise. In some cases, however, when the individual powder of cardiac resistance is slight, they appear early in the disease. Under these circumstances the child emaciates rapidly, becomes very weak and anaemic, and the cyanosis and dyspncea increase. There is apt to be cough from an accompanying bronchial irritation, produced most frequently when there is obstruction at the mitral orifice. As a result of a general venous stasis, enlargement 738 PEDIATRICS. of the liver, haemoptysis, and oedema of the face, legs, and arms appear. Children show such a wonderful recuperative power that even in these advanced cases under proper treatment the serious symptoms may grad- ually pass away, and often such complete cardiac compensation takes place that they are left with no symptoms of cardiac disease except a murmur and some hypertrophy. Relapses are common and .there is a great tendency to recurrence. Embolism may take place as a late as well as an early complication. Anaemia is a very common symptom, especially when endocarditis ac- companies rheumatism. Congestion of the lungs with resulting haemop- tysis may arise when there is insufficiency of the mitral valve. When the valves are affected murmurs are usually present, yet sometimes when there are lesions of the valves murmurs cannot be detected. In endo- carditis murmurs are most frequently heard in the region of the mitral valve, and insufficiency of the mitral valve is the most common of the inflammatory cardiac lesions in childhood. Acute simple endocarditis may last for several weeks, the symptoms gradually subsiding or becoming chronic ; or there may be recurrent attacks which are especially likely to result in chronic valvular disease ; or acute dilatation may result with increasing symptoms of cardiac insuffi- ciency, dropsy, and pulmonary complications, finally ending in death. Diagnosis. — The diagnosis of simple acute endocarditis during life de- pends upon the physical signs. These signs are an increase in the area of cardiac dulness and a change in the sounds of the heart. The change in the area of cardiac dulness must be differentiated from that which occurs in a pericardial effusion as described on page 759. The change in the cardiac sounds may be produced by changes in the blood or by organic lesions of the valves. The differential diagnosis be- tween these two conditions is given on page 748, and the diagnosis of the especial valvular lesion is given on pages 741-745. Prognosis. — The prognosis of simple acute endocarditis in early life is comparatively favorable as to the immediate outcome, but may eventually become serious by the occurrence of embolism or the development of a malignant endocarditis. Owing to the great recuperative powers in early life, in many cases, especially when it is the first attack, such complete compensation takes place that the child practically recovers. If it is the walls of the heart that are affected, the heart -may regain its normal size and position. If the valves alone, or the valves and the walls, are affected, recovery can still take place. The development of chronic valvular dis- ease is the usual termination. Death may, however, occur at the height of the attack, or the child may die later from exhaustion and sometimes suddenly from heart-failure. Malignant Endocarditis. — Symptoms. — The symptoms of malignant endocarditis are necessarily varied and indefinite, arising as they usually do in the course of some other disease with simply an exacerbation of ACQUIRED DISEASES OF THE HEART. 739 the previous symptoms, especially of the temperature. There are usually the general symptoms of intermittent temperature, sweating, delirium, and failure in strength. Two types of the disease, septic or pyaemic and typhoidal. are recognized. The septic type is characterized by the signs of septic infection, rigors, sweating, and irregular temperature, while the typhoidal type shows diarrhoea, dry tongue, distended and tympanitic abdo- men, enlargement of the spleen, profuse sweating, and a petechial efflores- cence on the skin. A clear distinction between the two forms, however, is often not marked. Cerebral symptoms may arise, and simulate menin- gitis and malaria. Embolic processes may produce special symptoms, such as paralysis, coma, bloody urine, retinal hemorrhage, peritonitis from infarction of the spleen, and in some cases pulmonary symptoms simu- lating pneumonia. Murmurs may be absent. The duration of the at- tack depends mostly on the disease to which it is secondary, and may vary from a few days to as many weeks. A marked leucocytosis is present. Diagnosis. — The diagnosis of malignant endocarditis is made from the simple form by the graver constitutional signs, the higher temperature, and the septic or typhoidal symptoms just described. From typhoid fever it is to be distinguished by its abrupt onset, irregular temperature, pre- cordial pain and distress, marked leucocytosis, and negative Widal reac- tion. Malaria can be eliminated by the absence of the Plasmodium ma- larias and the presence of leucocytosis. Prognosis. — The prognosis of malignant endocarditis is very grave, although the disease is not necessarily fatal. The heart is, however, permanently damaged. Treatment of Acute Endocarditis. — The treatment of acute endo- carditis during the early days of the attack is essentially rest in bed. When the disease is due to some specific disease, such as diphtheria, the specific remedy for that disease should be given at once. From the very beginning, however, we should endeavor to establish compensation. The child should be encouraged to sleep, in order that the circulation may be kept as quiet as possible and thus relieve the work of the disabled heart. The heart-beats of a young child during sleep are often reduced twenty in a minute, and thus sleep affords the best opportunity for compensation. Later the general health of the child should be carefully attended to by means of good food, pure air, and exercise of a mild type, never exces- sive. The surface circulation should be promoted by baths and gentle massage. Digitalis and iron are of great value, the former in aiding the establishment of compensation, the latter in combating the anaemia. When there are symptoms of heart-failure, stimulants such as alcohol, aromatic ammonia, and strychnine (page 470) are indicated and important. If at any time during the course of the disease the attacks of dyspnoea are excessive, nitroglycerin can be given in doses proportionate to the ago of the child ; 0.0003 gramme ( Y io grain) can be given to a child three or 740 PEDIATRICS. four years old. The younger the child, the more likely it is that we shall have to contend with a resulting atrophic condition and anaemia. The treatment of the malignant form of endocarditis is essentially that of a septic condition, and stimulants should be used freely. CHRONIC ENDOCARDITIS. Chronic endocarditis showing sclerosis of the valve may be chronic from the outset, but it usually succeeds an acute endocarditis ; this occurs especially in the rheumatic form. Etiology. — The usual causes of chronic endocarditis in later life, such as syphilis, alcohol, gout, and strain from undue muscular exertion, are very seldom met with in children, acute endocarditis being the chief etiological condition. Pathology. — Although the morbid process may attack the parietal endocardium, it is the valvular form that is of such clinical importance as to become the prominent feature in chronic endocarditis. The process in extra-uterine life most frequently affects the aortic and mitral valves, the latter being especially involved in childhood. It is a slow, insidious process, manifested by thickening, induration, and adhesions, followed by a contraction of the valvular segments. Later, lime-salts are deposited in the valves and this results in rigidity. As the sclerotic changes increase, the deformity of the segments becomes greater and results either in im- perfect closure of the valves (valvular insufficiency), allowing a regurgitation of the blood, or the orifice is narrowed (valvular stenosis), causing obstruc- tion to the blood-current. We meet, especially in children, with lesions at the mitral orifice in which the valves are curled and thickened so that they are insufficient, although there may be no narrowing of the orifice. The chordae tendinese gradually become shortened. The apices of the papillary muscles are enlarged, the endocardium becomes thickened, and marked changes following the valvular lesions take place in the walls of the heart. These changes are represented by varying degrees of hy- pertrophy or dilatation according to the degree and duration of the valvu- lar lesions and to the extent to which compensation has been interfered with. In the order of their frequency the mitral valve is most often affected, next the aortic, then the tricuspid, and very rarely the pulmonary valve. It is not uncommon for the aortic and mitral valves to be affected together. In very rare cases all the valves may be involved. General Symptoms. — The symptoms of chronic endocarditis develop gradually, especially when compensatory hypertrophy is complete. They often extend over a period of many months, corresponding to the slow progressive nature of the valvular lesions. When there is a leakage through the valves or when there is obstruction to the flow of blood an increased amount of work is thrown upon the auricles and ventricles, and symptoms of hypertrophy or dilatation result which are directly in propor- tion to the amount of compensation which is present. The final effect, ACQUIRED DISEASES OF THE HEART. 741 therefore, of all valvular lesions is a failing compensation and venous stasis throughout the whole body. In children there may be long periods when the morbid conditions do not increase and when, beyond occasional attacks of dyspnoea on exertion, other symptoms are not prominent. Symptoms, such as cough, epistaxis, palpitation, and anaemia, are apt to appear and then pass away, when for any reason the child is debilitated. A decided failure in compensation is liable to arise at any time from an attack of acute endocarditis, from over-exertion, or from the presence of one of the infectious diseases, such as scarlet fever or typhoid. As compensation fails the corresponding symptoms of a weak heart become more marked. There are present some, rarely all, in young chil- dren, of the following symptoms : increased dyspnoea, orthopncea, bron- chitis, dropsy, beginning in the feet, enlarged liver and spleen, ascites, renal congestion with albuminuria, indigestion, and, later, prominence of the superficial veins, clubbed fingers, and cyanosis. Emaciation is a marked symptom. There may be at any time during the course of the disease cerebral symptoms such as fainting and dizziness, and sometimes headache. These symptoms, even when extreme, may all pass away, and then at varying periods of months or years return. Death may take place from sudden paralysis of the heart or as a result of the additional tax on the heart from some intercurrent disease, such as pneumonia or nephritis. Embolism, with its resulting paralysis or oedema of the lungs, may hasten the fatal result. In connection with these symptoms certain physical signs of the heart itself are present which correspond to the especial valvular lesions which are present. Mitral Insufficiency. — Incompetency of the mitral valve with regurgi- tation is the most common of all the valvular lesions, and in most cases is caused by rheumatism. It is also especially met with in chorea. Before compensation has taken place, the lesion is represented by a systolic murmur most marked at the apex, synchronous with the impulse and with the first sound, which it may replace, and transmitted into the axilla and back. When compensation has taken place there is an accentuated pulmonic second sound and an increased area of cardiac dulness, corre- sponding at first to enlargement of the left auricle and right ventricle and later of the whole heart. In this latter condition there is not only an increase in the breadth of the heart, but also in its length, the apex being depressed and carried in varied degrees to the left of the mammillary line. There may be bulging of the precorclia. The aortic second sound is diminished. The pulse is diminished in volume and tension. As compensation fails the general symptoms of a weak heart appear, and dilatation predominates, over the hypertrophy with the sequence of symptoms already described. Mitral Stenosis. — Stenosis of the mitral valve is usually the result 742 PEDIATRICS. of chronic endocarditis. It develops slowly and is often a later stage of the same process which has earlier produced mitral regurgitation. It occurs most commonly in girls, and many cases are associated with tuberculosis of the lungs. In the early part of the disease there is little or no increase in the cardiac dulness, but later the cardiac area is increased in breadth and cor- responds to an enlarged left auricle and right ventricle. A sign which may be said to be characteristic of mitral stenosis is a thrill, which on palpation gives rise to a purring sensation, felt at the apex of the heart, just before and up to the time of the systole, when it ceases sharply. As in mitral regurgitation, there may be bulging in the precordial region, especially to the left of the sternum and within the mammillary line. The impulse is both seen and felt rather higher in the vertical line than is normal, and is due to the impulse of the conus arteriosus of the right ventricle. A presystolic murmur, rough and purring in quality, is heard in the mitral area over a rather limited space, and is not markedly trans- mitted. It begins shortly after the end of diastole and increases with a crescendo until systole begins, when it ceases abruptly with a very sharp first sound. The thrill can sometimes be felt when no murmur is heard, and can be transmitted into the axilla, while the murmur is only heard in the mitral area; in some cases, however, the murmur is transmitted into the axilla. The second sound is frequently reduplicated, and this is an important diagnostic sign, as it may be heard in some cases in which the murmur is absent. Irregularity in force and rhythm may occur at any stage. The pulmonic second sound is accentuated, may be reduplicated, and may be transmitted a considerable distance to the left. In uncomplicated cases there is usually no murmur heard in the aortic area. In the later stages of the disease, corresponding to marked dilatation of the right ventricle, tricuspid regurgitation develops and the murmur may disappear. The sharp first sound remains, and, with prolongation of diastole and great cardiac irregularity, is of much aid in the diagnosis at this stage. When in conjunction with a reduplicated second sound, it suggests mitral stenosis, which may be masked by the prominence of the signs of mitral regurgitation, which is so commonly associated with mitral stenosis. It is rather characteristic of mitral stenosis that, although the pulse may be markedly irregular, the general circulation remains good for long periods. Embolism is a very common complication, even more so than in lesions of the other valves. Haemoptysis is also apt to occur. Finally, compensation fails and the symptoms are the same as in mitral insufficiency with cardiac dilatation. Dropsy in many cases is absent. Hepatic enlargement and ascites are common. The increased area of cardiac dulness is often masked by the increased size of the lungs. The prognosis of pulmonary and pleural affections arising in the course of a mitral stenosis is especially bad. ACQUIRED DISEASES OF THE HEART. 743 A presystolic murmur at the apex may be heard in some cases of aortic regurgitation, but the murmur may be considered to arise from mitral stenosis if with absence of a predominating hypertrophy of the left ventricle there are the signs of pulmonary congestion, accentuation of the pulmonic second sound, and a sharp mitral first sound. Tricuspid ob- struction is almost impossible to differentiate from mitral stenosis, but is exceedingly rare. Following an attack of pericarditis a murmur may be heard which closely simulates mitral stenosis, but is differentiated by absence of the sharp first sound at the apex and the other signs of peri- carditis. Aortic Insufficiency. — Lesions of the aortic orifice are rare in child- hood, as rheumatism, the most frequent cause of endocarditis in children, in almost all cases attacks the mitral valves. Aortic disease may there- fore be said to belong essentially to a later period of life, and, when it does occur in early life, to be associated almost invariably with some other valvular lesion, usually the mitral. In most cases there is a thick- ening and shortening of the cusps, causing a regurgitation of the blood from the aorta into the left ventricle during diastole. As a result of the increased amount of work thrown on the left ventricle dilatation and hypertrophy occur, producing greater ventricular enlargement than any other form of valvular disease. As a result there is marked heaving, throbbing, and often bulging in the precorclia. There is great increase of the cardiac dulness, especially to the left and downward. Aortic insufficiency is shoAvn by a rather faint murmur coincident with or replacing the second aortic sound. The maximum intensity of this murmur seems to vary in different cases. It may be loudest in the aortic area, but is most common in the midsternal region, especially on the left side of the sternum at about the level of the fourth left costal cartilage. The murmur in some cases is also heard distinctly near the apex of the heart, and less frequently its maximum intensity may be at the second or third left costal cartilage or over the ensiform cartilage. Although in a certain number of cases the murmur may be transmitted into the axilla and even into the back, as a rule the transmission is limited to the precordia, although it may extend in all directions, but especially downward towards the apex. The aortic sounds, and sometimes the murmur, may be transmitted into the carotid and subclavian arteries. The carotid arteries may show evident pulsation, and there is the char- acteristic Corrigan pulse. The first sound of the heart at the apex is prolonged. The pulmonic second sound is not accentuated. The gen- eral symptoms usually come on slowly, and are characterized at first by dyspnoea, headache, and other signs of cerebral congestion. Compensation may last for long periods, but when it fails symptoms of faintness, precordial pain, angina pectoris, and sometimes, although rarely, dropsy and cyanosis appear, these latter two symptoms usually occurring when an associated relative insufficiency of the mitral orifice 744 PEDIATRICS. has taken place. Death follows quite frequently from cardiac paralysis, cerebral hemorrhage, or arterial embolism before insufficiency occurs. Aortic Stenosis. — Narrowing of the aortic orifice is rare, and is much less frequent than the other valvular lesions of the left side of the heart. It is very apt to be associated with aortic insufficiency. As a result of this lesion there is dilatation and hypertrophy of the left ventricle : the hypertrophy, however, being markedly predominant. Aortic stenosis is represented by a loud, late, systolic murmur, heard with greatest intensity in the second right intercostal space and transmitted upward to the carotids. The murmur is also transmitted widely all over the chest. The aortic first sound is usually obliterated, the aortic second is much weakened, and, if there is also an insufficiency of the aortic valves, a diastolic murmur is heard. The pulse is small, slow, and wavy, unless modified by insufficiency. Usually a thrill is heard and felt most distinctly in the aortic area and transmitted to the carotids. There are fewer general symptoms in this lesion of the heart than in any other, until the compensation, which is usually complete, gives way. When, however, compensation fails, the same general symptoms which have been described under aortic insuffi- ciency occur. Eventually insufficiency of the mitral valve develops, with its concomitant signs and symptoms. It is to be remembered that a systolic murmur in the aortic area is not distinctive of aortic stenosis, and also that an aortic systolic murmur may occasionally be heard with greatest intensity at the apex and be mistaken for that of mitral regurgitation. Other murmurs which may occur in the aortic area, and which are especially to be differentiated, are the functional murmurs of unusual distribution and the murmur of the very rare pulmonary stenosis. A patent ductus arteriosus may also pro- duce a systolic murmur in the aortic area. Tricuspid Insufficiency. — Endocarditis of the tricuspid valve acquired in extra-uterine life is very rare, and when it occurs is associated with lesions of the mitral or aortic valves or of both. Relative insufficiency of the tricuspid valve from stretching of the orifice occurs commonly as a result of mitral insufficiency and of such pulmonary diseases as emphysema and chronic bronchitis, which cause obstruction to the pulmonary circulation. The chief signs of the regurgitation of the blood from the right ven- tricle into the right auricle are as follows. There is a wave of trans- mission which gives a systolic pulsation of the jugular veins, causing them to stand out prominently, especially on the right side. This systolic pulsation may also occur, although less frequently, in the liver from con- gestion of the branches of the hepatic vein. There is a systolic murmur, rather soft and low, heard at the lower part of the sternum, the maxi- mum intensity being near the sternal junction of the fifth or sixth leit costal cartilage, usually not distributed widely, but in some cases trans- mitted to the right as far as the axilla. The pulmonic second sound is, ACQUIRED DISEASES OF THE HEART. 745 as a rule, not increased. The area of cardiac dulness corresponds to that of dilatation of the right ventricle, but is usually moderate, and extends to the right as well as to the left and downward. Cyanosis is especially pronounced. It must be remembered that tricuspid insufficiency is in most cases exceedingly difficult to diagnosticate : in some cases there are no physical signs recognizable during life ; in many cases the signs are those of the associated mitral lesion, and the pulmonic second sound remains strong even when a tricuspid lesion is found to be present. Tricuspid Stenosis. — Tricuspid stenosis as an acquired disease in extra-uterine life is so very rare in children, so uniformly of congenital origin, and so very difficult of diagnosis, that it need only be referred to as a possible condition. Its diagnosis would depend on an enlarged right auricle, a presystolic murmur loudest near the ensiform cartilage, and venous congestion as in tricuspid insufficiency. Its frequent association with aortic and mitral stenosis makes its recognition, however, during life almost impossible. Pulmonary Insufficiency and Stenosis. — Although organic disease of the pulmonary valve may result from foetal endocarditis, it is rarely acquired in extra-uterine life, and then only in septic processes. The diastolic murmur of pulmonary insufficiency should be distin- guished from that of aortic insufficiency by not being transmitted to the carotids, by an hypertrophiecl right ventricle, by sharp accentuation of the pulmonic second sound, by evidence of septic embolism in the lungs, and by the absence of the Corrigan pulse. When there is pulmonary stenosis the lesion is so universally of con- genital origin that its diagnosis can be referred to what has already been described under congenital diseases of the heart. Diagnosis. — The diagnosis of chronic valvular disease, when a single lesion of regurgitation or stenosis is present without an association with lesions of other valves, is made by the physical signs of the individual affection which have just been described. Combined valvular lesions are, however, exceedingly common, and render the diagnosis much more difficult. The diagnosis depends upon the character of the murmurs, upon the degree of dilatation and hypertrophy of the auricles and ven- tricles, and upon the general symptoms referable to the circulation and respiration. Too much importance must not be attached to the pres- ence or sound of murmurs alone, as they may be functional. The dis- tinction between organic and functional murmurs is given on page 748. Prognosis. — Although children often show a wonderful power of re- cuperation, yet, unless the lesion is very slight, it can never be completely recovered from. The dangers from embolism or a recurrent endocarditis must always be borne in mind as increasing the gravity of the prognosis. but so long as compensation is efficient the prognosis is good, although murmurs of all kinds may be present. 746 PEDIATRICS. Many of the influences which make the prognosis in later life bad, such as disease of the coronary arteries, are rare in early life. The mitral and aortic valves which are most commonly attacked in the acquired en- docarditis of children are the ones in which compensation is most readily attained. In young children, however, the prognosis, on the whole, is unfavorable in chronic valvular lesions. The nutrition of the rapidly growing heart is easily affected, and dila- tation develops rapidly. Recurrent attacks of rheumatism are very common in children, and each attack increases the gravity of the prog- nosis. In like manner the onset of one of the acute infectious diseases means an exceptionally bad prognosis in children in whom valvular dis- ease is present. Extensive pericardial adhesions, insufficient or improper food, and lack of supervision of the amount of exercise greatly increase the risks of disturbing the compensation of the heart. Treatment of Chronic Endocarditis. — The indications for treatment of chronic endocarditis depend less upon the character of the lesion than upon the degree of compensation which is present. When compensation is established and withstands the ordinary demands of life, hygienic and prophylactic measures alone are necessary. As compensation fails, active treatment is called for, and is directly proportionate to the severity of the symptoms. Simple hypertrophy of the heart, therefore, whether from endocardial causes, as from chronic valvular lesions, or from exocardial conditions, does not require the use of drugs. The regulation of the habits of life are of the first importance. Great care should be taken not to overtax any of the functions of the body. The digestive, nervous, and muscular systems should be kept well within the limits of fatigue. The diet should be carefully regulated according to the age and digestion of the child. Nervous strain from over-study and emotional excitement should be care- fully guarded against. Out-of-door life and moderate exercise should be encouraged, but the more vigorous forms of athletic sports should be pro- hibited. Each case must be judged by itself as to the amount of muscu- lar work which is permissible, and this can be determined only by begin- ning with the mildest forms of exercise and cautiously increasing the amount. It is often desirable to insist upon absolute rest in bed or on a lounge for an hour or two in the middle of each day. With the advent of the early symptoms of failing compensation the cessation of all exercise and the use of appropriate doses of nux vomica and iron for a few weeks may restore the lost compensation. If the symptoms are persistent, the nux vomica should be supplanted by small doses of the tincture of digitalis. A change of climate is sometimes to be recommended in those cases in which the failure of compensation is slowly progressive. Acute dilatation may come on suddenly with but few premonitory ACQUIRED DISEASES OF THE HEART. 747 symptoms. The treatment is then absolute rest in bed and active stimu- lation by the use of strychnine and digitalis in doses as recommended on page 470. Brandy or aromatic spirits of ammonia are useful to bridge over a crisis, and not infrequently small doses of morphine, guarded with atropine, given subcutaneously, can advantageously precede the use of the cardiac stimulants. Digitalis and strychnine are, however, the drugs on which most reliance can be placed in all the stages of a broken com- pensation. As the cardiac weakness increases, special symptoms arise which demand special treatment. Dyspnoea. — When the dyspnoea becomes troublesome, the child should be propped up by means of pillows or a bed-rest into a semi-upright position. The cause of the dyspnoea should be determined if possible, remembering that it may be due to flatulency, hydrothorax, hydroperi- cardium, ascites, or oedema of the lungs. If it is of gastric origin, the digestive disturbance should receive appropriate treatment, both for the relief of the immediate symptoms and the prevention of its recurrence by the proper change in the diet. Hydrothorax, if present, may require re- peated tapping, but this is of rare occurrence. The oedema of the lung, as evidenced by the dyspnoea, cough, and physical signs, is best controlled .by stimulation of the heart rather than by treatment directed to the lungs. When the dyspnoea is apparently due to high blood-tension, the use of nitroglycerin, in doses such as are prescribed on page 470, will often meet the requirements. Vomiting. — Vomiting is often a difficult symptom to control. If it is due to venous stasis, digitalis will often act well, but the vomiting may in itself be an early indication of the over-action of digitalis. If the vomit- ing is persistent, it may be necessary to omit all food by the stomach. Cracked ice in some simple charged water, or in champagne, or in milk and lime-water, can be used until stronger food is tolerated. Dropsy. — The successful treatment of dropsy depends upon the re- cuperative power which remains in the heart. Digitalis is of the utmost use, and should be given in sufficiently large doses to produce a decided effect, but with careful attention to its physiological action. Its diuretic proper- ties may be increased at times by giving it with small doses of calomel and caffeine, providing the kidneys show the evidence only of passive congestion. Saline cathartics can be given to diminish the oedema by de- pletion. It is often desirable to promote catharsis and diuresis on alter- nate days. If ascites or hydrothorax is excessive, the fluid should be aspirated at once, as delay may prove serious. The quantity of urine should be carefully noted when digitalis is being given. An increase in the quantity should follow its administration. When the urine diminishes steadily in spite of the digitalis, we should watch carefully for other symptoms of the cumulative action of the drug. Diuretin in doses of 0;3 to 0.6 gramme (5 to 10 grains) is a valuable diuretic in all forms of cardiac dropsy, and may be given alone or with digitalis. 748 PEDIATRICS. . Nervous Symptoms. — The nervous symptoms of restlessness and in- somnia may, if moderate in degree, be controlled by trional or the bro- mides, 0.12 to 0.3 gramme (2 to 5 grains) ; more frequently they require the use of morphine combined with atropine, which are the most effective remedies we have, but require good judgment in their use. Finally, it is of the greatest importance that a child with a chronic valvular lesion of the heart should be kept under medical supervision even during the intervals of complete compensation. By doing this we are frequently able to detect changes in the condition of the heart before the mother herself becomes aware of them, and by attention to the prin- ciples already outlined we may often avert the serious consequences which follow neglect of treatment. FUNCTIONAL DISEASES OF THE HEART. By functional disease of the heart we mean that there are no patho- logical conditions present beyond a weakness of the cardiac muscles and possibly, in some cases, a slight degree of dilatation of the cavities. It is a condition, therefore, represented by symptoms rather than by physical signs, with the exception that in many cases cardiac murmurs are present. It is rare to meet with functional cardiac disturbances before the middle, period of childhood, but they increase in frequency as puberty is ap- proached. Etiology. — Functional cardiac disturbance may occur in the course of such neuroses as exophthalmic goitre. Again, it may arise from poor food and hygiene, from a lack of sufficient out-of-door exercise, and from over- strain in school life, leading to malnutrition with nervous exhaustion. It may also result from the use of such cardiac irritants as tea and coffee, and may follow or occur in the course of any of the acute diseases. The various forms of anaemia may produce functional murmurs, known as hcernic murmurs. Symptoms. — The chief symptoms are palpitation, a weakened, irregular pulse, attacks of dyspnoea and fainting, and cardiac murmurs. These attacks occur in paroxysms and are not associated with the physical signs of organic cardiac disease. Of especial interest are the cardiac murmurs of functional origin, as they simulate closely and must be differentiated from organic murmurs, whether congenital or acquired. These functional or, as they are some- times called, haemic murmurs are variable in character according to the position of the child, and may sometimes be intensified by the pressure of the stethoscope. According to Jacobi, Steffen, and Hochsinger they may also be caused by the irritation resulting from deformity of the thorax such as occurs in rhachitis. Diagnosis. — In the great majority of cases functional murmurs are sys- tolic, soft, though they may be very loud, and are heard best in the pul- ACQUIRED DISEASES OF THE HEART. 749 monic area. They are apt to be associated with anaemia, are evanescent, are not connected with cardiac enlargement, and are not accompanied by an accentuated pulmonic second sound or by general systemic venous engorgement. While these functional murmurs may be transmitted in all directions, and are often associated with loud bruits in the vessels of the neck, yet, as a rule, they do not show their maximum intensity at the heart's apex and are not transmitted distinctly to the axilla and back. The systolic mur- murs heard occasionally over the anterior fontanelle in infants are probably arterial. In contradistinction to functional murmurs, organic murmurs are usually rougher and more musical, are distinctly transmitted to the great vessels of the neck or to the axilla and back, may be heard with maximum in- tensity over any part of the cardiac area corresponding to the various valves, are rarely loudest in the pulmonic area, and are usually associated with an enlarged cardiac area, accentuated pulmonic second sound, and in many cases with general signs of systemic stasis, such as cough, haemop- tysis, oedema of the lungs and extremities, ascites, and cyanosis. Prognosis. — The prognosis in the cases in which there is no organic disease of other organs, or when the disease in which they occur is be- nign, is exceedingly good, provided that the appropriate treatment is rigidly carried out. Treatment. — During the attack mild stimulants, such as aromatic spirits of ammonia, should be given, and if there is a strong nervous element the bromides. In prolonged attacks digitalis in small doses is indicated, and in some cases strychnine. When a cause can be detected, such as anaemia, it should be treated with iron or arsenic. When no especial cause can be found, all cardiac irritants should be avoided and careful directions given as to study, exer- cise, diet, and general hygiene. The following case was one of primary malignant endocarditis with secondary infection of the pericardium, mediastinum, veins, lungs, pleurae, and spleen. A boy, four years old, was attacked one month previously with fever, thirst, and pain in his knees. Later his feet became painful and swollen, and other joints were successively involved. He complained of pain in the back of his neck and along his spine. One week before entering the hospital he began to have moderate but inces- sant choreic movements, and showed much incoordination of mastication and articu- lation. A physical examination showed the lungs to be normal, the area of cardiac dul- ness somewhat increased to the left of the mammillary line, and a systolic murmur at the apex, transmitted into the axilla and back. On the following day a pericardial friction-sound was heard just above the left nipple, accompanied by precordial pain. Two weeks later the choreic symptoms disappeared, and the temperature became normal. The area of cardiac dulness did not extend under the sternum, but was found to correspond to the impulse of the heart, which was 1.4 em. Q inch) outside 750 PEDIATRICS. of the left mammillary line. During the last week of its life the child became very weak, had marked dyspnoea, and showed signs of effusion in the right pleural cavity, but presented no other symptoms. The post-mortem examination showed that both pleural cavities contained consid- erable blood-stained fluid, in some places there were adhesions of the parietal and visceral layers, in others there was slight fibrinous exudation over the surfaces of the lungs. On section both lungs showed congestion and areas of broncho-pneumonia. The anterior mediastinum was injected, and some of the mediastinal glands were enlarged. The parietal layers of the pericardium and pleurae were adherent and thickened. The heart was enlarged, and in places the myocardium was distinctly soft and pale. Along the free border of the right auriculo-ventricular valve there were a few fresh vegeta- tions. The left side of the heart was dilated. The edge of the mitral valve was thick- ened and eroded. Small, whitish points could be seen beneath the endocardium, both on the walls and on the papillary muscles. The aortic valves showed a few fibrinous deposits at the edges of contact. The coronary arteries were normal. The spleen and lymph-glands were enlarged and soft. The liver showed congestion. In the left jugular vein was found an adherent thrombus which extended down into the subclavian vein, the innominate vein, and the superior vena cava, completely obliterating them. Microscopic examinations showed the infection to be due to streptococci and the vegetations on the mitral valve to be distinctly verrucose. Pure cultures of streptococci were obtained from the lungs, pericardium, bronchial lymph-glands, and spleen ; the other organs were sterile. Dr. Councilman, who performed the autopsy, considered the endocarditis primary and of the malignant type, with a secondary infection of the lung. The mode of in- fection was probably from the heart to the pericardium, thence to the mediastinum, with thrombosis of the veins, from which the infection was carried to the lungs, setting up a broncho-pneumonia, which in its gross and microscopic appearances differed from the ordinary broncho-pneumonia of infants. The next case illustrates simple acute endocarditis, followed by dila- tation of the heart and loss of compensation. Fig. 153. IV- Acute endocarditis. Mitral insufficiency. Lack of compensation. Orthopncea. Female. 9 years old. The child was nine years old, and although she had always been delicate she had never had any especial disease until two weeks previously, when she was attacked ACQUIRED DISEASES OF THE HEART. 751 with fever, palpitation, cough, and a rapid, irregular pulse. On entering the hospital she was cyanotic, the face and extremities were cold, and there was considerable promi- nence over the cardiac region. The resonance of the lungs was normal, but there were a few moist rales at both bases. The impulse of the heart was in the fifth left interspace. 1.4 cm. (h inch) outside of the mammillary line, and there was a marked thrill with a systolic murmur transmitted into the axilla and heard distinctly in the back. The liver was slightly enlarged. The temperature during the acute inflamma- tory stage of the endocarditis was moderately elevated, reaching 38.8° C. (102° F.) on the fourth day, and gradually subsiding. The impulse of the heart was scarcely perceptible. The area of cardiac dulness extended to the right edge of the sternum, and slightly beyond the right sternal line beneath the third intercostal space. The case illustrates an attack of acute endocarditis, either primary in character or more probably ingrafted upon a chronic endocarditis, which had never given rise to symptoms, as the limits of compensation had never before been disturbed. The acute inflammatory stage passed ; dilatation took place, and there was marked failure of compensation, shown by the feeble impulse of the heart, the weak and fluttering pulse, the cold and blue extremities, the orthopnoea, and the tendency to oedema of the face, legs, and feet. Fig. 153 represents the position which the child assumed on her right side, supporting herself with her arms, and shows her anxious expression as she endeavored to keep herself in a position in which she could breathe easily. The following case illustrates the condition of pure mitral stenosis, with periods of broken compensation alternating with periods of re- established compensation : The boy, who was eleven years old, had measles when he was an infant, diph- theria when he was three years old, and pertussis when he was four years old. He had always been well until he was nine and a half years old, when, after indefinite pains in his joints, accompanied by no swelling and not sufficiently severe to confine him to bed, he began to have dyspnoea on exertion, and cardiac pain, cough, cyanosis, and considerable loss of weight. An examination of the heart showed the area of absolute dulness to be decidedly increased to the left. A loud presystolic murmur was heard at the apex, limited in its extent and accompanied by a thrill and a sharp first sound. There was no systolic murmur and no oedema. The physical examination showed nothing else of significance. In the course of two months' treatment compensation was established, but the boy returned to the hospital from time to time with the same symptoms which have been described. In the next case, in contrast to the one just given, we see the symp- toms of a mitral stenosis combined with mitral insufficiency. The child was a girl of thirteen years. When eleven years of age she had an attack of rheumatism followed by dyspnoea on exertion, and at times oedema of the feet. A week before I saw her she was taken with pain in the region of the heart, so severe that she could not sleep. On entrance to the hospital her temperature was 38.5° C. (101.2° F.), her pulse 104, and her respirations 65. The physical exami- nation showed the apex-beat to be in the fifth interspace in the mammillary line. The area of cardiac dulness was enlarged, extending to the upper border of the third rib and about 5.3 cm. (2 inches) to the left of the mammillary line, and about a finger's breadth to the right of the right border of the sternum. A presystolic murmur was heard at the apex and was confined to a limited area, while a systolic murmur, also 752 PEDIATRICS. heard at the apex, was transmitted to the axilla and hack. The pulmonic second sound was accentuated. In this respect the physical signs were negative, as, in spite of the marked hypertrophy and dilatation of the heart, compensation of the right heart was sufficient to prevent the results of venous stasis. Four weeks later, after being treated by complete rest in bed. the cardiac symptoms almost entirely disappeared, the area of cardiac dulness was much diminished, the murmurs were less distinct, and the child left the hospital much improved. The next case (Fig. 154), a boy, ten years old, is interesting as illus- trating several characteristics of cardiac disease in early life. When eight years old he entered the hospital with marked oedema of the face, body, and limbs, ascites, a slight amount of fluid in both pleural cavities, and oedema of the lungs. There was no definite history of rheumatism nor any other cause for the cardiac disease which was causing these symptoms, and which had apparently de- veloped insidiously, although if he had been under closer observation a definite period of onset would probably have been discovered. The impulse of the heart was found to be 1.4 cm. (^ inch) outside of the mam miliary line in the fifth left interspace. The area of cardiac dulness was somewhat increased. There was a loud systolic murmur at the cardiac apex transmitted to the axilla. The pulmonic second sound was much accentuated. Fig. 155 was taken at that time, and shows the marked oedema of the legs and the much distended abdomen. He was treated by complete rest in bed for five weeks, and in the beginning digitalis was administered until the urine, which was lessened in quantity, had increased and the oedema of the lungs had disappeared. On entering the hospital the ascites was removed by paracentesis abdominis. Under this treatment the child rapidly improved, the general oedema disappeared, the liver returned to its normal size, the area of cardiac dulness was markedly decreased, the cardiac murmur became less marked, and six weeks from the time when he entered the hospital complete compensation was established and he left the hospital seemingly perfectly well. After leaving the hospital the boy was reported to have been very well, except that he could not play or work hard. Two weeks before his second entrance he was attacked with fever, precordial distress, and cardiac pain j later he began to have oedema of the feet and dyspnoea. From that time he grew progressively worse, and his case illustrates a fresh attack of endocarditis supervening on an old chronic endocarditis (endocarditis recurrens) and resulting in a disturbance of the previous compensation. He had or- thopnoea to such an extent that he was unable to lie down in bed, and had to be con- tinually watched by a nurse, as he frequently had attacks of excessive paroxysmal dyspnoea which were liable to prove fatal. There was cyanosis of the lips and hands and marked general oedema. The skin of the nose and extremities was cold. The impulse of the heart was felt in the sixth left interspace 2.8 cm. (1 inch) beyond the mammillary line. The area of cardiac dulness extended beneath the sternum, and at the third intercostal space extended 1.4 cm. (§ inch) to the right of the sternum, thence upward in a curved line across the upper part of the sternum to the second rib, and then, keeping outside of the mammillary line, descended and joined the point of cardiac impulse. There was a loud systolic murmur, heard most distinctly at the apex, but transmitted over the whole cardiac area and through the axilla to the back. The pulmonic second sound was accentuated. The aortic sounds were weak. There were numerous moist rales heard in all parts of the lungs. The percussion of the lungs was resonant everywhere except in the lower parts, where there seemed to be a slight amount of fluid in both pleural cavities. The liver was enlarged so that it ex- tended 7.8 cm. (3 inches) below the margin of the ribs. Ascites was present, the fluid rising to about the line of the umbilicus. The spleen was normal in size. The child Fig. 154. Chronic recurrent endocarditis. Mitral insufficiency. Disturbance of compensation. Dilated heart. Enlarged liver. (Edema of lungs. Ascites. Male, 10 years old. Fig. 1 Chronic endocarditis. Mitral insufficiency. General oedema and ascites. (Before treatment. ACQUIRED DISEASES OF THE HEART. 753 was passing only a small amount of urine, which contained a trace of albumin. The cardiac and hepatic areas of dulness and the upper border of the ascites have been marked by black lines, the margin of the ribs by broken lines, the point of cardiac impulse by a black ring, and the edematous rales in the chest by smaller black rings. The prognosis in this case, although very serious, as he was liable to die suddenly at any time if extra blood-pressure should be brought to bear upon the dilated and crip- pled heart, was not entirely unfavorable, as he had previously shown such great powers of compensation and recuperation. As there was no great distention of the abdomen, the ascites was not removed by paracentesis. He was given infusion of digitalis, 3.75 c.c. (1 drachm), every three hours, and diuretin, 0.36 gramme (6 grains), once in six hours as a diuretic. His diet was milk. Within forty-eight hours rapid relief was obtained from the urgent symptoms, and at the end of three weeks the oedema of the lungs, the general oedema, and the ascites had disappeared entirely. The urine became normal in quantity and free from albu- min. One week later he was well enough to be out of bed for an hour each day, but at that time the heart and liver were still enlarged, as shown in Fig. 156. Fig. 156. Fig. 157. Chronic endocarditis. Mitral insufficiency. Returning compensation. Enlarged liver. En- larged heart. Chronic endocarditis. Mitral insufficiency. Broken line indicates enlarged heart. Black line indicates area of cardiac dulness with returned and complete compensation. Some weeks later the liver regained its normal size, and still later the cardiac area of dulness was found to be much reduced and in the vertical line almost normal. Fig. 157 shows the enlarged heart, which persisted longer than the enlarged liver, and is represented by a broken line ; the area of dulness of the heart as it appeared when he left the hospital is shown by a black curved line. 48 754 PEDIATRICS. DISEASES OF THE PERICARDIUM. The relations of the infant's pericardium, so far as I have been able to determine by the dissection of sixteen infants of different ages, does not differ from those of the adult. The amount of fluid which normally occurs in an infant's pericardium, although of variable quantity, is probably under 5 c.c. Hydropericardium, pneumopericardium, and haemopericar- dium are so very rare that they need merely be referred to. ACUTE PERICARDITIS. Etiology. — Acute pericarditis may occur at any period, but the earlier the age the less often is it met with. It has been found in the foetus and in the new-born. It is generally the result of an infective process, which may be primary or secondary. It may arise also as a result of direct extension of an inflammation from the pleurae, mediastinum, and adja- cent tissues. Various bacteria have been demonstrated in the inflammatory prod- ucts of pericarditis and in the pericardium itself, although they are not always connected in a specific manner with the disease. Different kinds of streptococci and staphylococci are found. The pneumococcus frequently occurs in cases following pneumonia, and is also found inde- pendently. Tubercle bacilli have been demonstrated in tubercular peri- carditis, and the pericardium shows an especial tendency to the invasion of this bacillus following tuberculosis of the pleura. Tuberculosis as a primary disease is even more rare in the child than in the adult. In the new-born, pericarditis may be the result of a septic condition following infection of the cord. At times it follows periostitis and ostitis in young children, here also probably being associated with septic infec- tion. Traumatism may also be a cause of pericarditis. Rheumatism, especially after the third or fourth year of life, gives rise to as much peri- endocarclial disease as at a later period. The inflammatory lesions may arise before the rheumatism has appeared elsewhere, and the intensity of the arthritic pain and the number of joints affected do not correspond to, or rather do not influence, the frequency of the pericardial complication. Inflammation of the pericardium is also frequently associated with pneu- monia. It may be secondary to any of the eruptive fevers, but occurs most frequently as a complication of scarlet fever. When it occurs in this latter disease it appears usually in the second or third week of the attack. Pathology. — Pericarditis may be circumscribed or diffuse, and there appears to be no essential difference between the pathological conditions affecting the pericardium in early life and those which occur later. The pericarditis sicca of the adult is comparatively unusual in the child, in whom, as a rule, an exudation of greater or less extent almost always takes place. The exudation may be sero-fibrinous, hemorrhagic, or puru- DISEASES OF THE PERICARDIUM. 755 lent. Not only is the tendency to exudation in the child greater than in the adult, but its formation is characterized by greater rapidity and is more likely to be purulent. A pericardial exudation tinged with blood is not uncommon in early life, and is not necessarily so significant of tuber- culosis as is a pronounced hemorrhagic exudation. Acute Plastic or Dry Pericarditis. — Symptoms. — The symptoms of acute plastic or dry pericarditis are often so mild as to be overlooked. There may be slight precordial pain and pyrexia. The characteristic physi- cal signs are represented by a double to-and-fro murmur, which is not ex- actly synchronous with systole and diastole, is more superficial than an endocardial murmur, and is of a rubbing or grating character. The sound is localized in a small area, is not transmitted as in endocardial murmurs, and does not replace the heart-sounds. The murmur is at times intensified by pressure with the stethoscope. These signs, however, are of temporary duration, as a rule, as the exudation of fibrin is soon followed by that of fluid. In many cases in early life friction-sounds and endocardial murmurs simulate each other very closely. Acute Pericarditis with Exudation. — Symptoms. — The subjective symptoms of acute pericarditis with exudation in infancy are very in- definite, and throughout childhood this latency of the early symptoms is so marked and occurs so frequently that it may be said to be character- istic of the symptomatology of pericarditis in early life. It is so difficult to locate pain when it occurs in the infant, and a tumultuous action of the heart with general circulatory disturbance is so commonly the result of a diseased condition outside of this central organ, that it is impossible to formulate a practical general symptomatology for the onset of the disease. When, however, the disease has progressed, dyspnoea and orthopnoea become marked. Large exudations appear to affect the functional activity of the heart more rapidly in children than in adults, and to occasion earlier the signs of disturbance of the circulation, such as cyanosis and coldness of the nose and extremities. Diminution in the amount of the urine, with a corresponding increase in the urine as the exudation decreases, has been noticed in children. Physical Signs. — The usual physical signs supposed to be character- istic of pericarditis are often very misleading, and when a pericardial friction-sound is absent the diagnosis of pericarditis in a young child may present great difficulties. Inspection. — rOwing to the flexible thorax of the child, there is a greater opportunity for the neighboring parts to yield before the pressure of the fluid, and we are more likely to have bulging of the intercostal spares, and on inspection a visible alteration of the cardiac area, than in adults. It has been held by certain authorities that the heart's apex is found in effusions to be tilted upward and inward towards the sternal end of the fourth left interspace, — that is, floated by the effusion. Direct proof of this is Avanting, and I believe, from my investigations on this subject. 756 PEDIATRICS. that it is an erroneous view. It would seemingly be impossible for the heart to be floated unless the specific gravity of the fluid was greater than 1050, as I have shown by experiment. It is highly improbable that the specific gravity would be greater than 1050 in an ordinary peri- cardial exudation, for the specific gravity of a purely purulent fluid is only about 1032. Ludwig and Bowditch have, moreover, observed that the impulse of the heart as seen normally in the fifth left interspace need not be caused by the heart's apex, but may be caused by a portion of the heart above the apex striking against the thoracic wall. We should also consider that the impulse of the heart in children is often chiefly in the fourth interspace. It seems plausible to account for this pulsation by the tumultuous action of that portion of the right ventricle which, as shown by Rotch, is not covered by the moderate amount of fluid in the fourth left interspace when an exudation is present. In the third case on page 761 it is recorded that the impulse was found throughout the whole cardiac area, but that it was still pronounced in the fifth left interspace. If in this case there had been a larger exudation, the apex and the lower segment of the right ventricle being surrounded by a mass of fluid, the impulse would have been lost in the fifth interspace, while in the fourth interspace, in which the ventricle may be covered by only a thin layer of overlying fluid, the impulse would have continued to be both seen and felt, thus simulating an apex-beat. I believe this is the explanation of what has been called misplaced apex-beats and floating of the heart in pericardial effusions. Palpation. — When the amount of fluid is considerable the palpable impulse is much diminished, and its intensity corresponds to the place in which the visible impulse is most distinct. Auscultation. — The friction-sound is often absent, but if present in the beginning disappears as the fluid increases, and may reappear when ab- sorption takes place. The heart-sounds are diminished in intensity, but may be heard most distinctly in the fourth interspace at the point of the visible impulse. On account of the small size of the child's thorax, the heart and pericardium are much nearer to the anterior surface of the thoracic cavity than in adults. This occurs both normally and in diseased conditions, especially when there is flattening, and thus levelling, of the chest. Under these latter conditions the heart and pericardium are brought in such close contact with the thoracic wall that on palpation the heart's impulse can be felt, and on auscultation the heart-sounds can be heard in a much more advanced stage of a pericardial effusion than would be possible in the adult with a proportionately large amount of fluid. According to Ewarts, a pericardial exudation may give rise to a patch of tubular breathing about two inches below and slightly to the left of the left scapula, but the same sign may occur in pleuritic exudation. Percussion. — Percussion is the most important physical sign, when the initial friction-sound has escaped detection, both for determining whether DISEASES OF THE PERICARDIUM. 757 an exudation is present and as a guide to the prognosis and treatment. In exudations of exactly the same amount the area of dulness may differ, owing to the difference in the elasticity of the lungs and to the presence or absence of adhesions. The greater the elasticity of the lungs and the fewer the adhesions the more regular will be the outline of superficial dulness. This superficial dulness is determined by the retraction of the borders of the lungs, which withdraw from the chest w T alls as the fluid gradually distends the pericardium. The deep dulness is due to the dis- tended pericardium, and this to a greater or less degree compresses the lungs, which may be held in position by adhesions. The infant, being less likely to have had previous lesions of the lung and pericardium, gives us the best opportunity for studying the outlines of a pericardial effusion, and the area of superficial dulness is the most valuable physical sign of effusion in infants and in young children. The experiments (Keating' s Cyclopaedia of Diseases of Children) on which I have based my conclusions regarding the area of dulness in peri- cardial effusions were made on sixteen infants, in none of whom did ad- hesions exist. In all of these presumably typical cases absolute dulness was found to the right of the sternum. An instance of how the area of dulness varies in cases complicated with adhesions was given by a case in which, although the pericardium was much distended with fluid, it failed to show dulness to the right of the sternum, and the autopsy re- vealed adhesions binding the lung tightly to the right edge of the sternum. The effusion was behind the lung, which permitted resonance to be ob- tained over an area where, in an uncomplicated case with the same amount of effusion, there Avould have been dulness. In addition to the difficulties of making a differential diagnosis arising from interference with the contractility of the lungs, such complications as pneumonia of the right lung, especially its middle lobe, pleuritic effusion on the right side, an enlarged liver, and an enlarged heart must be con- sidered. When this pneumonia, or pleurisy, or hepatic enlargement is present, an effusion into the pericardium cannot be diagnosticated by means of percussion, but the associated disease can usually be readily determined by its especial symptoms. The differential diagnosis, on the contrary, from an enlarged heart, especially a dilated heart in which the murmurs may be absent, can often be made only by means of per- cussion. The superficial dulness of the heart is determined not by the shape of the heart itself, but by the marginal lines of the lungs, varying according to their expansion or retraction. Moreover, the pericardium itself, whether distended with fluid or not, does not by its own shape, as has been delineated so often in the plates illustrating pericardial effusions, aid us materially in determining the shape of the area of superficial dulness in a pericardial effusion. This area is marked by the retracting or rather displaced borders of the lungs. 758 PEDIATRICS. When from 70 to 88 c.c. (2J to 2f ounces) of fluid are introduced into the pericardium of an adult, there is a slight increase in the vertical as well as in the transverse area of dulness. The curved line which bounds the area of dulness starts at the sixth rib, to the right of the sternum, passes upward to the junction of the fourth cartilage with the sternum, impinges on the lower part of the third left interspace, and then descends just outside of the mammillary line to the sixth rib, to pass in- ward until it meets the dulness of the left lobe of the liver. This line forms an irregular semicircle, with a shorter radius to the right of the sternum and a longer one to the left. A small section of the dull area, corresponding to the junction of the fourth and fifth ribs with the left side of the sternum, is formed by the heart itself, which is free from effusion at this point, while the rest of the dulness is produced by the effusion. The layer of fluid is very thin all over the upper portion of the effusion in the region of the fourth rib and fourth interspace, while the mass of the effusion is in the lower part of the sac on each side of the sternum in the fifth interspaces, the larger part of the mass being on the left side. The same conclusions as to the area of dulness were obtained with a proportionately small amount of fluid in an infant about two weeks old ; and of sixteen injections of fluid into the pericardial sac of infants of various ages the areas of dulness were identical in all, and in all the lungs were normal and there were no pulmonary or other adhesions. When the amount of fluid in the pericardial sac is large, the transverse area of dulness produced by the much distended pericardium is increased so that it extends farther to the right of the sternum in the fourth and fifth interspaces, and then, rising to the third interspace, it occupies a small area on either side of the sternum under the third, second, and first ribs and the second and first interspaces, the upper lobes of the lungs having retracted from beneath the sternum. As the effusion increases the lungs retract still more, and the upper curved lines of the effusion on either side of the sternum present areas with still greater diameters. According to Ewarts, a pericardial exudation may at times give rise to a patch of dulness in the back represented by a sharply defined square area bounded by the ninth or tenth rib above and the twelfth rib below, on the right by the spine, and on the left by a vertical line from the angle of the scapula. Over this area the respiratory sounds are absent and the voice-sounds feeble. I have observed these same signs in an unreported case in which the dulness disappeared as the pericardial effusion was absorbed. This dorsal patch of dulness is present normally in children up to the age of four years, due to the large size of the liver at this age. Ewarts has also given as a point in the differential diagnosis between pericardial exudation and cardiac dilatation, that in a dilated heart the curve of the right border of dulness is directed dowmvard and inward ' towards the ensiform cartilage, Avhile in a pericardial exudation the curve DISEASES OF THE PERICARDIUM. 759 is directed either downward or downward and outward. This distinction is more easily made in moderate than in very large exudations, as shown in Fig. 158, page 760. Diagnosis. — From what has been said regarding the latency of the general symptoms of pericarditis in childhood and the difficulty of inter- preting the local symptoms, it will be readily understood how important it is to recognize any especial symptoms which may characterize the dis- ease. Instances have been reported in which a distended pericardium was mistaken by experienced diagnosticians for an exudation into the left pleura. The diagnosis as to the character of the effusion, whether serous or purulent, can only be made by aspiration. In infants the fluid is almost uniformly pus ; this is also the case in the majority of older children, except in rheumatic infections. The condition which most closely simulates a pericardial exudation, both in its general symptoms and in its physical signs, is a dilated heart. The most distinctive of all the physical signs of pericarditis is the friction-sound, when it is present, but it must be carefully differentiated from the sound produced by a dry pleurisy in the cardiac area. When, however, an exudation has taken place, the friction-sound may not be heard. This absence of a friction-sound is especially frequent in young children. The heart's impulse may be clearly perceptible, even when a considerable exudation is present, owing to the thin layer of fluid which covers the heart in the area between the left nipple and the sternum. We are therefore forced by the similarity which at times exists between the general symptoms, in the inspection, palpation, and auscultation of a dilated heart and of a pericardial exudation, to depend upon percussion in making a differential diagnosis. According to careful observations which have been made by com- petent observers on the area of dulness which can be produced by an enlargement either of the ventricles or auricles of the heart, whether by hypertrophy or by dilatation, the relative dulness may extend to the right of the sternum from the second to the sixth rib, and in adults possibly to the distance of 3 or 4 cm. (1-J- or 1J inches) on a level with the fourth rib, but it is rare to find this dulness invading the fifth right interspace more than 2 or 3 cm. (f or 1^- inches). It is still more rare for the abso- lute dulness to be found in the fifth interspace at all, and even in the fourth interspace for more than 1.5 or 2 cm. (J or f inch). We may conclude, therefore, that the dulness which occurs in a peri- cardial effusion may correspond to that of an enlarged heart, but that the dulness of the effusion is also found in an additional area correspond- ing to a part of the fifth rib and fifth interspace. Absolute dulness, therefore, in the fifth right interspace 3 or 4 cm. (1-|- or 1^ inches) from the right sternal line in cases of pericarditis uncomplicated by pleural or pericardial adhesions is a sign of much value in the differential diagnosis from an enlarged heart. I have found in my experiments on the adult 760 PEDIATRICS. pericardium that the superficial dulness could be detected in the fifth right interspace when from 70 to 80 c.c. of fluid had entered the pericardium. In order to illustrate the difference between the area of dulness pro- duced by an enlarged heart and that produced by a pericardial effusion, I have indicated in Fig. 158, a boy, eleven and a half years old, the boun- Fig. 158. Areas of absolute dulness in enlarged heart, and in distended perieardiuu H. heart. fifth right interspace ; daries of the area of absolute dulness in an enlarged heart, in a small pericardial effusion, and in a large pericardial effusion. The top of the sternum, the boundaries of the enlarged heart, the ensiform cartilage, and the lower border of the ribs are marked by plain black lines, the boundaries of the small effusion by a broken line, and the area of the large effusion by a larger broken line. The figure 5 marks the fifth right interspace ; the letter H marks that portion of the heart which has been left uncovered by the small effusion. The small black circle represents the normal position of the apex of the heart, the larger circle the apex of the enlarged heart. It will be noticed how the enlarged heart extends beyond the right edge of the sternum at about the fourth rib and fourth interspace, and then returns beneath the lower part of the sternum within or a very little outside of the right sternal line. DISEASES OF THE PERICARDIUM. 761 The outline of the small effusion, as well as that of the large effusion, extends to the right of the sternum as low as the sixth rib. The following cases, taken from a number which have come under my care, illustrate the difficulty of making a differential diagnosis between cardiac and pericardial disease when, as at times happens, we fail to find a friction-sound or murmurs : TABLE 71. Differential Diagnosis between a Dilated Heart and a Pericardial Effusion. Case I. Endocarditis ; Dilated Heart. Case II. Pericarditis ; Effusion. Case III. Endocarditis ; Enlarged Heart ; Pericardial Effusion. Girl, eleven years. Boy, six years. Girl, eight years. August 3. Attack followed acute artic- ular rheumatism. Attack followed acute artic- ular rheumatism. Attack followed acute articular rheumatism. Orthopnoea ; precordial pain. Orthopnoea ; precordial pain. Orthopnoea ; precordial pain. Heart's impulse feeble, but perceptible a little to left and below left nipple, fifth interspace. Heart's impulse feeble, but perceptible a little to left and below left nipple, fifth interspace. Heart's impulse feeble, but per- ceptible all over cardiac area, with apex-beat a little below and to left of left nipple, fifth interspace. Vertical absolute dulness not increased. Vertical absolute dulness not increased. Vertical absolute dulness not increased. Absolute dulness under the sternum and to left of sternum ; identical with Cases II. and III. Absolute dulness under the sternum and to left of sternum ; identical with Cases I. and III. Absolute dulness under the ster- num and to left of sternum ; identical with Cases I. and II. Absolute dulness did not ex- tend to right of sternum. Absolute dulness in fifth right interspace two or three centimetres from edge of sternum. Absolute dulness in fifth right interspace three or four cen- timetres from edge of ster- num. Systolic murmur at apex. Pericardial friction-rub at base. Soft systolic murmur at apex, transmitted to axilla. Peri- cardial friction-rub at base. Recovery. Becovery. August 6 : Less dulness in fifth right interspace ; apex mur- mur much louder and harsh. August 11 : Dulness only to right edge of sternum. August 18 : Dulness only to middle of sternum ; friction- rub ceased. December 1 : Physical examina- tion the same as on August 18, showing enlarged heart and mitral systolic murmur. 762 PEDIATRICS. The symptomatology, both general and local, of these cases was, with the exception of the friction-sounds, murmurs, and percussion, identical ; when fluid was present dulness was found in the fifth right interspace, and when it was absent dulness was not found. Prognosis. — The prognosis of acute pericarditis depends largely upon its cause. In early infancy it is a very serious condition, and generally ends fatally. In later childhood its course and results are much the same as in adults, and the disease has a tendency to recovery, especially if the exudation is serofibrinous and of rheumatic origin. The purulent, septic, and tubercular forms are of grave import in all cases. Treatment. — The treatment of pericarditis in infancy and in early childhood does not differ materially from that in later life, and depends upon the various causes referred to in the etiology of the disease. The tendency to heart-failure, however, which is so pronounced in the child, should be guarded against. Early in the disease absolute physical and mental rest should be enforced. In the acute stage, before an effusion of any extent has formed, cold can be applied to the cardiac region by means of coils of tubing containing ice-water or by an ice-bag. An important part of the treatment is the judicious administration of digitalis to aid the heart in the crippled condition in which it is usually left after the early days of the disease. Stimulants should be freely used when there is any indication of failing compensation. The most important part of the treatment when an effusion of any extent has occurred is paracentesis of the pericardium, which should un- hesitatingly be performed, no matter what the cause of the disease may be, when life is in danger from undue distention of the pericardial sac. A small aspirating trochar should be used. Opinions differ widely as to the best point of puncture. Inasmuch as the heart, when an effusion is pres- ent, remains in its usual position, and does not, even when much enlarged, impinge on the fifth right interspace, and as the effusion, even when in so small an amount as 100 c.c, is found at that point, I consider it more rational to choose the fifth right interspace, 4 cm. (1J inches) outside the right border of the sternum, as the point for tapping, thus avoiding all danger of injuring the heart. At this point the right internal mammary artery will not be injured. I have tapped the pericardium in the fifth right interspace a number of times on the cadaver, and have removed the fluid as easily as in the fifth left interspace. The pericardium has been tapped during life in the fifth right interspace by Ebstein, of Gottingen, Wilson, of Nashville, Lovejoy, of Lynn, and a number of others. Another place to aspirate, recommended by Osier, is the left fourth interspace, either close to the sternal margin or 2.5 cm. (one inch) from it. in order to avoid wounding the internal mammary artery. The left fifth interspace, 3.75 cm. (1J inches) from the sternal border, may also be taken for the point of puncture, and if the aspirated fluid is found to be purulent, the case should be treated surgically by free incision. DISEASES OF THE PERICARDIUM. 763 As an illustration of how important it is to tap the pericardium when it is much distended with fluid and when symptoms of failing heart have arisen, the following ease may be cited : A boy. six years old, entered the hospital with the history of having had oedema of the face, hands, feet, and ankles for four weeks. There was no history of rheu- matism, and the case was apparently one of acute primary endocarditis with mitral insufficiency. The cardiac area of dulness was increased, and extended from the middle of the sternum to 1.5 cm. (| inch) beyond the left mammillary line, where the impulse of the heart could be felt. The child was kept quiet in bed, and after a few days the oedema lessened and he was very comfortable. While still under treat- ment, two weeks later, the temperature, which had been normal, rose to 39.1° C. (102.5° F.), the pulse was rapid and somewhat irregular., and the respirations were increased. A few days later a pericardial friction-sound was heard over the upper part of the sternum, and the temperature fell to 37.7° C : (100° F.). There was no change in the area of cardiac dulness, and no evidence of a pericardial effusion. On the following day the cardiac sounds were found to be rather muffled and the child did not seem so well, and was unable to lie on his left side. Two days later the area of precordial dulness extended farther to the right, and a little beyond the right sternal line in the fifth right interspace. The attendants were directed to watch the child closely, and warning was given that the necessity for paracentesis of the pericardium might at any time arise. Early the following morning the child began to have marked dyspnoea and became very cyanotic. The house-officer found that the precordial dulness had extended 2.7 cm. (1 inch) beyond the right edge of the sternum in the fifth interspace, and he therefore got the instruments ready for performing para- centesis. Suddenly the child's pulse became very weak and intermittent, the cyanosis increased very much, the dyspnoea became very marked, and, although stimulants were quickly given, the child suddenly gasped and fell back on its pillow dead. This oc- curred within three-quarters of an hour from the time when the first serious symptoms arose. The house-officer immediately introduced the aspirating needle in the fifth right interspace and withdrew some fluid from the pericardium. The child, however, did not revive. The following case illustrates a pericarditis sicca with adhesions : The child was six and one-half years old. She had never had rheumatism, but had had an attack of measles when she was two years old, pertussis when she was two and one-half years old, and parotitis when she was three and one-half years old. Four months previous to her second entrance to the hospital she had an attack of chorea, of so mild a grade, however, that she was able to go to school until she entered the hospital. At that time, although she did not show any especial cardiac symptoms, an examination of the heart showed a latent and insidious endocarditis, represented by an increase of the superficial area of cardiac dulness to the left of the mammillary line, but not extending under the sternum, with a systolic murmur transmitted to the axilla, but not heard in the back. Compensation soon became complete, and she re- covered from the chorea. Two days before her second entrance to the hospital she was attacked with dyspnoea, rapid respirations, and cardiac pain. On examination the child seemed very sick, and showed a considerable increase to the left in the area of cardiac dulness, and at the junction of the third rib with the sternum a marked precordial friction-sound, but. with no enlargement to the right. The precordial pain, discomfort, and heightened temperature lasted for a few days, and were in the beginning accompanied by orthopnoea and by an increase in the loud- 764 PEDIATRICS. ness of the friction-sound. There was at no time, however, any evidence of an effusion in the pericardium, and one week afterwards the friction-sound became less distinct, disappearing three days later. The child, however, grew much weaker, and, although she was treated by complete rest in bed and with digitalis, strophanthus, and stimu- lants, the precordial pain returned, and she gradually failed and died. The pulse varied from 130 to 150, and the respirations from 50 to 80. The temperature was only moderately elevated throughout the attack, ranging between 37.7° to 38.8° C. (100° to 102° F.) most of the time. The autopsy showed the pericardial sac to be obliterated everywhere by firm fibrin- ous adhesions. The heart was enlarged. Along the edges of the mitral valve were numerous small grayish-white vegetations. These were also present on the aortic valves and on the portion surrounding the tricuspid valve. The lungs were denser than normal, and were deeply injected and oedematous. The pleura on the inner surface of the right lower lobe was adherent to the pericardium by fibrinous adhesions. The surface of the liver was covered with a thin layer of fibrin. The liver and kidneys were a little denser than normal, but were not noticeably congested. The anatomical diagnosis was chronic adhesive pericarditis, acute vegetative endo- carditis, acute fibrinous pleurisy, acute fibrinous perihepatitis, and hypertrophy and dilatation of the heart. The next case was one of marked pericardial effusion, which was absorbed : A little girl, eight years old, during the first two years of her life had scarlet fever, varicella, and pertussis. When she was two years old she had an attack of measles, and when she was seven years old an attack of chorea. During the last year she was fairly well until two weeks before entrance, when it was noticed that her feet began to swell, she complained of pain in her limbs, and occasionally of headache, she lost in weight, and had had orthopncea with frequent paroxysms of dyspnoea. She also at times complained of pain in her left chest. Her extremities were apt to be cold. She had a short, dry cough. A physical examination showed the impulse of the heart to be feeble, but it could be felt all over the cardiac area. There was an area of precordial dulness extending to the right of the sternum almost to the right mammillary line, as low as and involving the fifth interspace and as high as the third interspace and to the left a little beyond the left mammillary line to the sixth rib. There was a systolic murmur at the apex, which was transmitted to the axilla. The pulmonic second sound was accentuated. There was a precordial friction-sound heard at the upper part of the sternum. The history of the case and the area of precordial dulness showed that it was a case of pericarditis with effusion. There may also have been some endocarditis, evidence of which is given by the mitral systolic murmur. The child was treated by rest in bed and by digitalis. Two weeks later the friction-sound disappeared, and the precordial dulness grew less, so that it extended only to the middle of the sternum. In the next two weeks the dulness beneath the sternum disappeared, and the mitral murmur lessened, but could still be heard 2 cm. (| inch) outside of the mammillary line. CHRONIC ADHESIVE PERICARDITIS. Chronic adhesive pericarditis may occur in infancy and childhood. It is the result of acute inflammatory processes, in the course of which the parietal and visceral layers of the pericardium become adherent by the fibrinous exudation, which later becomes organized fibrous tissue. These adhesions may be partia or complete, involving the obliteration of the en- DISEASES OF THE PERICARDIUM. 765 tire pericardial cavity. Well-marked adhesions of the pericardial surfaces have been observed in an infant who died thirty-six hours after birth. If the adhesions are limited to the visceral and parietal layers of the pericardium, there may be no resulting cardiac disturbance, and in many cases there is neither hypertrophy nor dilatation. If, however, an obliterated pericardium is associated with inflamma- tory adhesions between the outer layers of the pericardium and the pleura and chest walls, the hypertrophy of the heart may become extreme and eventually result in dilatation or sudden death. The white, opaque thickenings of the inner pericardial surface so frequently found in adults are rare in children, but have been found at ail ages, and when there is a deformity of the chest, as in certain cases of rhachitis, they have been especially noticed. The younger the subject the less likely are there to be adhesions between the pericardium and the pleura, an important fact, to be taken into consideration when making a diagnosis of pericardial effusion in infancy. The frequency of pericar- dial adhesions is shown in Lee's series of one hundred and fifty autopsies in cardiac disease of rheumatic origin, in which one hundred and thirteen cases had pericardial adhesions, and of these, seventy-seven had complete adhesion. An important result of pericarditis is the injury done to the myocardium through the intimate connection between the visceral layer of the pericardium and the heart-muscle. Lee in thirty-four of his cases found changes in the myocardium after pericarditis. In the fibrinous pericarditis of rheumatic origin the process is likely to be of a very mild grade, with but a slight increase in the connective tissue between the membranes, and consequently with but little thicken- ing. The most extreme cases of thickening of the pericardial membrane is met with in the chronic tubercular form. In these cases there is always a primary tuberculosis of the mediastinal or bronchial lymph-nodes. The tubercular process invades the pericardium by extension from these foci. This is not an uncommon process in children. Of sixty-five cases col- lected by Brackman, nineteen occurred in children. After the absorption of an extensive purulent or sero-purulent exuda- tion, the resulting thickening of the pericardium may be increased by the deposition of lime-salts within the membranes leading to calcification. Such areas of calcification are most frequently found over the auricles or at the base of the heart. According to Osier, the heart may be com- pletely invested by a calcareous membrane which in places may be from 1 to 1.5 centimetres ( T 6 g- to T 9 -g- inch) in thickness. Symptoms. — The symptoms of adhesive pericarditis are not distinctive. They are generally dependent upon the condition of hypertrophy and dilatation which is present and upon the degree of compensation. At times the symptoms are suggestive of cirrhosis of the liver, — that is, enlargement of the liver and ascites. When these occur without obvious cause in a young person, adhesive pericarditis should be suspected. 766 PEDIATRICS, When severe cardiac symptoms are present in young children and no valvular murmurs are heard, we should think of degeneration of the heart-muscle itself or of pericardial adhesions. When, again, the super- ficial area of dulness remains unchanged and there are well-marked sys- tolic retractions, the presence of pericardial adhesions is highly probable. Diagnosis. — The chief diagnostic points of adherent pericardium asso- ciated with chronic mediastinitis, are bulging of the chest, systolic retrac- tion at the cardiac apex, or in Traube's space, and systolic retraction in the line of the attachment of the diaphragm (Broadbenfs sign). Associ- ated with this retraction may often be seen a diastolic collapse of the cervical veins, the so-called Friedrich's sign. Systolic retraction, however, may occur in pronounced hypertrophy without adhesions. An extreme dilatation of the heart with an adherent pericardium will give rise to signs which closely resemble pericarditis with exudation. The distinction between these two conditions can only be made by the very closest observation of the physical signs of pericardial exudation as de- scribed on page 755. The majority of the cases of adhesive pericarditis are not recognized during life, and are only discovered at the autopsy. Treatment. — The treatment is symptomatic, the endeavor being made to maintain the compensation of the heart. When ascites is present, withdrawal by paracentesis may aid in the palliative treatment. DIVISION XII. DISEASES OF THE OESOPHAGUS, STOMACH, AND INTESTINE. INTRODUCTION. Before speaking in detail of the diseases of the stomach and intestine, a few general remarks are necessary to explain how limited is our knowl- edge of these diseases. Those diseases, however, which affect the oesoph- agus can easily be classified on a pathological basis, and are so few in number that they can be included in these general remarks. CESOPHAG-US. — The diseases of the oesophagus are rare in infancy and early childhood. There may be congenital malformations, such as absence or obliteration, narrowing or dilatation, and fistulous communica- tion with various parts, such as the trachea, or that congenital condition called "branchial fistula," described on page 296. The swallowing of hot or corrosive liquids may cause obstruction, which is occasioned by a cica- tricial stricture. Oesophageal stricture may also occur as a result of con- genital syphilis. Pressure outside of the oesophagus may cause obstruction. These strictures, especially those of cicatricial origin, are accompanied by a great deal of muscular spasm, which at times is constant, and again re- laxes. Thus, the child will swallow with comparative freedom at inter- vals, while at other times the obstruction appears to be complete. In addition to the inability to swallow, and the consequent regurgitation of the food, the secretion of saliva and mucus is often very profuse, and causes symptoms of distress and choking. The diagnosis and treatment of these cases are effected chiefly by means of bougies ; but, as much harm may come from these instruments, and as especial surgical knowledge is required to use them and to decide whether cesophagotomy should be performed, I shall not dwell on this class of cases. An inflammatory condition of the oesophagus is said to occur in young infants, and is spoken of as oesophagitis. It is rare. The symptoms, as described by Billard, are unwillingness to nurse, crying, immediate regur- gitation after beginning to suck, and often some tenderness about the neck on pressure. The prognosis is bad. The treatment of the active stage 767 768 PEDIATRICS. of the more severe forms, such as the corrosive, is by the administration of emollients and ice. Morphia may be required for the pain. It is quite common for children to swallow various foreign bodies, such as buttons and pins. These bodies may either be caught in the back of Fig. 159. "« 'id X 9 Congenital dilatation of oesophagus, female, 10 weeks old (% natural size). the throat or lodged in the oesophagus, instead of passing through to the stomach. A careful examination of the throat with the finger should first be made, and if the foreign body is not detected in the throat the oesoph- agus should be explored carefully with a bougie, and the foreign body is then usually pushed through into the stomach, unless it is thought wiser to remove it with the bristle probang. The diet for the following twenty- four to forty-eight hours, or until the body has been passed through the intestine, should be such as will give sufficient consistency to the faeces to protect the intestine from injury while the body is being passed over its surface. Various preparations of the cereals are useful for this pur- DISEASES OF THE (ESOPHAGUS. 769 pose. If necessary, a dose of oil can be given, but, as a rule, active treatment is contra-indicated. The oesophagus and stomach of an infant ten weeks old, with con- genital dilatation of the oesophagus is shown in Fig. 159. The infant was healthy at birth, and its mother had a plentiful supply of breast-milk. During the first two or three weeks of its life nothing abnormal was noticed about it, ex- cept that it vomited occasionally. When it was four weeks old it began to regurgitate, vomited the milk frequently, and lost in weight. The faecal discharges showed that the milk which reached the stomach and intestine was fairly digested, but the discharges were infrequent and small in number. It was weaned when it was nine weeks old, and small amounts of milk, carefully modified in various ways, were given to it. No improvement in the symptoms followed this treatment, and although at times a small quantity of milk would be retained, yet, as a rule, after a few minutes the milk was regurgitated. The infant had no other symptoms, but rapidly lost in weight, and finally died of exhaustion. The post-mortem examination was made by Dr. Whitney, and the only pathological conditions found were in the oesophagus. , The last two inches of the oesophagus were dilated into a more or less cylindrical swelling, with marked thinning of the walls and atrophy of the mucous coat. A dilatation had been formed in which evidence of a small area about to perforate into the mediastinum was found. The entire stomach, as well as its cardiac and pyloric orifices, was markedly contracted, apparently from lack of use. STOMACH AND INTESTINE.— Our knowledge of the diseases of the stomach and intestine is exceedingly limited, and is especially so when infants and young children are concerned. The classification of these dis- eases on a pathological basis has been proved to be inadequate, and in like manner a classification on the basis of symptoms is insufficient. Bacterio- logical investigations, however, have advanced our knowledge to such an extent that we may hope in the future to be able to classify these diseases on an etiological basis. The terms dyspepsia, dysentery, diphtheritic, croupous, and others have become almost unmeaning, and should be re- placed by terms more closely connected with the etiology of the disease. In 1894 the American Pediatric Society requested Dr. Holt and myself to prepare a nomenclature which would correspond more nearly to our present knowledge of this exceedingly difficult subject. I wish es- pecially to emphasize the value of Holt's work, which has aided me so much in my own studies on this subject. The classification finally adopted by the Society was one which especially relates to infants and young children, and it is this early period of life that is about to be described. The diseases of the gastro-enteric tract as they occur .in older children resemble so closely those of adults that they do not occupy a prominent place in the clinical medicine of children, especially as the pathology and symptoms of this later period of life differ very materially from those of the earlier periods. These differences are still more strongly marked from the fact that children succumb much more readily to the early stages of a disease than do adults, . and may die before the later and more characteristic lesions and symptoms of the disease have developed. There are certain known facts resulting from the anatomical and physiological 49 770 PEDIATRICS. peculiarities existing in infancy which play a significant part in all these diseases. It is well, therefore, first to explain the general principles which influence the symptoms and prognosis of these diseases before attempting to describe each disease separately. In many cases we can arrive at only approximate conclusions as to the actual lesion which exists and the prog- nosis which should be given. A practical clinical diagnosis should be made according to the region in which the stress of the lesion exists, rather than to all the pathological lesions which are present. General Etiology. — In the present state of our knowledge it is not practicable to discuss in detail the various supposed causes of gastro- enteric disturbances. We can suppose that these disturbances may be due to nervous conditions which may act alone or may render the tissue vulnerable to bacteria. Some of these diseases are caused by specific organisms, while others are due to a number of organisms. These bac- teria act either of themselves or through their products. In a general way, these diseases can be classified as functional and organic. The organic class may be divided into inflammatory and non- inflammatory diseases, although the boundary-line between these two con- ditions is at times very doubtful. A prominent and important peculiarity of these diseases as they occur in infancy is, as would naturally be expected at this early period of development, a variety of symptoms which are pro- duced by reflex causes. By the term reflex we mean peripheral irritation with a resulting action. By functional we mean a disturbance of the function of the organ without a known lesion. By organic we mean a known lesion. In addition to these cases are others which, as yet imperfectly under- stood, seem to be produced by certain morbid products eliminated from the blood by the gastro-enteric tract, as, for example, urea. This etiologi- cal factor can be spoken of under the term eliminative. General Pathology. — The general pathological anatomy of the gastro- enteric tract of infancy and early childhood is essentially that of the ileum and colon. In those cases in which the more severe lesions are present the stress of the lesion is usually in the lower ileum and the colon, and very frequently in the colon only. For this reason the terms ileo-colitis and colitis seem more descriptive than ileo-enteritis and enteritis. The pseudo-membrane in ileo-colitis is often extensive, but sloughing and per- foration are exceedingly rare in young children. It is at present believed that not all ulcers of the gastro-enteric tract are necessarily inflammatory. The great number of lymph-nodules and the abundance of the lymphatic plexuses are the principal anatomical conditions which influence the pathology of the enteric tract in early life. General Bacteriology. — The knowledge of the different bacteria which occur in the gastro-enteric tract, and of the connection which they have with the different diseases, is at present, with few exceptions, uncertain and unreliable. The proteus group has, however, been most commonly found in cholera infantum, while in the cases of fermental diarrhoea the DISEASES OF THE STOMACH AND INTESTINE. 771 ordinary saprophytic bacteria become prominent, especially the hay bacil- his. These bacteria usually enter the system through milk, but may enter through other sources. There is little doubt that the bacteria may find their way, by means of the stomach, to the intestine, and that the acid secretion of the stomach which they meet in their way through it is not sufficient to prevent their arriving alive in the intestine. We know that these bacteria play such an important role in their etiological relations to the various diseases that full weight must be given to their presence when we are treating the disease. It would seem that the bacteria which are commonly found in the intestine when it is in a normal condition do not cause any abnormal conditions ; but when the intestine has become irri- tated, from mechanical or thermic causes, the bacteria are able to pene- trate its mucous membrane, become noxious, and produce abnormal symptoms, often of a serious nature. General Symptomatology. — Vomiting as a symptom is often very mis- leading in early life, so far as the differential diagnosis between the stom- ach and the intestine is concerned, as it frequently occurs from disturbance in any part of the gastro-enteric tract, and should not be considered as indicative of any one disease. Serious symptoms during life are often proved at the autopsy to have been produced by no pathological lesion, while grave lesions may be found at the autopsy where the intestinal symptoms during life were very mild. Marked diarrhoea may exist during life and no lesions be present at the autopsy. Serious lesions may exist, and yet no blood appear in the dejections. Blood may appear in the dejections, and yet no serious lesion exist, the hemorrhage being only temporary, and comparable to epistaxis. General Diagnosis. — The observation of the temperature is very im- portant for the diagnosis of these diseases. As a rule, an elevated tem- perature of short duration points towards functional and toxic disturb- ances, while an elevated temperature long continued points towards inflammatory lesions. The chemical examination of the gastric contents in infants has so far proved to be unsatisfactory both for diagnosis and treatment. Intestinal discharges are often very misleading in making a diagnosis. Having considered and accepted these general principles relating to diseases of the gastro-enteric tract in infancy, the American Pediatric Society adopted the classification, as presented to them by their commit- tee. This classification must be understood to be merely provisional, and is for the purpose of aiding those who are interested in this subject to work with uniformity. At the same time it is believed that it is a great advance upon the unmeaning and misleading nomenclature now current. Since the meet- ing of the Pediatric Society in 1894 certain diseases, such as cholera in- fantum and tubercular ileo-colitis, have been transferred from the gastro- 772 PEDIATRICS. enteric to infectious diseases as manifestly being general rather than local. On examining the classification (Table 72, page 773) it is seen that whenever the etiology has been definitely determined it is made to desig- nate the disease, but the true etiology is still unknown in so many cases that other terms have of necessity been used, the names simply repre- senting the extent of the knowledge we have of the especial disease. The diseases of the gastro-enteric tract may, on this basis, be divided into diseases of the stomach (gastric), diseases of the intestine (enteric), and the disturbances which arise from animal parasites. The diseases are then divided into those which arise from developmental, those which arise from functional, and those which arise from organic causes. The organic diseases are subdivided into non-inflammatory and inflammatory, and the functional and organic diseases into acute and chronic. General Treatment. — In the treatment of these diseases we should endeavor to carry out four rules : (1) to combat the nervous symptoms if causative ; (2) to dislodge the bacteria as quickly as possible, perhaps by laxatives and irrigation ; (3) not to introduce into the gastro-enteric tract for a certain period food which may prove a favorable culture- ground for the bacteria, since it has been shown that where the food is sterile when it enters the gastro-enteric tract it is quite effective in re- ducing the number of bacteria in the intestine ; (4) to introduce such drugs into the gastro-enteric tract as may, by their anti-fermentative and germicidal powers, diminish the action of or destroy the bacteria. This last rule is, however, very difficult to carry out, and, with our present knowledge of drugs and their administration, practically impossible. It is true that we know that subnitrate of bismuth is an anti-ferment, and that it reaches the part of the enteric tract which we know to be most affected in enteric disturbances characterized by fermentation. Fig. 160 shows the intestine of an infant, given to me by Dr. Holt, to illustrate this point, to whom bismuth had been given, and in whom at the autopsy the bismuth was found thickly coating the mucous membrane of the small intestine, and also appearing in the large intestine. It is, however, questionable whether in any case the attempt to kill the bacteria by the internal admin- istration of drugs has been successful. Preparations, such as salol, which are known to be broken up into their carbolic acid components on reach- ing the intestine, cannot with safety be given to the infant in doses large enough to kill the bacteria, for in such doses there may be serious results from poisoning. We can, however, possibly, by means of these germi- cidal drugs, produce a condition in the intestine which, though not con- ducive to the death of the bacteria, may yet be so unfavorable for their growth as to aid our treatment when we are endeavoring to dislodge them. Nothing definite has, however, as yet resulted from using drugs for this purpose, and, so far as I can judge, the danger of treating infants or young children in this way is greater than the good that may result from it. DISEASES OF THE STOMACH. 773 I. Developmental. TABLE 72. Diseases of the Gastroenteric Tract. ( (a) Malformations. A. GASTRIC. -J II. FUNCTIONAL l III. Organic f I. Developmental. II. Functional B. ENTERIC. 1 [ III. Organic C. ANIMAL PARASITES. (. (b) Malpositions, (a) Acute .... (1) Nervous vomiting (2) Cyclic vomiting. (3) Indigestion. Central-Reflex. (b) Chronic Indigestion. (c) Eliminative. (a) Non-Inflamma- tory. I (b) Inflammatory. ( (a) Malformations. 1 (b) Malpositions. (a) Acute (1) Mechanical. (2) Ulcers. (3) New Growths. (1) Acute Gastritis (a) Catarrhal. (b) Corrosive. (c) Pseudo-membra- nous. (2) Chronic Gastritis . Catarrhal. (b) Chronic , (c) Eliminative. ( (a) Non-Inflamma- tory. L (b) Inflammatory. (1) Nervous. . . . (2) Indigestion . . (1) Nervous. . . . (2) Indigestion . . (3) Incontinence. (4) Constipation . (1) Fermental . . (2) Mechanical ^ (3) New Growths. (a) Proctitis. (b) Appendicitis (c) Ileo-Colitis . Central-Reflex. (a) Duodenal. (b) Intestinal. Central-Reflex. (a) Duodenal. (b) Intestinal. Atonic-Spasmodic. Acid-Albuminous. Dilatation of Colon. Volvulus. Intussusception. Hernia. Fissure. Prolapse. Polypi. Hemorrhoids. Fistula?. (a) Acute. (b) Chronic. (a) Acute. (b) Chronic. DISEASES OF THE STOMACH. GENERAL CONSIDERATIONS. — From what has been said it will be understood how difficult it is to make a differential diagnosis between gastric and gastro-enteric disturbance. The only symptom which defi- nitely shows the stomach to be involved, whether from reflex, functional, or organic conditions, is vomiting, and, as we know that in many cases vomiting is caused primarily by disturbance of the intestine, we really have no symptom which represents gastric disease alone. The difficulty 774 PEDIATRICS. of locating disease in the stomach is rendered still greater by the fact that serious organic lesions may exist in the stomach without any symptoms whatever, whether of vomiting, pain, or tenderness. We must, there- fore, be exceedingly cautious in making a diagnosis of diseases of the stomach. Diseases of the stomach may arise from developmental, functional, or organic causes. I. DEVELOPMENTAL. — Under developmental affections of the stomach are included malformations and malpositions. A malformation of the stomach may be represented by a narrowing of either the cardiac or the pyloric orifice, or by constrictions in various parts of the ventral cav- ity, which are known as hour-glass contractions. A malposition of the stomach may be met with in various places, one of which is in the thoracic cavity. These malpositions, however, are exceedingly rare, and of pathological rather than of clinical interest, as the diagnosis can scarcely be made during life. Congenital stenosis of the pylorus in infants, re- sulting fatally in a few weeks or months, has been described, but its existence has been questioned. II. FUNCTIONAL. — The functional diseases of the stomach play a great role in infants and in young children. They may be of an acute or a chronic variety, or may be what I have spoken of as eliminative. Acute functional gastric symptoms may be produced by a number of causes, but in general they are to be understood as arising from a nervous con- dition represented by vomiting or by a disturbance of the function of digestion, which had best be spoken of, until more is known of the sub- ject, as simple indigestion. ACUTE NERVOUS VOMITING. Vomiting may arise from gastric or from intestinal irritation in many diseases, such as tubercular meningitis, from heat, cold, fright, and from other causes. Direct irritation, from foreign bodies, food, or otherwise, may produce a reflex form of vomiting. In these cases the cause, if pos- sible, should be removed, and the stomach given a complete rest until the nervous disturbance has subsided. As a rule, no internal remedies are indicated in these cases, except an emetic when the vomiting arises from the reflex causes just described, or. if necessary, lavage. CYCLIC OR PERSISTENT VOMITING. There is one form of vomiting which is of such importance that it must be spoken of as a disease by itself. It has been called cyclic or per- sistent vomiting, as no single definite cause nor any pathological lesion has ever been proved to produce it. It has not even been shown that it is a primary disturbance of the stomach. In fact, in many cases it is possible that the source of irritation is entirely outside of the stomach, and perhaps connected with the great sympathetic ganglia, such as the solar plexus, or Fit;. 1(50. Colon showing presence of bismuth which had been given by the mouth. (Page 77-2.) DISEASES OF THE STOMACH. 775 it may eventually be proved to be of toxic origin and be placed under the eliminative class. Etiology. — The inciting cause of the vomiting in most cases is obscure, but is evidently very varied. It does not seem to be produced especially by errors of diet, but, on the contrary, occurs in children whose diet has been most carefully regulated. Undue exposure to cold, fright, and ex- citement all appear to me to have sometimes an etiological influence on the disease. This form of vomiting may occur at any age. I have met with cases in young infants and throughout the whole period of childhood. The attacks may occur not only in delicate, nervous children, but also in those who are quite vigorous. Symptoms. — The attack is very apt to come on suddenly, the child being previously in good health and not having shown any digestive dis- turbance. The period over which the disease extends and the intervals of the vomiting during the attack vary considerably, but in those cases which have come under my notice they are somewhat as follows. The child, without any especial warning, begins to vomit, and at first the vomitus will simply be the remains of food which still happen to be in the stomach. It will continue to vomit quite regularly every fifteen or thirty minutes. This may last for ten or twelve hours ; the intervals then grow longer, and sometimes the vomiting will cease for twelve or fifteen hours, and then begin again. Occasionally a little mucus appears in the vomitus, but not to any great extent. As the disease progresses, a slight amount of bile usually appears in the vomitus. A very prominent symptom is thirst, the child crying continually for water, and vomiting it soon after it is taken. As a rule, the temperature in these cases is normal or subnormal. The pulse varies, but is very apt to be slow, sometimes intermittent, and may become weak. After the first twenty- four hours the child emaciates rapidly, looks very ill, and becomes apathetic. Unless the disease is unwisely treated by endeavoring to introduce food or drugs into the stomach, it will usually prove to be self-limited, and will run its course in two or three days. In some cases the length of the attack is much shorter, being comprised within twenty-four hours, while in others it may last for many days. The recovery is often as sudden as was the onset of the disease. As soon as the vomiting has stopped, the appetite returns ; there are no special symptoms of indigestion ; the child takes its food well, and the emaciation disappears rapidly. Relapses occasionally take place. Diagnosis. — The diagnosis of this form of vomiting is often difficult, more on account of a lack of sufficient knowledge concerning the dis- ease than from much evidence of the existence of the diseases which it is supposed to simulate. Thus in early infancy acute persistent vomit- ing may be the first symptom of a beginning tubercular meningitis. In these cases an examination of the abdomen should be made at once, in- 776 PEDIATRICS. eluding a rectal examination. This is necessary in order to exclude such sources of vomiting as intussusception and appendicitis. The absence of any marked increase in the temperature and a careful examination of the thorax will in most cases exclude the sudden onset of some pulmonary disease or of the acute infectious diseases. The disease which is most commonly suspected in these cases is tubercular meningitis. In some in- stances, after the disease has lasted for two or three days, the resemblance to tubercular meningitis may be quite striking ; but if the whole course of the affection is taken into consideration, the diagnosis soon becomes clear. In cyclic vomiting the face and general appearance of the child indicate nausea rather than the apathy which would be present in tubercular men- ingitis. The mind also, in contradistinction to what takes place in the latter disease, is clear, the child remaining quiet merely because it is ex- hausted. The great thirst which has been already mentioned as being present in persistent vomiting also aids materially in the differential diag- nosis from tubercular meningitis. The sudden onset of the vomiting in a previously healthy child in the middle period of childhood is quite differ- ent from the slow progress and the occasional vomiting of a cerebral type met with in tubercular meningitis. After the first twenty-four hours, this disease is readily differentiated from attacks of simple indigestion, for, when the vomiting arises from indigestion, the stomach is speedily relieved, and the vomiting does not continually recur without apparent cause, as in cyclic or persistent vomiting. Cyclic vomiting is also very commonly diagnosticated as acute gastric catarrh, but in the latter disease the heightened temperature, coated tongue, pain, and tenderness in the epigastrium will, after the first twenty-four hours, allow us to differentiate the two diseases. Prognosis. — The prognosis varies according to the age of the individual affected. In young infants, especially in those whose vitality is weak, it may prove to be a very serious disease, from the exhaustion which inva- riably arises in the first twenty-four hours. The rule is that the younger the individual the more prostrating and serious is the disease. Even older children are at times so prostrated by the continuous vomiting that grave doubts are often entertained as to their ultimate recovery. In general, however, the prognosis in these cases is good, and I have never seen the disease result in death. Treatment. — The treatment is essentially starvation during the first twenty-four* hours. The child should be kept perfectly quiet in a dark- ened room. If after twenty-four hours the vomiting still continues, or even before, if there appears to be much exhaustion, or if the child is rest- less and sleepless and has an intermittent pulse, hydrate of chloral and bromide of potassium, dissolved in brandy and water, should be given by the rectum. These are intended to procure sleep and to stimulate the nervous centres. As a rule, however, the child is quiet, and sleeps in the DISEASES OF THE STOMACH. 777 intervals of vomiting, and, as the disease usually attacks an infant or a child who has been perfectly well, cardiac weakness is not commonly shown in the first forty-eight hours. No food and no drugs should be given by the mouth. After forty-eight hours, small enemata of peptonized milk can be given, and when the disease appears to have run its course, as it often does in three or four days, small quantities of a carefully modi- fied alkaline milk can be tried cautiously by the mouth. A mistake is usually made in the treatment of the disease in feeding by the mouth too early. The following cases are illustrative of this disease . An infant, eight months old, strong and healthy, had always been fed on the milk of a wet-nurse. Without any previous symptoms he began to vomit, and continued to vomit every fifteen minutes for twelve hours. The intervals then became longer, and the vomiting ceased entirely on the third day of the attack. During the attack he emaciated rapidly, so that he seemed to be in the last stages of some wasting disease. He lay perfectly quiet and slept in the intervals of the vomiting. His mind was clear. His temperature was subnormal, and his pulse weak and intermittent. He was treated by rectal enemata of brandy, peptonized milk, and bromide of potassium. He had several attacks of this kind in each of the following years of his life until he was five or six years old, when he would sometimes go for six months or a year with- out an attack. As he grew older the attacks became less severe, and when he was ten years old they ceased entirely. Another case was that of a girl twenty-two months old, who was perfectly well until the vomiting began. Her pulse was slightly accelerated at first but gradually be- came slow and intermittent. Her temperature was normal. During the first four days of the attack the vomiting was almost continuous, and she became so weak and exhausted on the fourth day that it was feared she might die suddenly. There were great restlessness, dilated pupils, throwing of the head backward, slow pulse, and normal respirations. The emaciation was rapid. The urine was scanty. On the fifth day, the vomiting having continued, she fell into a state of collapse, the pulse was hardly perceptible, her countenance was ghastly and her extremities were cold. At one time after a severe attack of vomiting she became cyanotic, and was almost stifled by tenacious mucus. Some of this mucus entered the larynx during the attacks of vomiting, so that it seems as though her life was saved a number of times by the prompt action of an experienced nurse. On the sixth day the vomiting grew less, and on the seventh day it ceased. She was not, however, able to be up and about until the eleventh day, and was not fully well until the third week from the time that she was attacked. The treatment in this case was the same as in the one just described. The third case was that of a boy nine years old. He was attacked suddenly with vomiting as described in the previous cases. The duration of the attack was about two weeks. The prostration was extreme and the boy's strength was supported solely by enemata, as at no time during the two weeks could anything be retained by the stomach. These last two cases were unusually protracted. GASTRAL.GIA. In certain children, usually of a nervous temperament or in a debili- tated condition, attacks of pain, seemingly referred to the epigastrium, seem to occur which are not accounted for by the more common sorts of 778 PEDIATRICS. pain in this region, such as in cases of vertebral caries and in indigestion, from which the pain of gastralgia is to be differentiated by the rules laid down in speaking of these other diseases. It is possible also that dia- phragmatic pleurisy may cause a pain of this kind, and it must therefore be borne in mind in the diagnosis. These attacks are apparently neu- ralgic and produce symptoms of acute gastric indigestion, and, in severe cases, of obstruction. They should be treated during the acute attack with rest in bed, hot applications to the abdomen, deprivation of food by the mouth, and in extreme cases with a close of tinctura opii camphorata 1 to 1.2 c.c. (8 to 10 minims). Between the attacks the general health should be improved by tonics and good hygiene. As malaria may be a source of the attacks, the plasmodium should be looked for, and if neces- sary the case should be treated with quinine, and later, when necessary, with arsenic in the form of Fowler's solution. ACUTE GASTRIC INDIGESTION (Acute Dyspepsia). By indigestion we mean a disturbance of the gastric secretions inter- fering with the function of the stomach to such a degree as to cause mor- bid symptoms. Exactly what this disturbance is in infants and young children has not been clearly proved. The cause of acute indigestion in infants, and in almost every case in young children, is the food which is given to them. This is especially noticeable in the first year. The ages in which indigestion most frequently occurs in this period are, first, in the early days of life, when the equilibrium of the breast-milk has not been established ; second, in the middle of the first year, when the breast-milk is so apt to be replaced or supplemented by some other food ; and, third, at the end of the year, when entirely new articles of diet are usually given to the infant. Symptoms. — The symptoms of acute indigestion are extreme pallor, nausea, eructations of gas, a general appearance of discomfort, due prob- ably to the pain induced by the development of gas in the stomach, with its resulting distention, and finally vomiting. If the diet is exclusively of milk, the vomitus will usually contain large curds of the coagulated pro- teids. In connection with the gastric disturbance there is commonly con- stipation, although sometimes there may be a relaxed condition of the bowels. The faecal discharges accompanying these attacks are of an ab- normal color, usually a mixture of green, white, and yellow, and of sour odor. There is little or no fever. At times the symptoms are so severe that the infant looks as though it were going to die. In rare cases, also, reflex symptoms of a serious aspect may arise, such as have been de- scribed under asthma dyspepticum (page 946). Diagnosis. — Sometimes the diagnosis is obscured by the absence of vomiting, but the pallor and nausea are usually of sufficient prominence to allow us to decide that the seat of the disturbance is in the stomach. The differential diagnosis is most important between this condition and DISEASES OF THE STOMACH. 779 acute gastric catarrh. Acute indigestion is much more common, its dura- tion is shorter, there is less fever, tenderness is unusual, and the response to treatment is much more rapid and evident. Prognosis. — The prognosis of acute gastric indigestion is in most cases good, but in infants whose vitality is extremely low, or in those that are debilitated by some wasting disease, these attacks are of serious import, and may prove fatal. Treatment. — The treatment of acute gastric indigestion is to empty the stomach, either by washing it out or by the administration of warm water. A mild laxative should be given in order to clear away the undi- gested food, and the diet should be regulated. The laxative may be one or two teaspoonfuls of castor oil, .007 to .006 gramme (one-eighth to one- tenth grain) of calomel for four or five doses, or a teaspoonful of liquid magnesia. If the food has been human milk an analysis of the milk should be made at once, and the milk should be modified according to the rules which have already been given. If the infant is being fed on an im- properly modified milk, or if improper food of any kind has been given to it. a recurrence of the attacks can easily be obviated by a modification of the elements of the food which seem to have produced the disturbance. Thus, in a number of cases I have found that whenever the infant's food was modified so as to raise the percentage of the sugar above 5, acute in- digestion followed. In like manner in certain cases the percentage of the fat had to be reduced to 3, or perhaps 2.5, and the proteids even as low as 0.45, for a number of weeks until the digestive function of the stomach became normal. As relapses are common where food in any form is given too soon after the attack, nothing should be given excepting boiled Avater with a few drops of brandy for six or eight hours. In older children the symptoms are similar to those which have just been described, and the diagnosis and treatment the same as in the infant. After allowing the stomach to rest, a recurrence of the attack is best pre- vented by at once placing the child for several days on an exclusive diet of a milk modified in such a way as to contain a percentage of from 2 to 3 of fat, 5 to 6 of sugar, 1 to 2 of proteids, and 10 of lime-water. CHRONIC GASTRIC INDIGESTION (Chronic Dyspepsia). If the attacks of acute indigestion are allowed to occur frequently from lack of proper treatment, a subacute or chronic form of the disease develops. Symptoms. — In infants the symptoms of chronic indigestion are much less severe than those of the acute form. The infant is apt to vomit after taking its food, to be restless, fretful, and either to lose in weight or not to gain. Its sleep will be very much disturbed, apparently by pain from flatus. In chronic indigestion the bowels are apt to be constipated, but this is not always the case. The chronic indigestion of older children presents a somewhat different aspect. The temperature is at times some- 780 PEDIATRICS. what heightened. The tongue is apt to be coated, and the breath to have an odor. These children do not vomit so frequently as do infants. They lose in weight, become fretful, and get tired easily. Treatment. — I have seldom found the use of any especial drug to be of much benefit in these cases of chronic indigestion. In quite a number of cases of both acute and chronic indigestion, before any food is intro- duced into the stomach it is often wise first to wash out the stomach thoroughly (lavage). This procedure is especially indicated if the indi- gestion has produced continuous vomiting. The technique of washing out the stomach is very simple. A soft rubber catheter with a double eye, No. 21 French scale, for infants under six months, and No. 25 for older children, is attached by means of a piece of glass tubing 7.5 cm. (3 inches) long to another rubber tube which is 50.5 cm. (20 inches) long attached to a funnel, preferably of hard rubber, and capable of holding from 90 to 120 c.c. (3 or 4 ounces). The infant is seated upright in the nurse's lap, with its head inclined forward and resting on the nurse's arm. Its arms are controlled by a towel pinned around them. The catheter, having been wet with warm water, is easily passed over the base of the tongue into the stomach. As there is often considerable gas in the stomach, the funnel should be raised as high as possible above the infant's head, in order that the gas may pass out from the stomach. From 90 to 120 c.c. (3 or 4 ounces) of sterilized water should be poured into the stomach by means of the funnel. The funnel is then depressed below the level of the stomach, and the gastric contents will in this way be siphoned out. As the curds are often too large to pass through the eye of the catheter, a number of washings will often be necessary to break them up. By washing out the stomach not only are the irritating substances which are producing the indigestion removed, and the mucous lining of the stomach left free to recover its normal condition, but it is also possible to have a chemical examination of the contents made. Clinically, however, the latter is not necessary, although it is of great interest physiologically. No food should be introduced into the stomach for at least two hours after the washing. The washing of the stomach is almost entirely free from danger, and, in addition to being an important part of the treatment of indigestion, is often of great use where poisonous substances have been swallowed. This method of treating disturbances of the stomach is more valuable in young infants than in older children, because the latter resist so vigor- ously that the remedy is often of more harm than good. The tube can, however, usually, even in older children, be introduced by aid of the ordinary gag which is used for intubation. Two assistants are usually necessary in introducing the tube in older children, while in infants one assistant is sufficient. In some cases it is found necessary to introduce the tube through the nose. The tube should be passed into the throat rapidly, since the gagging and vomiting occur chiefly when the tube DISEASES OF THE STOMACH. 781 touches the pharynx. There is usually an escape of gas or gastric con- tents as soon as the tube enters the stomach. When the inflow of water through the tube is shown to be too rapid, by the fact that the infant holds its breath too long, or by its crying, vom- iting, or coughing continuously, the flow should be stopped for a short time. Care must also be taken not to introduce the catheter too far into the stomach, as it may bend on itself and interfere with the flow of the returning water and gastric contents. If the gastric contents are expelled along the side of the tube rather than through it, the tube should be with- drawn until the vomiting has ceased. There seems to be no danger of passing the tube into the larynx, or of perforating the stomach with it. Lavage is contra-indicated when there is cardiac disease or any severe pulmonary disturbance, and when the introduction of the catheter con- tinues to excite vomiting it should be used with extreme caution. The fact that the infant is in a feeble condition is not a contra-indication to this treatment. In connection with lavage it is well to speak of forced feeding (gavage) in the treatment of infants and young children. In cases of acute and chronic indigestion, and also where a catarrhal condition of the stomach is present, the infants at times refuse to take any food whatever. This does not occur merely when the disturbance is in the stomach ; I have frequently met with it in severe cases of all kinds of disease. In a num- ber of instances, when the infants would probably have died of starva- tion had not gavage been employed, this means of providing for their nourishment has been very successful. Forced feeding may sometimes have to be employed for a number of days, and even weeks, before the child will of itself swallow again. The technique of gavage is similar to that of lavage. The same appa- ratus is employed, and the child should be placed flat on its back in bed or held half reclining. The head is held by an assistant. The catheter should be passed into the stomach rapidly, the funnel raised up in the air for a few minutes in order that the gas may escape, and the amount of food adapted to the age of the child should then be poured into the funnel. As the last of the food disappears from the funnel, the catheter is pinched tightly and quickly withdrawn. This precaution is important, in order that the pharynx shall not be irritated either by the slow withdrawal of the catheter or by the trickling of the remains of the fluid, as vomiting may in this way be excited. One of the advantages which has resulted from the use of the stomach- tube is the knowledge we have acquired of the time which the food re- mains in the stomach at different ages. Thus, it has been found that during the early weeks of life the stomach is nearly emptied in an hour, while in older infants two hours are required for the same process. This knowl- edge is especially valuable Avhen we are regulating the intervals of feeding in premature infants, and in infants during the first six months of life. 782 PEDIATRICS. When other means can be employed, they are preferable to the stomach-tube, but in many instances when infants or children refuse to take their food the simplest way of forcing it upon them is to pinion the arms with a towel and have the nurse hold the child half reclining in her lap. Sometimes an assistant is needed to hold the head, but this is often unnecessary. Simply pressing the child's nostrils with the thumb and finger will cause it to open its mouth, and the food can then be poured in with a spoon, or introduced by the Breck feeder or by means of a dropper with a large end. A child two and one-half years old, who has recently been under my care, for several weeks would not take any food without being forced to do so. Although this child was very ill with pneumonia, involving both lungs, it was fed every two or three hours, night and day, by this method. After the first two or three feedings it did not resist, and the nose did not have to be pinched, all that was necessary being to threaten to do so. 120 c.c. (4 ounces) of milk were, after a little practice, intro- duced by means of the dropper into the child's stomach in five or six minutes. I have found that the most speedy cure of chronic indigestion is to give the child a carefully modified alkaline milk. In some cases it will be necessary to reduce the fat or sugar, in others the proteids, but in every case, as soon as it is determined which of these elements in full strength does not suit the individual digestion, an improvement in the symptoms will soon follow the reduction of the percentage of that element. In some cases peptonization of the milk after modification is found valuable. After the indigestion has been relieved by this means, other articles of diet adapted to the age of the child can gradually be added. In addition to the direct treatment of the stomach, the intestinal dis- turbance which almost always accompanies the gastric indigestion should be relieved by occasionally giving a dose of some mild laxative, preferably one of the salts of magnesia, such as the citrate. This latter treatment is indicated not only for children, but for young infants, because, when there is gastric indigestion, the undigested food which passes into the duodenum is a prolific source of intestinal disturbance. This, by adding to the dis- comfort of the child, weakens it, and tends to prolong the gastric indiges- tion. In the more intractable cases, small doses of bismuth, soda, or dilute hydrochloric acid may be useful. Bismuth is indicated for allaying irritation and counteracting fermentation. Soda and hydrochloric acid have to be used somewhat empirically, as we know so little about the chemical conditions present. After the more prominent gastric symptoms have disappeared, considerable benefit can be obtained by using small doses of the tincture of nux vomica for several weeks. EUMINATTVE. In the eliminative class of diseases of the stomach, certain morbid and irritating substances are supposed to enter the stomach, as though it were DISEASES OF THE STOMACH. 783 an excretory organ, and may possibly explain many of the obscure gastric symptoms which arise in early life, but at present our knowledge of this class of cases is so slight and indefinite that it need only be alluded to. III. ORGANIC. — The organic affections of the stomach may be di- vided into non-inflammatory and inflammatory. They are very rare in comparison with the functional diseases. A. Non-Inflammatory. — The non-inflammatory conditions of the stom- ach comprise a diminution in the size of the organ, mechanical dilatation, ulcers, and new growths. CONTRACTION OF THE STOMACH. In certain cases the gastric capacity of the stomach is decidedly dimin- ished. This diminution in size, as a rule, depends upon a lack of use, such as occurs in infantile atrophy. Sufficient food to fill the stomach is not taken, and in this way the stomach is not called upon to perform its normal work. In cases, also, in which there is continuous vomiting, this same lack of use may produce a diminution in the size of the stomach. These cases are of pathological rather than of clinical interest, as they can seldom be diagnosticated, and their treatment is essentially that of the especial disease to which they are secondary. DILATATION OF THE STOMACH. A moderate dilatation of the stomach is rather more common in infancy than in older children. The higher degrees of dilatation are rare. It may rarely arise from some malformation, such as a stenosis of the pylorus, but in most cases is the result of errors in feeding. It is more apt to occur when the infant is not nursed, unless especial care is taken to give the infant the quantity of food which is adapted to its age and gastric capacity. When the infant is nursed, the breast seems to provide the amount of food which is suitable. Dilatation from errors in feeding may be caused by the fact that the food is not adapted, either in quality or in quantity, to the age of the individual infant. When the quality is at fault, the nutrition of the tissues of the stomach is interfered with, and its walls become weak, and are thus more easily distended by the gas which results from the abnormal changes in the food. In this way dila- tation occurs. This class of cases is notably represented in the disease rhachitis, in which dilatation of the stomach takes place very readily. When the quantity of the food is not properly adapted to the size of the stomach, dilatation can take place in even a healthy infant, so that the careful regulation of the amount of food which is given at each feeding during the first year of life is most important. Pathology. — The pathological condition which exists in cases of gastric dilatation is Avell represented in Fig. 161. This stomach was taken from an artificially fed rhachitic infant, seven months old, who died under my care at the Boston City Hospital. The gastric capacity in this case 784 PEDIATRICS. was 300 c.c. (10 ounces), which corresponds to the gastric capacity of an infant twelve months old. The shape of the stomach is very significant of the symptoms. The lesser curvature is not much altered, while the greater curvature is very much increased. The pathological condition of the tissues in these cases is such as would be Dilated stomach. Rhachitic infant, 7 months old (Actual size. expected from general malnutrition. In such diseases as rhachitis there is a stretch- ing of the muscular fibres, as well as an atrophied condition of the entire gastric walls. Symptoms. — The symptoms of dilatation of the stomach are essentially those of chronic indigestion. Vomiting is quite frequent, and continues until the stomach has been entirely emptied, when a period of relief conies, to last until fresh irrigation arises from another supply of food. Abdomi- nal pain, flatulence, and general discomfort are prominent symptoms. Rapid loss in weight and emaciation also occur. In some cases, in young infants, convulsions may arise, apparently due to the reflex disturbance DISEASES OF THE STOMACH. 785 which is produced. There are usually considerable thirst and loss of ap- petite. When the dilatation is of a high grade, the vomiting may occur only after considerable intervals, — twenty-four to forty-eight hours, — during which time the food does not pass out through the pyloric orifice to any degree, but collects in the stomach. Under normal conditions the stomach is somewhat tubular in shape and oblique in position. The food thus easily passes through the cardiac to the pyloric orifice. In dilatation of the stomach, on the contrary, the greater curvature is so much increased and depressed below the level of the pyloric orifice that a pouch is formed. The food, collecting in this pouch as though it were at the bottom of a well, has to be practically pumped, by the contraction of the muscular Avails, up to and through the pyloric orifice. The already weakened stomach thus has to perform work for which it is not fitted, and finally is relieved by spasmodic vomiting. When only the small amount of food adapted to their normal gastric capacity is given to young infants whose stomachs are dilated, a large space of empty stomach is left above the level of the liquid which has entered the stomach. This creates a feeling of emptiness and general discomfort, so that the infant appears to be hungry when, in fact, it is only suffering from the feeling of incomplete filling of the stomach. On inspection the abdomen is seen to be distended and tense, and on percussion to be highly tympanitic in its upper part. Succussion is not an especially valuable diagnostic sign in dilatation of the stomach. Suc- cussion is so frequently found in many conditions, and is so likely to be con- founded with that which occurs in the colon, that it cannot be relied upon. The outlines of a normal stomach when somewhat distended vary so much in infancy that the results of percussion are often very misleading. When, however, the tympanitic resonance is found to extend below the line of the umbilicus, we may suspect that we are dealing with gastric dilatation, but even then it is uncertain whether it is the gastric tympany which we have obtained. In infancy the cardiac end of the stomach is so slightly developed that any great increase in the area of gastric resonance to the left is an important aid in making the diagnosis. Diagnosis. — The differential diagnosis is to be made chiefly from dila- tation of the colon. In many cases when the colon is dilated it is impos- sible to determine whether the stomach is also dilated, since under these circumstances the colon can almost completely cover a largely dilated stomach. In cases in which the diagnosis is uncertain, a valuable means of determining the presence of dilatation is artificial distention. This can be done without harm or much discomfort to the child by filling the stomach, several hours after the last feeding, by gas generated by giving part of a seidlitz powder in divided portions, by air through a stomach-tube, or pref- erably by water. The gastro-diaphane, recommended by Koplik, can also be used as a method of diagnosis. 50 786 PEDIATRICS. Prognosis. — If the dilatation is due to congenital stenosis of the pylorus the prognosis is very unfavorable. In other cases the prognosis depends upon whether the condition arises from improper amounts of food or from some disease, such as rhachitis. In the former class the prognosis is good, and the stomach under a proper regulation of the diet soon resumes its natural size. In the second class it is not so good, and, as a rule, the stomach will remain more or less distended until the disease which causes the dilatation has been cured. Treatment. — If the case is an obstinate one, lavage is an important part of the treatment. In many cases, however, good results are obtained simply by regulating the quality and quantity of the food. When the food is first given in the proper amount it will not fill the stomach nor satisfy the demands of the infant. Under these circum- stances the infant will be very restless, and will often cry almost continu- ously from the time of one feeding until the next. The nurse must be made to understand that these signs of discomfort are liable to last for a number of days, until the stomach has more nearly resumed its normal size, and that an additional supply of food must not be given to the infant because it cries for more. The following case illustrates dilatation of the stomach as it occurs in the first year of life. A male infant four months old was well and strong at birth. It was not nursed, but was fed on a mixture of milk, cream, and water. It was unusually vigorous, and is reported to have never been satisfied with the small quantities of food suitable to its age. When it was three weeks old it was given 150 to 180 c.c. (5 or 6 ounces) at each meal. Somewhat later, in its second and third months, it gradually developed symptoms of in- digestion, and when I was called to see it was in a very serious condition. It had been having frequent and prolonged convulsions. At times when it was in the convulsions it would fall into a state of collapse, the pallor of its face would be extreme, and it would look as though it were dying. On examination nothing abnormal was found in the thorax. The entire abdomen was found to be distended, especially in the upper part, where the gastric tympany was pronounced and easily marked out by percussion. The percussion showed the stomach to be dilated, and to extend below the line of the umbilicus and far to the left of the median line. The infant was given small amounts of food at frequent intervals. For the first two or three days it cried and screamed for more food, but the convulsions ceased, its general condition improved, by the end of the week the distention of the stomach had subsided very markedly and the infant had become tranquil, and this time there was no recurrence of the symptoms. A second case was that of a colored boy six years old. He was markedly rhachitic. He was reported to have been in fair health, though delicate, until one month previous to entering the hospital, when he began to have persistent vomiting. He had lost greatly in weight, had been very restless at night, and he had continual borborygmi. Physical examination showed marked abdominal enlargement. On percussion the gastric tympany was found to extend downward as far as the umbilicus, 7.8 cm. (3 inches) to the right of the median line, and 10.4 cm. (4 inches) to the left. In the figure the line of percussion which represents the greater curvature of the stomach is marked with white dots. As the resonance of the colon was also exaggerated in this case, and as its differentiation from that of the stomach was somewhat difficult because it evidently over- lapped the lower border of the stomach, an endeavor was made to eliminate this obstacle DISEASES OF THE STOMACH. 787 to diagnosis by mechanical means. The child was given one-half a seidlitz powder dis- solved in water. The other half, which had also been dissolved in water, was next swallowed. The child showed no signs of discomfort, and stated that he did not feel any pain or any more tenderness in the epigastrium than before the powders were taken. Ftg. 162. Dilatation of stomach. Age, 6 yeai The outline of the distended stomach could be fairly well seen, and on percussion the line of the greater curvature was found to be 2.5 cm. (1 inch) below the line of the umbilicus, the colon having been pushed out of the way by the distended stomach. I have indicated the line of greater curvature by a broad white line. (Subsequent history.) In this case it was not found necessary to wash out the stomach more than once or twice, for as soon as small amounts of food were given at frequent intervals the vomiting ceased and the stomach gradually resumed its normal size. At the end of two months the child left the hospital free from any abnormal gas- tric symptoms. ULCERS. Ulcers of the stomach in infancy and early childhood are very rare. but cases have been reported. They may be non-inflammatory or in- flammatory^ the distinction between the two often being very difficult to 788 PEDIATRICS. make. They may occur as a result of hemorrhage into the tissues of the stomach. They may be of follicular or tubercular origin, and the round perfo- rating ulcer has also been found. There are no diagnostic symptoms, but when vomiting of blood occurs ulceration may be suspected. The prognosis is bad. The treatment is necessarily symptomatic. Fig. 163 represents the stomach of a female infant one year old under the care of Dr. Northrup. Fig. 163. Follicular ulceration of stomach. Female, 1 year old. The infant was under treatment for one month. It had vomiting and diarrhoea. During the first week that it was in the hospital its temperature varied from 38.8° to 39.4° C. (102° to 103° F.), after that being normal or subnormal. The respirations varied from 40 to 50, and the pulse from 120 to 140. In the second week it began to refuse its food and to emaciate. The diarrhoea continued and the vomiting was per- sistent. The vomitus was somewhat brownish in color, and the child died of exhaustion. On examining the stomach it was found that the lining mucous membrane was covered with small ulcers, varying in size from dots to 1 cm. (f of an inch) in diameter. The lesions appeared to be follicular ulcerations. In the middle of the specimen was a much larger ulcer which perforated the posterior wall. There was no evidence of an DISEASES OF THE STOMACH. 789 inflammatory condition, and the cause of these lesions was unknown. There was, how- ever, a certain degree of necrosis around the ulceration. NEW GROWTHS. Morbid growths in the stomachs of infants and young children are so extremely rare that their occurrence need merely be referred to. B. Inflammatory. — The inflammatory lesions of the stomach may be either acute or chronic, and are termed gastritis. ACUTE GASTRITIS. Acute gastritis may be divided into (1) gastritis catarrhalis, (2) gastritis corrosiva. and (3) gastritis pseudo-membranosa. The cases in which or- ganic lesions of the stomach can be proved to exist are very limited in comparison with those in which the functional disorders are present. In a large number of cases which are spoken of as gastritis catarrhalis no catarrhal condition is present, and they would be much better classified under the heading of indigestion. Cases are numerous in which a diag- nosis of gastritis has been made during life and in which at autopsy no definite lesion has been found. When, however, gastritis is present, as a rule the acute form is more common in infants, while the chronic form occurs more frequently in children towards the age of puberty. Gastritis Catarrhalis Acuta (Acute Gastric Catarrh). — The cause of acute gastric catarrh is somewhat obscure, but it is usually supposed to arise from an exaggerated form of indigestion, or from the presence of irritants of various kinds. Infection may also be a cause, especially in the membranous form. Pathology. — The pathological lesions which characterize acute gastric catarrh are hyperemia of the mucous membrane, hypersecretion of mucus, small punctate hemorrhages, and slight thickening of the mucous coat. In certain cases the inflammation has been found especially to affect the follicles. According to Booker, when a catarrhal condition of the gastric mucous membrane is present, the milk remains much longer in the stom- ach than under normal conditions, possibly four or five hours, or even more. A microscopic examination of the gastric contents in these cases shows various micro-organisms, and sometimes epithelioid and pus cells. The small number of bacteria found in cover-slip preparations from the contents of the stomach affords a most striking contrast to the large num- ber of bacteria which under like circumstances are found in the faeces. Two forms of acute gastric catarrh are usually described, the division being made according to the severity of the disease into subacute and acute. Symptoms, Subacute. — In the subacute form there is little or no fever, while in the acute the temperature is high. The subacute form is by far the more common. It is difficult and almost impossible to state definitely the symptoms of this form of gastric catarrh, as they so nearly approach to those which occur in cases of indigestion in which we believe no gross 790 PEDIATRICS. pathological conditions exist, that we should always be guarded in our use of the word catarrh. Pain is so common a symptom in all gastric disturbances, the existence of tenderness is so difficult to determine in infants and young children, and a hypersecretion of mucus is so often known to occur without the presence of an inflammatory condition, that there does not seem to be any one symptom on which we can rely. A general picture of the disease which is supposed to represent this form of gastric catarrh is that of slight fever, nausea, vomiting of food mixed with mucus, and at times of mucus alone, with a sense of tenderness, uneasiness, and discomfort in the epigastrium. There may be frontal head- ache, a rather swollen, coated tongue of somewhat glossy appearance, and often a slight follicular pharyngitis. There is loss of appetite, with at times hiccough and eructations of gas. The bowels are usually consti- pated at first, but after three or four days diarrhoea may be present. When an infant or child seems prostrated for a few days, and sick beyond what would be expected in an acute attack of indigestion, and when in combination with a slightly heightened temperature there is frequent vom- iting of mucus, we are justified in supposing that we are dealing with a subacute gastric catarrh. Symptoms, Acute. — Acute gastric catarrh is rare, but is a much more serious disease than the subacute form. It is characterized by high fever, 39.4°. 40°, 40.5° C. (103°, 104°, 105° F.). The invasion is sudden. The disease may last for two or three weeks and show severe and alarm- ing symptoms. There may be active vomiting, delirium, and sopor in the beginning, so that it may be impossible to determine whether or not one of the other acute febrile diseases is developing. The characteristic symptoms of gastric catarrh develop later, and then the differential diag- nosis is easily made. Instead of the cessation of the vomiting in the first twenty-four or forty-eight hours, as in scarlet fever, and of the continuance of the cere- bral symptoms, as in meningitis, or of the development of pulmonary symptoms, as in pneumonia, the vomiting continues, though not quite so frequently as in the beginning, the mind becomes clear, and the symptoms point to the abdomen rather than to the head or thorax. The onset of pneumonia in some cases, though in my experience rarely, simulates this disease. The pulse is rather irregular. There is usually constipation at ' first, followed by diarrhoea later. Progxosis of Subacute and Acute Gastric Catarrh. — The prognosis in both these forms of catarrh is good except in very debilitated children. Treatment. — The treatment of cases of subacute and acute gastric catarrh is the same as that described in speaking of indigestion. Food should be withheld from the stomach for many hours, for it remains so long in the stomach that a fresh supply at short intervals will act as an ad- ditional source of irritation. In those cases which do not respond readily to long intervals of rest and to feeding with small quantities of a modified DISEASES OF THE STOMACH, 791 alkaline milk, lavage will prove of value. Much judgment should be used as to the time when the food is to be increased in strength, for unless great precautions are taken relapses will frequently occur, and as a result the disease may finally become chronic. After convalescence has been estab- lished the child will begin to gain in weight. Some simple tonic, such as nux vomica, is usually indicated for a week or ten days until the child has recovered its strength. During the beginning of the attack, when food is being withheld, if the child is made very restless by extreme thirst, tea- spoonful doses of iced soda-water can be given, but with caution and as seldom as possible. After the irritation has been somewhat allayed, it is found valuable in certain cases to give dilute solutions of brandy, barley water, or white of egg in the form of albumin water before begin- ning with the treatment just spoken of. Albumin water is best made by dissolving the white of an egg 20 to 30 c.c. (f to 1 ounce) in water 120 c.c. (-1 ounces), and heating to 40° C. (104° F.). In this way the albu- min is held in solution, and the albumin water can be put on ice until needed for use. In especially intractable cases nothing should be put in the stomach for some time, nutriment being given in the form of pep- tonized milk with enemata. In the acute form, besides the treatment just mentioned, the child should be placed in a darkened room, soothing applications applied to the abdomen, and small quantities of iced soda-water given. If there is much exhaustion, stimulants are indicated. Gastritis Corrosiva Acuta. — Corrosive lesions of the mucous mem- brane of the stomach are at times produced by swallowing irritants, such as arsenic, carbolic acid, and caustic fluids. In these cases the lesions are usually found on the summits of the rugae. Treatmext. — The treatment is by washing out the stomach with large quantities of water, administering the proper antidote, and feeding the child on a liquid diet so modified as to be as little irritating as possible to the injured mucous membrane. Gastritis Pseudo-membranosa. — The membranous form of gastritis is extremely rare in infancy and childhood. Cases have been reported, notably those of Wollstein. In these cases the congestion of the rugae was very marked, and along the greater curvature extended over an area of a number of inches. There was a thick grayish-green membrane, with some erosions. The gastric walls were much thickened. Symptoms. — The symptoms of gastric disturbance in these cases are often almost entirely absent, but there may be vomiting, pain, and tenderness in the epigastric region, and insatiable thirst. A pathognomonic symptom would be the vomiting of shreds of membrane, with or without an admixture of blood. This symptom is, however, extremely rare, because the mem- brane is usually adherent, so that a differential diagnosis is often impossible. Prognosis. — The prognosis is very unfavorable. Treatment. — The treatment is purely symptomatic. 792 PEDIATRICS. CHRONIC GASTRITIS. Chronic gastritis is not usually met with in infancy, but occurs in later childhood, and is then in form catarrhal. It is especially common in the summer months, and is generally the result of neglect or of improper treatment of the acute form of the disease. Gastritis Catarrhalis Chronica {chronic gastric catarrh). — Pathol- ogy. — The pathological condition which is found in chronic gastric ca- tarrh is the result of long-continued hyperemia. There is often a slaty discoloration of the mucous membrane, with cellular infiltration of the submucosa. In addition to this there is usually found a considerable quantity of tough mucus. Symptoms. — The symptoms are not so clearly defined as in the acute form of the disease, but are variable and of a rather sluggish type. The tongue is apt to be much coated and the breath to have a disagreeable odor. There is considerable abdominal distention after meals, so that the children complain that their clothes feel uncomfortable. Frontal headache is apt to occur. The children gradually grow thin and anaemic. They vomit at irregular intervals, and are usually consti- pated. There is often a slight cough, and the symptoms, so far as the stomach is concerned, may form so small a part of the general picture of the disease that the child is not infrequently brought to the physician on account of its cough and because it is supposed to have some pulmonary affection. Prognosis. — Although the disease is often somewhat intractable, the prognosis under proper treatment is good. It may last for three or four months ; but in many cases which are usually considered chronic gastric catarrh it has seemed to me there is no organic lesion, but that the disease is functional in its character, and the prognosis consequently very good. Treatment. — It is often necessary in these cases to precede the treat- ment by carefully washing out the stomach. We must remember, how- ever, that a considerable quantity of mucus may be in the stomach, which cannot be removed by washing, so that if the symptoms continue after one or two washings, even though no mucus is returned by the tube, we should repeat this treatment from time to time. The diet should be an alkaline modified milk, with a low percentage of proteids, if necessary peptonized, and a moderate percentage of fat and sugar. The percentages of the different elements should be increased as improvement in the gastric symptoms takes place, and later broths and milk can be tried. Symp- tomatically in certain cases pepsin, dilute hydrochloric acid, and bismuth are occasionally indicated. A valuable tonic in the after-treatment of these cases is nux vomica. DISEASES OF THE INTESTINE. 793 DISEASES OF THE INTESTINE. GENERAL CONSIDERATIONS. — Diarrhoea. — As vomiting is the most significant symptom of gastric disturbance, so diarrhoea resulting from increased intestinal peristalsis is the most characteristic symptom of intestinal disturbance. Diarrhoea is always a symptom, never a disease. There seems to be a predisposition to diarrhoea in the first two years of life, which decidedly lessens as the child grows older. The most fre- quent time for the occurrence of diarrhoea is during the summer months. Prophylaxis. — Much can be done at all seasons of the year to pre- vent the occurrence of diarrhoea, but prophylaxis is of the utmost im- portance in warm weather. The children should be protected by proper clothing from extremes of heat and cold, and from dampness. They should, if possible, be taken away from crowded or unclean districts in cities and towns during the hot weather, and have the advantages of fresh country or sea air and good hygienic surroundings. Both the quality and the quantity of the food should be carefully regulated, care being taken not to give too much food, as the depression due to heat weakens the digestive function. In very hot weather an extra amount of water should be allowed and the solid food somewhat diminished in amount. As milk is the most common source of infection in the diarrhceal diseases, and as bacteria multiply more rapidly as the weather becomes warmer, it is espe- cially important to have the milk fresh and sterile during the summer months. It must be understood that not only bacteria but also their toxines, which are not destroyed by pasteurization or sterilization, may produce most serious results. Uncooked fruits and food are contra-indi- cated in very hot weather. Especial attention should be paid to any slight indisposition which may arise in hot weather, as it may render the child more vulnerable to the various causes of diarrhoea. Intestinal Contents. — The intestinal contents should be studied in regard to their color, consistency, composition, odor, and amount. The changes which take place in the intestinal contents are significant of dis- eased conditions, but not necessarily of any especial disease. Color. — The color of the faecal discharges varies greatly, and it would be impossible to describe completely all the variations from the normal when there is disturbance of the intestinal contents. A number of the abnormal colors more usually seen are shown in Plate III., lacing page 84. The square numbered 16 is what is usually spoken of as clay-colored. This clay color may be due to a diminution in the amount of bile which enters the intestine, or to undigested fat. This color is abnormal, and is usually met with in intestinal diseases of a subacute or chronic type. It does not necessarily indicate a serious condition, however, as even a small plug of mucus may interfere with the flow of bile into the duodenum. Number 17 may be simply a change that has taken place after the 794 PEDIATRICS. faeces have been passed, and which often is not significant of any especial pathological condition. It may, however, show that the changes which have taken place in the food during its passage through the intestine have not been entirely normal. It is the least important of the changes which take place in the color of the intestinal contents. The colors in 18 and 19. are what may be seen in a more serious disturbance of the en- teric tract. These colors may appear in any of the intestinal diseases which are accompanied by diarrhcea, but are significant of no especial disease. They are merely to be considered pathological in contradistinc- tion to the normal colors seen in 3, 4, 6, 7, 8, 9, and the beginning ab- normal condition represented in 17. Besides these shades of green there are a great many varieties of color produced by the mixture of green, yellow, white, and brown. These are valuable merely as instructing us whether we are dealing with a normal or an abnormal condition of the intestinal contents, and are not sig- nificant of any one disease, either functional or organic. Much variety in the color also arises from the admixture of blood, mucus, and shreds of membrane. In this connection it is well to remember that the yellowish- white lumps seen in undigested faeces are often made up of fat as well as of proteid material. The color of the intestinal contents may also be changed by the ad- ministration of various drugs, such as iron, which causes a more or less black color. Bismuth gives the colors which are seen in 12, 13, and 14. Number 12 is the color which was produced by giving to an infant 0.18 gramme (3 grains) of bismuth every two hours for six doses ; number 13, when 0.24 gramme (4 grains) of bismuth was given every two hours for six doses ; and number 14, when the latter dose had been omitted for twenty-four hours. The size of the dose and the intervals between its administration will of course produce different shades of color. When the solids of the intestinal contents are much reduced in pro- portion to the serum, as in cases of acute and frequent diarrhoea, the dis- charges become more and more fluid, and sometimes almost entirely lose their color and look like water. Consistency. — In the first year of life, or while the infant is having only milk for its food, the consistency of the faecal discharges is inter- mediate between solid and fluid, and the discharge, as a rule, is smooth and free from lumps. As the infant begins to take other forms of food and a mixed diet, the faecal discharges gradually become more solid. The consistency of the faecal discharge is abnormal when it becomes liquid, as in diarrhoea, or when it is too solid, as in constipation. Composition. — In addition to the various substances which make up the food which enters the intestine, the faecal discharges contain bile, mucus, epithelial remains, and many bacteria. In diseased conditions they may also contain certain morbid elements, such as blood, pus, and membrane. In intestinal diseases of both an acute and a chronic type the DISEASES OF THE INTESTINE. 795 mucus may be very largely increased, but it cannot be considered to be especially characteristic of an inflammatory condition, as the secretion of mucus apparently may be very much increased in purely functional con- ditions. The bacteria are very numerous and of many varieties, but in most cases the detection of any especial form of these organisms does not aid us in diagnosticating the especial disease. Notable exceptions to this statement are where one finds the typhoid bacillus, the comma bacillus, and the amoeba coli. Odor. — While in the normal faecal discharges of infants fed entirely on milk the odor is comparatively slight, it becomes much stronger as other articles of food, either of a starchy or of a proteid nature, are added to it. When an abnormal condition exists, various changes take place, as in acid fermentation, in which the odor is supposed to be sour, and in albuminous decomposition, in which the odor is supposed to be very foul, but these distinctions cannot with our present knowledge be said to be definitely proved. Although these can scarcely as yet be considered of great diagnostic importance, they are sufficiently so for us to make use of them in the diagnosis and treatment of intestinal diseases. Thus, when acid fermentation is supposed to be present, a reduction in the percentage of the sugar is indicated, while when albuminous decomposition is sus- pected a reduction of the proteids in the food is called for. Amount. — In estimating the amount of the faecal discharges we must consider the total amount in twenty-four hours, and not the large or small amount which may occur at one movement. The total amount in twenty- four hours is of much importance in both the acute and the chronic dis- eases of the intestine. In the acute diseases, the more frequent the diar- rhoea and the larger the amount the greater is the exhaustion and the worse is the prognosis. In some chronic diseases the total amount of faecal discharges may be very large. In these cases the larger the total amount the less has been the absorption and the worse is the prognosis, for this condition is an indication that the child is being starved from a lack of power to absorb the food which has been given to it. Diseases of the intestine may be divided into three classes, — develop- mental, functional, and organic. I. DEVELOPMENTAL. — Certain malformations and malpositions of the intestines occur as a result of abnormal development. The malfor- mations have already been considered under diseases of the new-born. Malpositions are met with in infants when there is a transposition of the abdominal organs, or when portions of the intestines are found to be outside of the abdominal cavity. II. FUNCTIONAL. — The functional diseases of the intestine may be classed as acute, chronic, and eliminative. The acute functional diseases of the intestine may arise from nervous disturbance or from indigestion, which is sometimes more marked in the duodenum, and sometimes in the intestine beyond the duodenum. 796 PEDIATRICS. ACUTE NERVOUS. In certain infants and children whose nervous system is easily affected exaggerated peristalsis causing diarrhoea may arise from a number of causes without any known lesions, fever, or gastric disease. Among these causes may be cited heat, cold, and fright. In like manner in these indi- viduals foreign bodies, food or otherwise, may by simple reflex irritation cause such a nervous disturbance as to produce diarrhoea. In these cases either the small or the large intestine, or both, may be affected, and, so far as we know, the mucous membrane is either normal or simply hyper- aemic. There is more or less serous exudation. These cases are rare in comparison with the other forms of diarrhoea, such as those which are caused by bacteria, and in them intestinal decomposition and intestinal inflammation are not present primarily. Symptoms. — The symptoms of simple diarrhoea are very apt to appear suddenly. There is usually abdominal pain, not, as a rule, of great in- tensity. At first there are two or three rather liquid yellowish-brown dis- charges occurring at intervals of perhaps one-half or one hour, and often accompanied by considerable flatus. There is a certain amount of rest- lessness, pallor, and exhaustion. Vomiting is rarely excessive. The tem- perature, as a rule, is not raised, or is raised very slightly. The pulse is rather weak and somewhat accelerated. The number of the discharges may be eight, ten, or twelve in the twenty-four hours, and these soon become watery and of a lighter color, but are seldom green. The odor is somewhat increased, but not excessively. These symptoms, unless they are exaggerated by improper food or by bad treatment, usually dis.- appear in a few days. Treatment. — The treatment is essentially to remove the cause. If the cause is atmospheric, a change in climate is sometimes necessary. If un- digested food is causing intestinal irritation, a dose of castor oil, 3.75-7.50 (drachms 1 to 2), or calomel, .006 gramme ( r \ grain), every hour for ten doses, may be given, but, as a rule, this is not necessary. The child should be kept in bed. Food should be withheld for some hours. After the cause has been removed, the treatment should be to control the peristalsis and the pain. For this purpose a few drops of tinctura opii camphorata and hot applications to the abdomen are indicated. If there is a tendency for the diarrhoea to continue, the subnitrate of bismuth may be given, and in some cases when there are signs of exhaustion a stimu- lant may be needed. In the cases in which the excessive peristalsis seems to be prolonged by weakness, brandy in small doses is more useful than astringents or opium. For several days the diet should be simply milk heated for twenty minutes at 75° C. (167° F.), and containing ten per cent, of lime-water. These simple diarrhoeas, especially in hot weather, should never be allowed to continue, as they render the intestine vulner- able to the more serious diseases caused by micro-organisms, which may at any moment gain an entrance in this way. DISEASES OF THE INTESTINE. 797 ACUTE INDIGESTION. Disturbances arising from intestinal indigestion, although in most cases having their origin in the duodenum, seem also in quite a number of cases to be located in the intestine beyond the duodenum. It has yet to be proved that any pathological lesion is present in these cases, and for the present they must be looked upon as functional. These cases vary in their symptoms with the individual and according to the part of the intestine which is most involved. In one set of cases where the irritation is probably below the duodenum, the disturbance of digestion is shown simply by the increased peristalsis, such as has been described in the nervous cases, but here the evidence points to an undi- gested condition of improper articles of food which have been given and which appear in the discharges. The treatment of this class of cases is very simple, and consists in first giving a laxative and then regulating the diet according to the age of the individual. Symptoms. — What is usually spoken of as a "bilious attack 1 ' represents another class of cases. This condition is very rare in infancy, and usu- ally occurs in middle and later childhood. In these cases, in addition to the increased peristalsis and evidence of undigested food, there are fre- quently icterus and vomiting of bile, indicating that there is irritation in the duodenum. In addition to these symptoms there may be headache and excessive nausea. The icterus is usually slight in degree, but often is marked and is noticeable in the conjunctivae and in the urine. Plate III. (facing page 84), No. 11, shows the staining of bile on the napkin from the urine of an infant during an acute attack of indigestion involving the duodenum and accompanied by icterus. The temperature in these cases is usually slightly raised for a few days and then becomes subnormal. In a certain number of cases the faecal discharges become clay-colored. This color is often produced mechanically, as has already been explained. Prognosis. — Although the symptoms in these acute attacks may often appear quite serious, the prognosis is always good. In some individuals they are liable to recur even when the diet and the general health are well attended to. Treatment. — In the treatment of this class of duodenal disturbances we must consider that the fats in the food are in all probability especially liable to prolong the disease by not being properly digested so long as the function of the duodenum is involved. We should, therefore, in treating these cases, lessen the amount of fat given in the food. I have found that the treatment which most speedily shortens the attack is (1) total restriction from food for twelve hours, with the administration of small quantities of cold, sterilized water if the thirst is excessive, and (2) the administration of small quantities of milk modified as in the following- prescription : 798 PEDIATRICS. Prescription 86. Fat • 0.16 Sugar 6.00 Proteids -..'.. 3-00 Lime-water 10. 00 The mixture to be heated to 75° C. (167° F.) for twenty minutes ; from 120 to 180 c.c. (from 4 to 6 ounces), according to the age, to be given every three hours. In some cases also the diet of proteids may be varied by giving expressed beef-juice or solutions of white of egg. Under this treatment the icterus usually passes away in a few days, and the child can then soon be given its ordinary food. CHRONIC. — The chronic functional diseases of the intestine may be the result of acute nervous disturbances, or they may arise from a num- ber of prolonged attacks of acute indigestion. They may be divided into (a) nervous, (6) tubular, (c) duodenal Indigestion, (c/) intestinal indigestion, (e) incontinence, (J) constipation. CHRONIC NERVOUS. In the chronic form of nervous functional intestinal disturbance either the small' or the large intestine may be affected, and the condition of the mucous membrane, so far as we know, is either normal or hyperaemic. The causes are the same as in the acute form. This class of cases is not especially common, as they are merely a prolongation of the symptoms which I have already sufficiently described in speaking of the acute cases. The treatment of these cases is essentially with stimulants and care of the general health. TUBULAR. In addition to these more common intestinal affections of nervous origin is one that is called tubular. This disease is so rare before the age of puberty that it need only be alluded to. It is a condition of the mucous membrane of any part of the intestine in which an exudation of mucus takes place in such a way that masses closely simulating a mem- brane may occur on the surface. When discharged through the rectum they are sometimes found to have formed a cast of the intestine. These masses are mostly made up of mucus, and may occur in shreds of greater or less extent, as well as in the tubular form. The disease is supposed to be of nervous origin. Symptoms. — The symptoms are pain, tenderness, and tenesmus. The temperature is usually normal. Prognosis. — The prognosis, as a rule, is good, although in some cases the disease may be much prolonged. Treatment. — The treatment is to be directed towards the improvement of the general health and the nervous condition, the local treatment being simply symptomatic. DISEASES OF THE INTESTINE. 799 CHRONIC DUODENAL INDIGESTION. The chronic form of functional intestinal indigestion plays an important part in intestinal disease, especially when it is located in the duodenum. Chronic indigestion of the duodenum constitutes a disease of itself, and is one of the most difficult to cure. It has usually been spoken of under the names of chronic gastritis, duodenal catarrh, and mucous disease. We at present, however, have no proof that catarrhal or any other pathological lesions of the mucous membrane are present in these cases, and the weight of evidence is in favor of the view that the disease is purely functional. Etiology. — The etiology of chronic duodenal indigestion is in many cases obscure, but in a large number of cases it is produced by the con- tinued administration of food which is not adapted to the age or digestive capacity of the child. It is at times met with as a sequela of some ex- hausting disease, such as typhoid fever, pneumonia, pertussis, or one of the acute exanthemata. It very rarely occurs in early infancy, being com- monly met with during the middle and later periods of childhood. Symptoms. — The symptoms. are at first somewhat varied. The disease may be preceded by a number of attacks of gastro-enteric indigestion of a subacute character. A tendency to nausea and vomiting extending over a number of months may sometimes precede the full development of the disease. The gastric disturbance, however, is not marked, and is proba- bly a reflex condition depending upon the functional disturbance of the duodenum. At first the faecal discharges show merely the various changes which occur in ordinary indigestion, sometimes manifesting a tendency to diarrhoea and sometimes to constipation. The color of the discharges at this early period is not significant of anything beyond ordinary indigestion, and is usually a mixture of yellow, white, and green. As the disease progresses, certain characteristic symptoms arise and definitely mark its presence. Mucus begins to appear in the faecal discharges, and soon be- comes quite large in amount. It may occur in shreds or masses of con- siderable size, and is sometimes found covering hard lumps of faeces. With this hypersecretion of mucus, which is not necessarily an indi- cation of an inflammatory condition, the child begins to be fretful, to be wakeful at night, to grind its teeth, and to lose in weight. The skin be- comes dry, and there is usually a coexisting follicular pharyngitis which causes a short, dry cough. The child gets tired easily, and complains of pain in the epigastrium after eating. The abdomen is apt to be distended and tympanitic. There are frequently frontal headache, a coated tongue. and a disagreeable odor to the breath. The faecal movements now begin to become clay-colored, and the skin to assume a sallow tint, with at times a slight amount of icterus. Sometimes an exacerbation of all the symp- toms takes place, resulting in an acute attack of indigestion. These symptoms, varying in intensity, and sometimes ceasing to be prominent 800 PEDIATRICS. for days or weeks, usually continue for months, and in intractable cases may last for years. The temperature in this disease is usually normal, sometimes subnormal, but may of course, where an exacerbation occurs, be somewhat raised. The pulse is usually moderately slow. Sometimes a subacute form of bronchial catarrh accompanies the disease, but it does not appear to be a part of it. The appetite varies, is often unnaturally great, and there is sometimes a craving for large quantities of sugar. Diagnosis. — When all the symptoms are present, the diagnosis of chronic duodenal indigestion is not difficult. The appearance of the child is characteristic. Its eyes are dull and heavy ; its skin is dry and harsh and sometimes slightly icteric, while the loss of flesh, the distended and tympanitic abdomen, and the coated tongue are more marked than in any other disease. When, in addition to this picture, an examination of the faecal discharges shows them to be clay-colored and to contain a large amount of mucus, the diagnosis is quite evident. The disease which is most commonly mistaken for chronic duodenal indigestion is pulmonary tuberculosis. The short, dry cough, the emaciation, and in some cases the bronchial catarrh, often make parents and physician fear that this serious disease is present. If, however, the entire history of the case is studied carefully, pulmonary tuberculosis can soon be eliminated. Prognosis. — The prognosis of chronic duodenal indigestion is in most cases good. Even in those cases which last for a period of years the health is usually entirely restored. When, however, the disease has lasted for a long time, and the child is in a very debilitated condition, the prognosis becomes more serious. Treatment. — The treatment of this disease is essentially by diet, and not by drugs. Such articles of food should be given as will be chiefly digested by the stomach and will not tax the duodenal digestion. This of course indicates a proteid diet, and contra-indicates the administration of starches, sugars, and fats. In order not to tax the disturbed duodenum by overloading it in its weak condition, small amounts of food at shorter intervals than usual are found to produce a better result than the regular three or four daily meals. The diet which I have found most valuable in treating these cases is a milk so modified as to have a low percentage of sugar and fat, a high percentage of proteids, and ten or fifteen per cent. of lime-water. Soups of various kinds, and meat, can also be given, and the crust of bread in limited quantity. A valuable adjuvant to this treat- ment, as a mild astringent and stimulant, is a small amount of claret, preferably given in seltzer water. The meals should be five in the twenty- four hours. It is exceedingly difficult in most cases to keep the child on this diet, but if it is rigorously enforced the duration of the disease will be decidedly shortened. As the epigastric pain and the amount of mucus in the discharges grow less, the diet may be somewhat varied by giving fish and eggs, and the percentage of lime-water in the milk may be re- duced to five. As relapses occur very easily, however, it is generally best DISEASES OF THE INTESTINE. 801 to continue with this rigid diet until the faecal discharges have become normal in color and have not shown the presence of mucus for a number of weeks. In mild cases when there is much constipation, small doses of calomel, or any mild laxative, are indicated. Podophyllin can also be given, as in this prescription (Prescription 87) : Prescription 87. Metric. Apothecary. Grammes. R Podophyllin 0,06 R Podophyllin gr. i ; Alcohol 3|75 Alcohol 3 i. M. M. Sig. — From 3 to 5 drops, according to the age of the child, in the morning and even- ing, lessening the dose if it causes more than two discharges daily. When there is a tendency to diarrhcea, small doses of bismuth are found to be valuable. Tincture of nux vomica freely diluted in water and given in closes of a few drops after each meal seems in some cases to be of value. The remainder of the treatment is essentially symptomatic, and if the children are weak and anaemic tartrate of iron and potassium can be given. During the whole course of this disease cod-liver oil is contra-indicated, but when the disease has been cured and the child is left weak and emaci- ated it may in some cases be beneficial. Its administration, however, should always be carefully supervised, as it may cause a relapse. The specially restricted diet should be continued for some time after the charac- teristic symptoms of the disease have disappeared, or relapses will occur. The following case is illustrative of chronic indigestion of the duodenum. A girl six years old and healthy at birth, was nursed until she was thirteen months old. During her first year she had an attack of bronchitis. Previous to this attack she had never had any intestinal disturbance. Her abdomen was always rather prominent. From her earliest infancy she had been a nervous child, had not slept well, had talked much in her sleep, and had occasionally walked in her sleep. During the first six months of the disease the symptoms were chiefly loss in weight and cough. She then had an attack characterized by vomiting for twenty-four hours, followed by anorexia, fever, languor, and apathy ; the bowels became constipated the skin icteric, the urine dark-colored, and the faecal movements light-colored. She had an intense craving for sugar, and ate all that she could lay her hands on, so that she had to be watched very closely to prevent her satisfying this morbid appetite. Her appetite for other articles of food was poor. The abdomen was distended and tympanitic, and the tongue coated. The breath had a disagreeable odor, and there was loss of flesh. There was a follicular pharyngitis, which evidently caused the cough. The child was placed on the following diet. Her first meal was milk so modified as to contain fat 2, sugar 3, proteids 4, lime-water 10. With this meal she was allowed to have a small amount of the crust of French bread. The second meal con- sisted of broth and the crust of French bread, and one ounce of claret in half a tum- bler of seltzer water. The third meal consisted of meat, the crust of French bread, claret, and seltzer water ; the fourth, of soup, the crust of French bread, claret, and seltzer water ; the fifth of the modified milk and the crust of French bread. After each meal three drops of tincture of nux vomica were administered, 51 802 PEDIATRICS. This diet was carried out rigorously for one week. At the end of that time the child looked much better, the urine was clear, the faecal movements began to resume a more natural color, the mucus in the discharges was very much lessened, and the abdomen was not so much distended. The tongue was less coated, and the cough had almost disappeared. It was also found that the craving for sugar had much de- creased. The diet was then slightly increased in variety. At the end of a month the child had recovered entirely, and some weeks later an ordinary diet at the usual times was given to her. CHRONIC INTESTINAL INDIGESTION. There is a class of cases in which the disturbance seems to be located in the intestine beyond the duodenum and to be comparatively free from gastric symptoms. These cases are characterized by their chronic course, by the irregular character of the intestinal discharges, which at times are normal, and by presenting when abnormal most varied appearances. Symptoms. — As a rule, these infants do not gain regularly or normally. They become anaemic. The skin may be dry. They are fretful, do not sleep well, and in fact present the usual signs of malnutrition. Treatment. — The treatment is to study carefully each case and feed it according to its especial idiosyncrasy. No especial drugs are indicated. INCONTINENCE OP FiECES. Incontinence of faeces is a condition in which the faecal movements occur involuntarily. This may be due to inability to control the sphincter ani, or to loss of power of the sphincter itself. The first class of cases, due to disease or injury of the spinal cord, or to absence of reflex sen- sation, is rare. The second class is due to an atonic condition of the sphincter. The treatment of the first class of cases is essentially that of the disease in which it occurs. The treatment, of the second class is illustrated in the following cases : A hoy, eleven years old, much overworked at school, had been made to study a number of languages, and allowed to take only a very limited amount of exercise in the open air. He completely lost control of the sphincter ani, and became very anaemic and weak. Nothing abnormal was found on a physical examination. The boy was taken from school, relieved entirely of his studies, and kept in the open air most of the day. Under this treatment, in addition to the administration of tartrate of iron and potassium and claret, he improved rapidly, and in two months was entirely well. Another boy, seven years old, came to the Children's Hospital, with a history of incontinence of faeces lasting over a year. He illustrated the condition of incontinence from habitual constipation, as the incontinence was found to depend on the stretching of the rectum by impacted faeces. The rectum was emptied by a dose of castor oil and an enema each day. At the end of a week the boy had ceased to have involuntary faecal movements, and has since continued well. CONSTIPATION. By constipation is meant a condition in which the movements of the bowels do not take place as often as is normal for the individual, and in DISEASES OF THE INTESTINE. 803 which the consistency is abnormally increased. Constipation is a symp- tom and not a disease. It is a relative term, as what would be normal in one individual may be abnormal in another. During the first year of life two or three daily discharges may be considered normal, in the second year two discharges, and in the third and fourth years one discharge is the usual number. The causes of constipation are varied and, in many cases, rather obscure. They may be mechanical, but are usually functional, and either spasmodic or atonic. As the sigmoid flexure is proportionately long in infancy, flexions may occur with the result of producing a me- chanical obstruction. Spasmodic. — The spasmodic cases are rare, but should be recognized, as they frequently cause much disturbance of the child's general health. They are usually due to fissures about the anus or to an increased size and consistency of the faeces, which, by causing pain in defecation, result in spasmodic closure of the sphincter. Treatment. — The treatment of the spasmodic cases, when the cause is from fissure or, as in some instances, from hemorrhoids, is described on page 813. When an abnormal size or consistency of the faeces is pro- ducing the spasm, the rectum should be thoroughly emptied for a number of days by mechanical means. This may be in the form of enemata of equal parts of glycerin and water, or in extreme cases by using the finger, well oiled, to break up and draw out the pieces. The subsequent treat- ment would be the same as described below in the atonic cases. The size of the faecal masses may at times be enormous, and in these cases a mechanical dilatation of the rectum may result. Gradual dilatation of the sphincter with bougies two or three times a week has proved a valuable adjunct to the treatment of these more severe cases, the rectum gradually recovering its normal caliber. Atonic. — The atonic is the most common form of constipation, and simply represents a sluggish condition of the intestinal peristalsis. This may arise from weakness of the intestinal muscles. A weakened condi- tion may result from a child not being taught to have its bowels moved at regular times. The lack of exercise which is so common in the child's life during the winter months accounts for many cases in which during the summer months, when the child is out of doors playing all day, the bowels are no longer constipated. Any disease of a debilitating nature, as well as the indiscriminate use of laxative drugs may cause this weakness of the intestinal muscles. The most common of all the causes, however, is the food, which is insufficient in amount or improper in quality for the digestion of the especial child. In infants who are being fed exclusively on milk, a low percentage of fat in the milk seems in a number of cases to produce constipation. I have noticed, however, that when a breast- milk contains a low percentage of fat and a high percentage of proteids the faecal movements are feeble and watery. In some cases boiling, or even pasteurizing, the milk produces obstinate constipation, but in many 804 PEDIATRICS. cases no such condition is produced. In young children a lack of the proper amount and combinations of vegetables, meats, and fruits is a very common cause of constipation. Symptoms. — In addition to the usual symptoms of infrequency of defe- cation, straining, and increased consistency of the faeces, there are others which are often overlooked. There may be general nervous symptoms, such as fretfulness, apathy, insomnia, and pain varying in its locality, sometimes being prominent in the head and sometimes in the abdomen. It is not uncommon to find streaks of blood with the faeces when the strain is excessive. Diagnosis. — The diagnosis of the condition of constipation is self-evi- dent ; the difficulty arises in detecting the cause and locating the part of the intestine in which the atonic condition exists. When it is the rectum that is chiefly affected there are, as a rule, no especial symptoms which cannot be relieved by the use of enemata or suppositories ; when it is the upper part of the small intestines the symptoms connected with intestinal indigestion aid us in the diagnosis. Prognosis. — As a rule, constipation can be easily cured, but some cases are extremely intractable and last for a number of years. In the mechanical cases, as soon as the intestine has become more developed and assumed the relative proportions found in adult life, the constipation is very apt to pass away ; so in these cases we may give a favorable prog- nosis. Treatment. — The treatment of the atonic cases is to remove, when possible, the causes which have already been cited, and to give the proper treatment to the disease from which the constipation has resulted. Regu- lar habits as to the movement of the bowels, exercise, and meals are very important. Diet, — Reliance should be placed on the regulation of the diet, rather than on drugs, which should, as a rule, be looked upon as of only tempo- rary use. When the infant is being fed on modified milk, we should re- member that a variation in the percentage of the sugar, as well as of the fat, may produce constipation in certain individuals. During the first year the percentages to be obtained as soon as possible are ; Fat 4.00 Sugar 7.00 Proteids 2.00 to 3.00 During the second year whole cow's milk, with the addition of cream, should be given. It is often advisable to reduce the amount of cereals and increase the amount and variety of vegetables and fruits. Of the latter, baked apples, orange-juice, stewed prunes, and ripe peaches are especially indicated. Broths and meat-juices should also be given, and as the child grows older, sometimes at two years, butter, and at two and a half years meat, should be added to the diet. Hot or cold water given DISEASES OF THE INTESTINE. 805 before breakfast, either with or without orange-juice, is often efficacious. Massage of the abdomen in certain cases of obstinate constipation has been a most successful form of treatment. Suppositories of either gluten or glycerin are especially efficacious when the rectum is chiefly at fault. Enemata, either of soapsuds and water or equal parts of glycerin and water, are very useful in temporarily removing the symptoms until the more radical form of treatment by the regulation of the diet is thoroughly established. Drug*. — When drugs are indicated, purgatives and, as a rule, laxatives should be given but sparingly, and only with the idea of giving tempo- rary relief. In older children, cascara can be given, either in the form of the elixir. 3.75 to 7.50 c.c. (1 to 2 drachms), or the fluid extract, 0.18 to 0.3 c.c. (3 to 5 minims). Nux vomica, according to the age of the child, is especially valuable in the form of the tincture, 0.12 to 0.24 c.c. (2 to 4 minims). For young infants the milk of magnesia, 1.88 to 3.75 c.c. (J to 1 drachm), or olive oil, 3.75 c.c. (1 drachm), or phosphate of soda, 0.12 c.c. (2 grains), should be given. All these drugs should be given in as small doses and as seldom as is sufficient to produce a satisfactory result, and should be omitted as soon as possible. ELIMINATTVE. Under the term eliminative disturbances of the intestine are included a number of unexplained and obscure symptoms which we at present are unable to classify elsewhere. It is probable that they will be more fully understood in the future. It seems as though the intestine often acts as an organ for the elimination of various morbid products from the econ- omy. The diarrhoea which results from the irritation of these foreign elements is not distinguishable from that which occurs when the irritation is primarily in the intestine itself. Our knowledge of this class of dis- turbances is, however, so small that I shall merely refer to its possible occurrence. III. ORGANIC. — The organic diseases of the intestine may be divided into non-inflammatory and inflammatory. A. Non-Inflammatory. — The non-inflammatory diseases of the intes- tine may be divided into fermental, mechanical, and new growths. ACUTE FERMENTAL. The non-inflammatory conditions of the intestine, which for want of a better term we speak of at present as fermental, include those which arise from acid fermentation and albuminous decomposition, which are pro- duced by micro-organisms. The disturbances which arise from these causes represent the greater proportion of the diarrhceal diseases which occur during the warm months of the year. Etiology and Pathology. — The causes of fermental disturbance in the intestine lie in impure or improper foods and bad hygienic surroundings. 806 PEDIATRICS. In both acid fermentation and albuminous decomposition it is probable that the small intestine is most affected. The condition of the mucous membrane may be normal, or there may be desquamative catarrh. The process may go no farther, or it may be followed by inflammatory changes in the intestinal mucous membrane. The fermental class of cases holds a position midway between the nervous forms of intestinal disturbance and the inflammatory forms with their pronounced lesions. Symptoms. — The great variety of causes which give rise to these fer- mental processes result in a variety of symptoms. The onset may be subacute, with little or no fever and without vomiting, or it may be acute and accompanied by a high temperature and active vomiting. After a variable period of general discomfort and restlessness, diarrhoea sets in, which varies so greatly as to its frequency, amount, color, and consistency that it would be impossible in the present state of our knowledge to divide these variations clinically. The onset of fermental diarrhoea is, however, so often characterized by the toxic symptoms of sudden rise of tempera- ture, followed after a day or so by a normal temperature, that when we meet with this occurrence we are usually justified in eliminating the in- flammatory and more serious intestinal lesions. In some cases the diar- rhoea, although accompanied by much prostration and various nervous disturbances, disappears after a few days ; in others, especially in the warm weather, it may last for a number of months. In this fermental diarrhoea the color of the discharges is commonly some shade of green or greenish yellow, and the odor is often very offensive, sometimes being the excessively sour one which is supposed to arise from acid fermenta- tion, and at other times the extremely foul one of albuminous decompo- sition. The discharges are generally accompanied by considerable pain and a large amount of gas. They are usually not more than a dozen in number, and are larger in amount than those which occur in ileo-colitis. The symptoms are often so severe that the disease has a serious aspect, but in a considerable number of cases after the intestine has been thor- oughly emptied the temperature falls and the nervous symptoms subside. In some of the more severe cases certain special symptoms become so prominent as almost to produce different types of the disease. The most important of these are excessive vomiting, continuous hyperpyrexia, and extreme restlessness with insomnia. There is usually rapid and great loss of weight. In cases which are not prolonged by fresh irritation or by unwise treatment recovery often takes place quite rapidly. According to Morse, albuminuria occurs in about fifteen per cent, of all cases. Casts, usually hyaline and fine granular, occur in about sixty per cent, of the cases of albuminuria. The renal condition in these cases is a degenera- tive one, and not a true nephritis. Diagnosis. — When the attack is subacute, with slow onset, without vomiting, and with infrequent discharges, the diagnosis is not difficult, and DISEASES OF THE INTESTINE. 807 is to be made from the nervous disturbances, which can usually soon be differentiated by the absence of fever and by rapid recovery. When, however, the onset is acute and is accompanied by vomiting, the diagnosis must often be held in abeyance, as the symptoms of high temperature, vomiting, and diarrhoea may be present in infants and young children in the initial stage of a number of acute diseases. The disease from which it is especially to be differentiated is cholera infantum. In fermental diarrhoea the prostration is much less, and the temperature after the early hours of the attack is much lower. The serous discharges and the continuous vomiting which soon arise in cholera infantum are quite different from the greenish discharges and the less frequent vomiting which occur in fermental diarrhoea. We must remember, however, that cholera infantum and the acute inflammatory intestinal diseases are usually pre- ceded for a number of days by this fermental form of diarrhoea, and that the special micro-organisms which produce the former disease gain an entrance for themselves and their toxines by means of the abnormal intes- tinal conditions produced by the fermental changes. The differential diag- nosis from ileo-colitis is considered under that disease, on page 822. It is also well to remember that gastro-enteric symptoms are often so pro- nounced during the early days of a pneumonia that they may mask the presence of that disease. Prognosis. — In previously healthy children the prognosis of fermental diarrhoea is good. It depends, however, upon the degree and the kind of fermental process which is causing the disease, and also on the amount of resistance to these processes which the individual possesses. It also de- pends upon the vulnerability of the individual to the other bacteria which may at any time complicate the disease, as in the more severe cases of the disease described above. The cases of infantile atrophy are especially liable to die when attacked by this as well as by any other form of intes- tinal disturbance. In these cases it seems as though the infant were totally unable to resist even a slight amount of toxic absorption. The prognosis, therefore, when an already debilitated child, or one with infantile atrophy, is attacked by fermental diarrhoea must always be guarded. It also de- pends upon how soon and in what way the disease is treated. The renal complications do not alter the prognosis. Treatment. — The treatment of fermental diarrhoea is to remove at once the source of the disturbance by thoroughly emptying the intestine. When the vomiting is excessive it is sometimes necessary to wash out the stomach, but, as a rule, this procedure is not indicated. A dose of castor oil, one teaspoonful for infants under one year, and two teaspoonfuls for older children, is the best initial treatment. When the stomach is so sen- sitive that it does not seem advisable to give castor oil, 0.06 to 0.12 gramme (1 or 2 grains) of calomel can be given in divided doses. In the more severe cases, and when there is a tendency to a prolongation of the acute symptoms, irrigation of the intestine is indicated. Food should be 808 PEDIATRICS. withheld for a number of hours, — at least half a day, if possible. Stimu- lants are indicated when there is much prostration. The only other drug which in my experience seems to be needed is bismuth subnitrate, which should be given in large doses until the disease has run its course and the diarrhoea has ceased. The amount of bismuth in the severe cases should be from four to eight grammes (sixty to one hundred and twenty grains) in twenty-four hours. Milk can in most cases be given after the first twelve to twenty-four hours if it is properly modified. It should contain from ten to fifteen per cent, of lime-water, and at first should have the percentages of all its ele- ments considerably reduced. The milk which is used for this purpose must be fresh, since it is not sufficient to sterilize it, as the toxic products of bacteria may still be present in it and thus add fresh irritation to that which has already been produced by the fermentation. In many cases it is impossible in the present state of our knowledge to determine what special form of fermentation is present. When acid fermentation appears to be prominent, the milk should be so modified as to contain a low per- centage of sugar, while when albuminous decomposition with its exces- sively foul odor is met with, the proteids should be reduced to a fraction. Whether this treatment will in the future be proved to be the best it is impossible to state, but on the ground that various forms of bacteria are the cause of these disturbances, and that the special form of bacteria which is producing them has been developed in the food on which it thrives best, it certainly seems reasonable, and should be adopted until further light is thrown upon the subject. When breast-milk or fresh modified cow's milk cannot be obtained, weak animal broths, such as those made from mutton, chicken, or beef, can be used. Opium is almost invariably contra-indicated in these cases, and serious results may arise from its administration. The peristalsis which occurs as the result of fermental irritation is a conservative process of nature, intended to carry away the morbid products which have re- sulted from the fermentation. Under these conditions the administration of opium prevents the elimination of the poison from the intestine and allows it to remain and produce still further irritation, or to be absorbed and give rise to still graver septic symptoms. Towards the end of the attack, when the intestine has been thoroughly emptied, small doses of opium in the form of tinctura opii camphorata may be used with caution to diminish pain and to control the excessive peristalsis which may result from nervous exhaustion after the disease has run its course. In these cases, however, stimulants are more valuable than opium. Extreme and continuous hyperpyrexia should be treated by bathing in water heated to 32° C. (90° F.)and gradually reduced to 25.5° C. (80° F.). Excessive restlessness is to be treated with bromide of soda in doses of 0.012 to 0.006 gramme (2 to 10 grains). In some cases subcutaneous injections of morphia, beginning with 0.0006 gramme ( T ^ grain), is indicated. DISEASES OF THE INTESTINE. 809 When a child in the warm weather has once had an attack of fer- mental diarrhoea it is very apt to have a number of attacks. Its diet, therefore, should be carefully regulated for a considerable period, and if possible it should be taken to the sea-shore or the country until the return of cool weather. As especial illustrations of the great variety of fermental diarrhoeas which are liable to be met with in warm weather the following cases may be taken as examples : A child three years old and perfectly well was attacked suddenly with abdominal pain, nausea, pallor, and prostration. He vomited once or twice and was found to have a temperature of 40° C. (104° F.). Within a few hours he began to have fre- quent fa?cal dejections of sour odor, lessened consistency, moderate amount, and a peculiar dark green color (Plate III., No. 18, facing page 84). This green is one of the more common colors met with in fermental diarrhoea. At first the discharges took place every hour, and later every three or four hours. After the first twenty-four hours the temperature became normal and in three or four days the diarrhoea ceased entirely. The next case was that of an infant thirteen months old. On entering the hos- pital it was much emaciated and had a slight diarrhoea, caused apparently by improper food. Its temperature was only slightly raised. On examining it nothing else abnor- mal was detected. The diarrhoea was infrequent and was not accompanied by any other especial symptoms. It soon began to improve, gained in weight, and had a nor- mal temperature. After it had been in the hospital one week it suddenly began to have diarrhoea characterized by large frequent discharges of lessened consistency, of foul odor, and of the color which is seen in Plate III., No, 19, facing page 84, which is a mixture of yellow and light and dark green. The discharge seemed from its foul odor to be an illustration of what is called albuminous decomposition. These colors are. however, only relative and are not diagnostic. In this acute attack the tempera- ture w T as raised at first but soon fell to a little above normal. The infant lost greatly in weight, became extremely emaciated, and looked as if it would die. The skin often became cold, and the prostration was extreme. These symptoms continued for three or four days, and the number of the discharges in the twenty-four hours varied from seven to ten. The symptoms gradually became less severe and the diarrhoea abated. Later the diarrhoea stopped entirely, and the infant gained rapidly in weight and strength. CHRONIC FERMENTAL. The cases of acute fermental diarrhoea at times are prolonged for many weeks, and even months, and thus produce a chronic form of diar- rhoea. This occurs especially in children who are the subjects of rhachitis, syphilis, and general tuberculosis, also in those with chronic broncho- pneumonia. The continuous administration of improper food may pro- duce this condition, as may also improper exposure from insufficient clothing. MECHANICAL. The mechanical diseases of the intestine are quite numerous, but with few exceptions are not of special importance medically, and belong rather to the province of surgery. 810 PEDIATRICS. DILATATION OF THE COLON. In comparison with dilatation of the stomach, dilatation of the colon is very rare except as a temporary condition. It is liable to occur at any time from an over-production of gas. If permanent, it is usually congeni- Fig. 164. ■ Dilatai )lon. Male, 12 vears ok tal, or it may be secondary to some congenital malformation such as stricture of the intestine. The chief symptoms are constipation and dis- tention of the abdomen. The condition is usually fatal, but adult life may be reached. The treatment is essentially surgical. The following case illustrates a dilatation of the colon, which was seemingly caused by a congenital stricture, and in which an artificial anus was made by Halsted. The child recovered from the operation, but later, owing to still further obstruction, he had to be operated on again and died. In this case the extreme distention of the abdomen, which was tympanitic through its whole extent, the evident obstruction to the faecal discharges, and the absence of symptoms pointing towards gastric disease, would suggest a dilatation of some part of the intestine, presumably of the colon. DISEASES OF THE INTESTINE. 811 VOLVULUS. By volvulus is meant a twisting or bending of the intestine. This condition is more apt to occur in early life than later, possibly because of the greater proportionate length of the mesentery at this time, which allows the intestine greater latitude of motion. It occurs either by itself or in connection with intussusception, from which it is to be differentiated by the absence of blood and mucus in the discharges. INTUSSUSCEPTION. Intussusception or invagination is a condition in which a part of the intestine has passed down into another part. Under these circumstances there is an outer layer of intestine within which is the part of the intestine forming the invagination. Only a small portion of the intestine may be invaginated. or it may extend from the ileo-csecal valve to the rectum. Small invaginations are frequently found at the post-mortem examinations of infants and young children. These probably take place during the death-struggle, as no pathological condition is found in connection with them. This form is usually multiple and in the small intestine. The form of intussusception which occurs during life is very rare under three months, and is most, common from the third to the sixth month. At this age the large intestine is shorter in relation to the small intestine than in the adult, while the mesentery is relatively wider, and thus allows much greater latitude for misplacement, especially of the caecum and colon. The etiology of intussusception is obscure, but it is probably directly due to increased local peristalsis. The pathological condition depends upon the tightness of the constric- tion and the length of time from the beginning of the obstruction. In some cases the incarcerated portion of the intestine is so little constricted that the bowel remains pervious. In other cases the constriction is so great that the tension of the intestinal capillaries quickly becomes so ex- treme that hemorrhage occurs, and inflammation, with resulting adhesions, is apt to follow rapidly. The intestine may not only be invaginated, but may be bent on itself, an important point to remember in regard to treat- ment. Symptoms. — The symptoms of intussusception are usually more acute in infants than in older children. In infants they are often at first rather obscure. Paroxysmal pain and discharges of blood from the rectum occur. Later the blood is mixed with mucus and looks like currant jelly. There is usually vomiting, which may be stercoraceous. The mind is clear, and in young infants the face is often tranquil between the parox- ysms of pain, so that on looking at the infant it would scarcely be sup- posed that a serious condition was present. Later, however, the face grows haggard and the eyes become sunken. During the first twenty-four to forty-eight hours, and even longer, the infants will often take their food quite readily. Tenesmus is at times present. There may be fever, espe- 812 PEDIATRICS. dally when inflammation has occurred. The pulse is usually quickened. These symptoms all vary, and depend on the amount of the invagination. In some cases these are the only signs which indicate that there is abdomi- nal disturbance. In many instances, however, either at once or within a few hours, a tumor can be felt in the abdomen. Diagnosis. — The chief points in the diagnosis of intussusception are the occurrence of discharges of blood, vomiting, abdominal pain, and the detection of an abdominal tumor, usually on the left side of the abdomen. In these cases a careful rectal examination should always be made, for a tumor can often be found in this way when an external examination has failed to detect it. Prognosis. — Without treatment the prognosis is unfavorable, though there are a certain number of recoveries by spontaneous reduction, or rarely by sloughing of the invaginated portion of the intestine, which is then passed by the rectum. If death takes place, it usually occurs about the third or fourth day, or at any rate within a week, after the incarcera- tion is complete. When the incarceration is not complete the infant may live for many weeks, and in older children in rare instances the disease may become chronic. Treatment. — The treatment of intussusception, when the diagnosis has been definitely made, should be immediate, as in no other disease does a delay result in more serious consequences. Food and cathartics or laxa- tives are contra-indicated. If the infant shows signs of collapse, small quantities of brandy-and-water should be given. In the early hours of the attack an attempt should be made to reduce the intussusception by hydrostatic pressure. This can be easily done by having the infant's but- tock's somewhat raised and introducing water under a pressure of about one metre (3J feet) by means of a fountain syringe. The water should be lukewarm, and should have dissolved in it salt in the proportion of one teaspoonful to a quart. The abdomen should be gently rubbed at the same time. In some cases this procedure results in a reduction of the intussusception, but when this is not accomplished an anaesthetic should be given and the attempt repeated. Even when inflammation has not begun and adhesions have not formed, the pressure of the column of water may fail to reduce the intus- susception, because the invaginated portion may be bent on itself, so that the hydrostatic pressure increases the obstruction rather than relieves it. When adhesions have taken place and when there is great congestion, as sometimes occurs during the first twenty-four hours of the attack, hydro- static pressure is usually unsuccessful and may be dangerous. If this method has failed, the infant should be placed at once in the hands of a surgeon, as under these circumstances an early laparotomy will give the most favorable results. The following case of intussusception illustrates the importance of not delaying operation. DISEASES OF THE INTESTINE. 813 A male infant, six months old, nursed by its mother, and previously perfectly healthy, after a slight loss of appetite for several days began to have abdominal pain in the morning, and in the middle of the day had a discharge of blood from the rectum unmixed with fecal matter or mucus. The bowels had been thoroughly moved on the previous day. and there had been no tendency to constipation. During the afternoon there were five or six discharges of blood. In the evening the infant looked well and did not show any signs of discomfort except occasional slight attacks of abdominal pain and an indisposition to nurse. The rectal temperature was 39° C. (102.2° F.). An examination of the abdomen externally and by the rectum revealed nothing abnormal. The infant had a restless night, vomited several times after nursing, and had six dis- charges of blood. The temperature was 38.3° C. (101° F.), the pulse 135, strong and regular, and the general appearance good. The abdomen was soft and not tender on pressure, but towards the umbilicus, under the left costal border, a rather ill-defined cylindrical tumor could be detected. Hydrostatic pressure was employed to reduce the intussusception, but failed. The surgeon who saw the infant on the second day decided to wait twenty-four hours before performing laparotomy. On the following day the infant died suddenly. At the post-mortem examination nothing abnormal was found except an ileo-caecal intussusception. An examination of the invagination showed that the retained caecum was so twisted that the lower opening was directed to one side of the axis of the intestine, and the hydrostatic pressure from below must have simply packed the sac tighter and rendered reposition more difficult. The invagination involved 20 cm. (8 inches) of the intestine. The serous surfaces were firmly adherent through their whole extent, and considerable force was required to reduce the invagination without tearing it. The re- duction, however, was successfully accomplished, the adhesions giving way and the intestine being left uninjured and apparently healthy. This case illustrates how neces- sary it is to employ the most skilled surgical aid in these cases. HERNIA. Hernia is essentially a surgical disease, and has been referred to in the division on diseases of the new-born. FISSURES. There are a number of lesions which occur about the anus in infants and young children which, though somewhat rare, should be recognized for purposes of differential diagnosis. They are, however, so purely sur- gical in their treatment that they need only be mentioned here. One of these conditions is that of fissure, which occurs either at the anus or more commonly a little distance from the orifice. Pruritus and reflex urinary symptoms are common. Defecation is often painful, and constipation of the spasmodic type may thus result. A general nervous irritation at times results from fissures of the anus which may seriously interfere with the nutrition of the child. The treatment is cleanliness and the application of boracic acid ointment or the stick of nitrate of sil- ver every two or three days. If these measures fail, stretching of the sphincter under anaesthesia usually cures the disease. PROLAPSE. Prolapse of the rectum is not uncommon in young children. It is usually produced by straining from various causes, especially in extreme 814 PEDIATRICS. constipation or in diarrhoea. The wall of the rectum comes down through the anus, and is easily recognized by the appearance of the mucous mem- brane. The prolapse is ordinarily transitory, but in the more severe forms the rectum remains down. Treatment. — The treatment is to remove the cause. Constipation should be relieved first by enemata and then by keeping the movements of the bowels semi-liquid by means of gentle laxatives. The tenesmus ac- companying diarrhoea may be relieved by sponging with ice- water or by the use of 0.015 gramme (J grain) suppositories of cocaine. The child should be kept in bed for a number of days, the protrusion being gently pushed back each time that it comes down. The prolapse should be reduced with the fingers well oiled, the central portion being pushed back first. If the parts are very sensitive the reduction is facilitated by the application of a solution of cocaine. After reposition it should be kept in place by means of a pad and a T bandage. Under this treatment a large number of cases recover. The more serious and intractable cases, however, should be referred to a surgeon. POLYPI. Polypus of the rectum is more common in early life than at any other period. Hemorrhage from the rectum, when not due to constipation, diarrhoea, or fissure, usually arises from polypi. A careful examination for this growth should be made when rectal bleeding is frequent or large. Rectal polypi are of various sizes, and may be myxofibromata or adeno- mata. The surface of the polypus is usually smooth, and the pedicle is often long and thin. The diagnosis is easily made by a digital examina- tion. The treatment is either to twist or cut off the polypus. The growth is not apt to recur. HEMORRHOIDS. Hemorrhoids are rarely met with in infancy or early childhood, but can occur and should be treated by the same methods as in later life. FISTULA. Fistulae in ano is not a very common condition in infancy or early childhood, but is met with at times. The condition has the same charac- teristics as in the adult, and should be treated in the same way. NEW GROWTHS. New growths in the enteric tract are very rare in infancy and child- hood, and are mostly confined to the myxomatous polypi of the rectum. B. Inflammatory. — The inflammatory diseases of the intestinal tract not otherwise classified comprise proctitis, appendicitis, and the various forms of ileo-colitis, which are usually designated as dysentery. This latter class represents a number of infectious diseases which are general in type, and each may be caused by a special organism, but in the present state of our knowledge they are most conveniently described in connec- tion with diseases of the intestine. DISEASES OF THE INTESTINE. 815 PROCTITIS. Proctitis is an inflammation of the rectum, and may be acute or chronic. It is usually coincident with inflammation of the colon, but may occur alone as the result of trauma or the extension of inflammatory processes around the anus. Symptoms. — The symptoms are essentially pain, traces of blood mixed with mucus, and tenesmus. Diagnosis. — The diagnosis from reflex inflammatory conditions is made by direct inspection. Treatment. — The treatment is to keep the child in bed, to keep the faeces soft with laxatives, to cleanse the rectum, and, according to the especial lesions, use astringents or soothing injections. When there is pain or tenesmus, suppositories of opium and cocaine are indicated. APPENDICITIS. Etiology. — Inflammation of the vermiform appendix in children is most frequent between the ages of five and fifteen years, and is not of uncommon occurrence. It is very rare under two years. Several cases have been reported as early as seven weeks. Boys are more often attacked than girls, and in about the same proportion as in adults. Functional disturbances of digestion, constipation, diarrhoea, and indiscretions in diet are only remotely connected with the etiology of the disease. Foreign bodies are infrequent, despite the general opinion, but the presence in the appendix of faecal concretions, often resembling seeds and stones of fruits, are very common, but their exact relation to the primary cause of the inflammation is not clear. Direct trauma, as from a blow in the abdomen, is sometimes a definite exciting cause. The prevailing opinion is to con- sider the process an infective inflammation, though as yet no specific organism has been shown to cause it. On the contrary, cultures of the colon bacillus alone, or mixed infections of the colon bacillus associated with the streptococcus, pneumococcus, staphylococcus albus or aureus, the bacillus aerogenes, and certain undetermined anaerobic organisms are found. The transformation of the appendix into a closed tube is to be considered as a consequence rather than a cause of appendicitis (Brum). Pathology. — The pathological conditions occurring in the course of an appendicitis are exceedingly varied, and will only be outlined. In the early stages of a purely appendicular lesion, the appendix is in normal position and may show only slight swelling and congestion. Usually it is voluminous from extensive infiltration of its Avails, very turgescent. and often shows spots of ecchymoses with intense congestion of the peritoneal coat. In more advanced stages the mucosa is soft and granular, some- times gelatinous, with ecchymoses and ulcerations. The muscular coats are thickened and their fibres often separated by minute or extensive ac- cumulations of pus. All these changes may develop in from twenty-four 816 PEDIATRICS. to thirty-six hours after the onset of symptoms. Perforation and gan- grene of the appendix, in part or in whole, are simply further steps in the inflammatory process, and, according to Brim, are especially likely to occur in children. The inflammation is rarely confined to the appendix, but by extension involves the peritoneal coat of the appendix and the peritoneum itself. The subsequent course is very variable. The process may remain local, and. lead to a peri-appendicular inflammation, in which the appendix, caecum, and end of the ileum are shut off from the rest of the peritoneal cavity by false membranes, with or without the formation of pus ; or the infection may spread directly from the appendix to the general peritoneal cavity, with the production of general septic peritonitis. The location of the pus in cases of abscess formation depends to some extent upon the location of the appendix, in which there is considerable variation. It may be either iliac, pre-rectal. sub-umbilical, retro-caecal, or lumbar in its disposition. A most malignant form of general peritonitis may follow a simple parietal appendicitis without perforation or gangrene of the appendix, and give rise to a clinical picture more suggestive of septicaemia than of peritonitis. A simple appendicitis, sometimes called catarrhal, may produce so" much thickening of the walls and infiltration of the submucosa with leuco- cytes, and subsequent formation of granulation tissue, as to cause an obliteration of the lumen of the appendix. If the lumen is completely obliterated, it may render the patient immune to subsequent attacks, but if only partial, it favors the collection of pockets of pus and cyst-formation, and the organs is a constant source of danger. Ulcerative appendicitis may be caused by the presence of concretions or by the action of micro-organisms. The presence of concretions, how- ever, may not be accompanied by any inflammatory or necrotic reaction. Typhoid and tubercular ulcerations of the appendix are not uncommon in their respective diseases, and an actinomycotic ulcer has also been described. Symptoms. — Sudden pain in the abdomen, referred to the umbilicus or to the right iliac fossa, with tenderness on deep pressure in the region of the appendix, associated with a fever of moderate or high grade and gastro-intestinal symptoms, usually mark the onset of an acute inflamma- tion of the appendix. Clinically it is convenient to distinguish between certain types of the disease. Simple Appendicitis. — This is the least severe of the acute forms, and is characterized by its sudden onset and short duration. Without any prodromal symptoms the child is seized with sudden, severe abdominal pain at about the level of the umbilicus and more to the right than to the left. Vomiting, in some cases only nausea, follows. There is moderate fever. The pain is continuous, and the bowels are usually constipated. DISEASES OF THE INTESTINE. 817 Tenderness over the region of the appendix with a unilateral rigidity of the muscles is the most important sign by which we exclude other causes of abdominal pain. The temperature is moderate, 23.5° to 24.1° C. (100° to 101° F.). lasting a day or two. The acute symptoms subside in from twenty-four to forty-eight hours, but the tenderness is apt to remain for several days, at the end of which time the abdomen is sometimes so re- laxed as to enable one by careful examination to feel the slightly thick- ened appendix. These mild cases probably occur much oftener in children than are diagnosed. Appendicitis with Periappendicular Peritonitis. — This is the more common form, formerly recognized as perityphlitis, and in its mildest grade is not to be distinguished clinically from the severer types of a simple appendicitis. The initial symptoms are more exaggerated, but are the same in character as in a simple appendicitis. The digestive symptoms are much more pronounced. The vomiting is apt to be repeated, and the temperature much higher, 39° to 40° C. (102.2° to 104° F.). The pulse is rapid, 112 to 120 per minute, and the pain and localized tenderness is more intense. After a lapse of some hours, if the abdomen is not too tense, we may sometimes feel in the right iliac region an indistinct thick- ening, sometimes a definite mass, but the swelling may not be located until the child is under the influence of an anaesthetic. There is apt to be leucocytosis, though one must not be misled by a normal white blood count. In some cases, under expectant treatment, these symptoms will gradually subside in the course of a week or ten days, and with the alle- viation of the acute pain and tenderness the swelling of the appendix and surrounding tissue is more readily recognized. In time this mass may entirely disappear so far as external palpation can determine, or, on the other hand, some induration may remain after complete establishment of health. If the inflammatory process ends in abscess formation the persistence of the fever and the presence of leucocytes aid in the diagnosis. The return of the fever after its subsidence is also indicative of the advent of suppuration. The absence of fever, however, cannot be taken as positive evidence of the absence of pus. If the swelling increases in size or if it remains stationary we strongly suspect that there is a local accumulation of pus. If the pus has once formed it may terminate by absorption or by perforation externally or into some portion of the intestines, vagina, or bladder, but — and this should always be borne in mind by the physician who takes the responsibility of expectant treatment — it may rupture into the peritoneal cavity, usually with the result of a fatal septic peritonitis. Appendicitis with General Suppurative Peritonitis. — Aside from those cases of general peritonitis which are caused by a rupture of an appendix abscess into the peritoneal cavity, there are others of general peritonitis in which the infection starts from a diseased appendix with symptoms of such rapid development as to indicate a general peritonitis 52 818 PEDIATRICS. almost from the very beginning. There is sudden severe pain in the region of the umbilicus rapidly spreading over the whole abdomen, but with its greatest intensity on the right side. The vomiting is incessant, and the constipation so sudden and complete as to suggest intestinal ob- struction. The temperature rises suddenly to 39° to 40° C. (102.2° to 104° F.). and the pulse is increased to 130 to 140 per minute. The ab- domen rapidly becomes rigid throughout, and deep palpation is impossible. The tenderness is general, but most marked on the right side in the neighborhood of the appendix. The symptoms progress rapidly. The vomiting of bile is followed by that of faeces. The abdomen becomes dis- tended. The respiration is labored. Delirium often sets in. Aside from the localized tenderness and rigidity, the examination of the abdomen is negative, for the amount of intraperitoneal fluid is too small to be recog- nized by percussion, though at times a rectal examination gives evidence of fluid in the cul-de-sacs. Without an early operation, death usually ensues in these cases in from two to four or five days. There is still another form of appendicitis with diffuse peritonitis, de- scribed by Brun, Jalaguier, and others, which is the most malignant and rapid of all, and in its course suggests a septicaemia having its origin in a virulently infected appendix. Its onset is quite different from the type of disease just described. It begins like an attack of acute intestinal indi- gestion with vomiting and foetid diarrhoea, rarely, if ever, with constipa- tion. Neither the pain nor the tenderness in the iliac fossa is so marked as in the other cases. The abdomen is soft, flat, and easily palpable, and with almost complete absence of resonance on percussion. The progress is rapid. The features are anxious, leaden-colored, the eyes sunken and surrounded by dark rings. The thirst is keen, the respiration rapid and shallow. There is extreme restlessness. The temperature at the first may reach 39° C. (102.2° F.), but on the second day is more apt to be 37° C. (98.6° F.) or below, in striking contrast to the weak, rapid pulse of 150 to 160. The mind remains clear to the end, without any change in the abdominal symptoms, and death often supervenes within thirty-six to forty-eight hours, rarely extending beyond three or four days. Chronic Appendicitis. — An appendix once inflamed is prone to re- current attacks, with the train of events connected with the primary attack. The cause for this probably lies in an obliterative appendicitis with or without adhesions, or perhaps from a localized abscess circum- scribed by dense fibroid tissue. The attacks may recur at intervals of a few months, and finally cease or develop into an acute attack which may run a typical course. Chronic appendicitis may, however, manifest itself from the beginning as indefinite twinges of pain in the right iliac fossa, brought on especially by over-exertion and fatigue, without ever develop- ing alarming symptoms, and with but little else in the way of symptoms ; on the other hand, these inconstant pains may be prodromal symptoms of a susceptible appendix, which later becomes acutely inflamed. DISEASES OF THE INTESTINE. 819 Diagnosis. — The diagnosis of appendicitis in young children is often made difficult by the inability of the child to locate accurately his sense of pain, and to appreciate the distinction between pain and tenderness. Moreover, the contraction of his abdominal muscles and his inability to relax them at will renders the result of palpation less certain. The presence of fever and localized tenderness in the right iliac fossa are the principal points in the exclusion of hepatic and renal colic. Intestinal colic is more often associated with diarrhoea than with constipation, and here again the localized tenderness is a crucial point in the diagnosis. It is well established that in pneumonia in children the pain is frequently referred to the abdomen, but careful attention to the symptoms and course of the disease will enable one to distinguish between the two con- ditions. An appendix abscess arising from an appendix unusually placed might easily be confounded with a perinephritic abscess, but in either case operation is indicated, and the error in diagnosis should not prejudice the interests of the child. Appendicitis with the sudden onset of septic peritonitis may readily suggest an intestinal obstruction, but the fever, localized tenderness, and leucocytosis are not likely to occur in the latter condition. In intussusception the straining, tenesmus, and small and frequent discharges of blood and mucus, and the sausage-like tumor, which can often be felt in the region of the transverse colon, usually suf- fice for a diagnosis. Moreover, appendicitis is very rare under two years, and intussusception is very common. In certain cases the two conditions simulate each other very closely. Perforation of gastric ulcer, pus tubes, and pelvic peritonitis, abscess of the broad ligament, acute pancreatitis, appendicular hypochondriasis and hysteria, which may in the adult be mistaken for appendicitis, are not likely to occur in infants and young children, but in older children should be borne in mind. An acute in- flammation of the gall-bladder and appendicitis are often confounded, and an unusual position of the appendix should always be remembered. Prognosis. — The prognosis depends largely upon how early the diag- nosis is made and the skill of the surgeon who is called for consultation and operation. Cases undoubtedly recover in many instances without operation, but the extreme gravity of the results of an extension of the inflammation to the peritoneum, and the realization that this accident may occur at almost any time, even in the cases which are apparently running a mild course, render general statistics of little value in the considera- tion of an individual case. We should not lose sight of the fact that in infancy we see most frequently the very severe and acute forms of the disease, and there is the special tendency to perforation and gangrene and extension to the peritoneum, with its very serious consequences. Treatment. — Personally, I consider the disease one for surgical obser- vation and treatment. It is safer to call the surgeon in consultation early than late, and if the diagnosis is determined it is wiser to trust to his judgment as to the expediency of immediate or delayed operation than 820 PEDIATRICS. for the physician himself to attempt to decide. There is no medical treat- ment other than that which is purely symptomatic. Absolute rest in bed, irrespective of the severity of the symptoms, is of first importance ; local applications of ice should be used to control the pain, or, if the child objects, as is frequently the case, hot fomentations should be tried. Cathartics and laxatives should be avoided, and the bowels moved by enemata. Blisters should not be used. Opium is strongly objected to by surgeons as tending to mask the symptoms ; if it can be avoided, it is far better to do so ; but very small doses, sufficient to keep the patient from excessive pain and fairly quiet, are probably in children a lesser danger than that which would be caused by hours of pain, crying, and intense restlessness. If no operation could be performed I should prefer to trust to opium in the early stages rather than to cathartics. ILEOCOLITIS. General Etiology. — Under the term ileo-colitis are included all the more marked and grave lesions of the intestine. They are commonly grouped under the name dysentery, but as our knowledge of them in- creases it is becoming evident that any such general term as dysentery is inadequate to cover what will, in all probability, be proved to be a number of diseases, each arising from its own specific organism. All these forms of ileo-colitis (dysentery) are considered to be in- fectious. They may occur as acute primary diseases, but are usually secondary to the fermental diarrhoeas, and sometimes to the infectious diseases, especially measles. The sporadic cases have not as yet been sufficiently studied bacteriologically to allow us to come to any definite conclusions concerning them etiologically. Flexner has, however, shown that it is entirely possible that two specific organisms may be responsible for both the epidemic and endemic varieties of what has been called tropical dysentery, and that they consist of (1) a baeillary and (2) an amoebic form. Amoebic ileo-colitis is so well recognized as a specific infectious dis- ease that it has already been described with the other infectious diseases, on page 501. Our knowledge of the baeillary form is still too limited for us to more than mention it. The etiology of the other supposed forms of ileo-colitis (dysentery) is so little known, and their lesions are so varied, that it would be impossible to classify them in detail. Practically, also, we can divide them only in such a general way that for the present they had better be described as in the case of the fermental diarrhoeas, under diseases of the gastro-enteric tract. Variations in Type. — The divisions which have been adopted to sim- plify the subject are (1) simple catarrhal inflammation, which includes the non-ulcerative form of follicular inflammation, (2) follicular inflammation, and (3)' a pseudo-membranous inflammation. DISEASES OF THE INTESTINE. 821 Although these three forms differ essentially in their prognosis, they are so often represented by the same symptoms that they can be differ- entiated only in the most general way. A symptom common to all these diseases is found in the temperature, which, although not necessarily high, is. as a rule, raised throughout the whole course of the disease. In this way we can usually differentiate these diseases from the non- inflammatory conditions. The pseudo-membranous form of ileo-colitis may be primary or secondary. In the primary form it represents what is usually spoken of as epidemic or sporadic dysentery. The secondary form is that which follows certain infectious diseases. The pathological lesions found in connection with the catarrhal and non-ulcerative follicular and the ulcerative follicular inflammations ap- proach each other so closely and the symptoms are so similar that the clinical distinction between the two conditions is very difficult. Pathology. — In the pseudo-membranous forms of ileo-colitis, the ileum and colon are chiefly affected. The disease is characterized by the presence of a membrane on the surface of the mucous membrane, which extends into it, and is due to a combination of fibrous exudation and necrosis. The pathological conditions found in the various forms of ileo-colitis may best be studied in connection with the histories, autopsies, and figures of the cases presently to be reported. Acute Ileo-Colitis. — Symptoms. — The symptoms of the various forms of acute inflammatory ileo-colitis vary greatly, as a rule, but in a general way they can be recognized by a group of symptoms which differ from those of the non-inflammatory diarrhoeas, spoken of as fermental diarrhoea and cholera infantum. The symptoms, however, of these different forms of ileo-colitis are very unsatisfactory and unreliable for differential diag- nosis. The onset of the disease may be preceded by a fermental diarrhoea, or it may be acute from the beginning and have prodromal symptoms of no more than a few hours. The temperature is elevated, the pulse is accelerated, and the infant loses rapidly in weight and strength. The dis- charges are perhaps ten or twenty, or even more, in the twenty-four hours, but are comparatively small in amount. Where the lesions are in the rectum there is tenesmus both before and after the discharge, and in the beginning of the attack an almost constant desire to have a move- ment. The discharges contain faecal matter at first, but soon become small, and consist of mucus, sometimes with pus, blood, and shreds of membrane. The odor may be very offensive, but when the mucus pre- dominates there is very little odor. The color and consistency are ex- tremely variable, but generally the consistency is lessened and the color is a mixture of green, brown, and yellow. The blood is usually from congestion of the blood-vessels and straining, rather than from ulceration, so that we cannot determine from the presence of blood whether ulcera- 822 PEDIATRICS. tion is present or not. At first the abdomen may be soft and not tender, but later in the disease it becomes distended, tympanitic, and somewhat tender, especially along the course of the colon. Vomiting may occur at times. In severe cases the child is very restless, and there may be de- lirium and convulsions. The appetite is usually much lessened. The urine is nearly always diminished in quantity, is high-colored, and some- times contains a small amount of albumin, especially when the tempera- ture is high. Casts may also be found. The renal condition in these cases is a degenerative one, and not a true nephritis. Acute nephritis is rare. When there is much tenesmus and straining, and when the dis- charges are especially frequent, prolapse of the rectum may occur. The discharges often cause great irritation around the anus and on the but- tocks. Although there are no symptoms typical of the different forms of acute ileo-colitis, yet their clinical pictures differ somewhat. It is usually found in the simple catarrhal ileo-colitis, when ulcera- tion has not taken place, that the symptoms are milder and that there is apt to be vomiting. The cases generally begin to improve in one or two weeks, and recover entirely in another week. An intestinal disturbance of a mild character may result, however, and prolong the disease. The children are usually a long time in regaining their strength, and relapses are quite common in this form if the diet is not carefully regulated. Sometimes, however, simple catarrhal ileo-colitis may be represented by symptoms of a very severe type, and it may run a rapid course, and end fatally. When follicular ulceration has taken place the stomach is not apt to be much involved, the temperature is not, as a rule, high, and the course of the disease is rather slow, irregular, and prolonged. The infant fails steadily and commonly dies. A remission in the symptoms and an im- provement in the character of the faecal discharges should lead us to infer that ulceration has not taken place. When the inflammation is simply follicular, without ulceration, the cases are very apt to recover. Pseudo-membranous ileo-colitis is rare in infants, but when it occurs it is the most severe of all the forms. I have already stated that it is this form which is usually spoken of as epidemic or sporadic dysentery. The temperature is high,— 39.4°, 40°, or 40.5° C. (103°, 104°, or 105° F.). There are apt to be blood and membranous detritus in the dis- charges. The progress of the disease is usually rapid and without remis- sion, and death may take place in a week or ten days. The nervous symptoms, such as restlessness and delirium, are quite prominent. Diagnosis. — These forms of ileo-colitis are diagnosticated from the fermental diarrhoeas by the continued heightened temperature, the more frequent discharges, the small amount in each, the presence of blood or membrane, and the tenesmus. They may be differentiated from cholera infantum by the absence of continuous and excessive vomiting and by the DISEASES OF THE INTESTINE. 823 serous discharges of the latter disease. The diagnosis, however, can be made positively only by finding shreds of membrane in the discharges. Prognosis. — The prognosis of ileo-colitis, when ulceration has not occurred, is usually favorable, the duration of the disease being a few weeks. Some cases, however, are more severe, and sometimes prove fatal in a few days. When there is ulceration, the prognosis is rather unfavorable. When there is a diminution in the frequency of the discharges and fsecal matter begins to reappear, and when .the nervous symptoms and exhaus- tion lessen, the prognosis is good ; but when the symptoms increase in severity and the face looks pinched, when intractable vomiting arises and the nervous symptoms predominate, the prognosis is very unfavorable. The prognosis is less favorable when the ileo-colitis is complicated by broncho-pneumonia or tuberculosis. It is much influenced by the time of the year at which the attack takes place, the prognosis being worse if the disease occurs at a time when the convalescence is during a long heated period. The prognosis is also worse when the infants have to be treated in crowded cities and in the midst of unsanitary surroundings. Treatment. — The treatment of these forms of ileo-colitis should usually be in the beginning the same as has already been described for fermental diarrhoea. It may in this sense be spoken of as prophylactic, for in a large number of cases the organisms which produce ileo-colitis find a means of entrance through the irritated mucous membrane pro- duced by a preceding fermental diarrhoea. When the case is seen in its earlier stages, a mild laxative should be given, in order to clear away, so far as possible, the pathogenic organisms, which are present in large num- bers. Small doses of castor oil act most efficiently, and can usually be given, especially to infants, without causing nausea or gastric irritation. In addition to this treatment by the mouth, thorough irrigation of the colon should be employed. This should be done twice in the twenty- four hours with warm sterilized water containing 3.75 grammes (1 drachm) of borate of sodium to the pint of water. One or two gallons of water should be allowed to flow in and out of the intestine at each irrigation. After the irrigation, small enemata of thin mucilage, about 120 c.c. (4 ounces), containing 15 grammes (J ounce) of bismuth in suspension, may be given once in three or four hours. According to the degree of pain, restlessness, and general discomfort, a slight amount of opium can be given in these injections, but in all cases this drug should be administered with great care ; 0.03 c.c. (J minim) of tincture of opium in the first year, and 0.06 c.c. (1 minim) in the second year, once in five or six hours, will usually be sufficient to make the infant comfortable. The effect of the opium should be carefully watched, and the dose increased or decreased as is necessary. When the tenesmus is extreme, it is well to use suppositories con- taining from 0.015 to 0.03 gramme (J to J grain) of cocaine. These suppositories will often give great relief if the painful lesions are mostly 824 PEDIATRICS. ■ in the rectum, but when the lesions are higher in the colon they are not of much value, and when the tenesmus is continuous and exhausting, and the suppositories ineffective, a subcutaneous injection of morphia, 0.003 gramme (^ grain), with atropia, 0.0003 gramme (^ grain), can be given. The use of antiseptics by the mouth I do not recommend. Bismuth can be given by the mouth with some advantage in these cases, but the dose must be considerable to accomplish good results. 1.87 gramme (J drachm) in the twenty-four hours should be given to a child a year old, and for older children the dose should be proportionately increased. Alcoholic stimulants can be given with benefit at all stages of the disease if there is evidence of a weakened heart, or if much exhaustion is present. A very limited amount of food of any kind should be given during the first twenty-four hours. Sterilized water containing an alcoholic stimulant and barley-water had better be given at first, as it has been found that when a sterile liquid is taken by the mouth the number of bacteria in the intestine diminishes rapidly. After this preliminary treat- ment if a perfectly fresh milk can be obtained it may be used, if sterilized and modified in its various elements so as to be adapted to the digestion of the especial case. A moderate percentage of fat and sugar, such as 3 and 5, and a proteid percentage of about 2, is a very good prescription to begin with. Weak broths can also be given. Chronic Ileo-Colitis (chronic dysentery). — Etiology. — In some cases of ileo-colitis, after the acute symptoms have ceased, the diarrhoea con- tinues for many months, and the disease becomes chronic. Pathology. — The pathological conditions most commonly found in these chronic forms of ileo-colitis are great thickening of the muscular tissue, pigmentation of the mucous membrane, and very extensive ulcer- ation. Symptoms. — There is no especial pain or tenderness, and the tempera- ture may be normal. The appetite often returns, but the child does not gain in weight, or it loses. The discharges are not so frequent as during the acute stage of the disease, varying from six or eight to two or three in the twenty-four hours. The discharges have a lessened consistency, and contain mucus and undigested food. There may at times be exacer- bations of the symptoms, and the children are very apt to die of some intercurrent disease. The duration may be many months. Treatment. — The treatment is, if possible, a change of air, and is otherwise essentially diatetic. The rules already given for the treatment of the chronic forms of fermental diarrhoeas are also applicable to this class of cases. As illustrations of the difficulty and in many instances the impossibility of diagnosticating intestinal lesions, the following cases, which were under my care, are of interest. DISEASES OF THE INTESTINE. 825 One of these eases was that of a little girl, five years old, who during the hut weather in August had been having a slight attack of fermental diarrhoea, which began with vomiting, headache, and a slight rise of temperature lasting a few hours. This was soon followed by four or five greenish-yellow discharges in the twenty-four hours, and a normal temperature. The diarrhoea diminished in two or three days, and the child seemed much better, but after a few days she was suddenly attacked with a temperature of 39.4° to 40° C. (103° to 104° F.) and with frequent discharges of mucus and blood. She lost rapidly in weight, and looked very sick. After twenty- four hours, however, the movements became normal ; and on the following day, although left weak and prostrated, she seemed perfectly well, and had no return of the attack. During the acute symptoms it seemed as if she were attacked by one of the more severe forms of colitis, but the rapid recovery left the diagnosis very doubtful. The next case was that of a child, seven years old, who entered my wards at the Boston City Hospital with a history of having had a slight diarrhoea for a few days. The temperature was but slightly raised. The movements were infrequent, of a greenish- yellow color, and contained no blood or membrane, and scarcely any mucus. The child seemed fairly well on entering the hospital, but during the following few days became much exhausted. Although no other intestinal symptoms appeared, he sank rapidly, and died apparently from exhaustion. The autopsy showed extensive lesions of the whole colon, the mucous membrane was greatly thickened, and there were numerous ulcerations. The third case was that of a boy, four years old, who was brought to the Children's Hospital for frequent vomiting following an attack of diphtheria. During the first three weeks that he was in the hospital the vomiting was the chief symptom. He was fed by nutritive enemata, and improved in his general strength. Later, however, he became very much emaciated, the vomiting increased in frequency, and a few days before he died there was a slight diarrhoea. The temperature was normal or sub- normal during the whole course of the disease. During the last four or five days the symptoms had pointed almost entirely to the stomach, but the post-mortem exami- nation showed nothing abnormal in the stomach, lungs, heart, kidneys, or spleen. The mesenteric glands were swollen in the region of the ileo-csecal valve. The walls of the ileum and colon were thickened and reddened. There was a slight deposit of fibrin over part of the mucous membrane of the ileum. The lower 35 cm. (13f inches) of the colon were found to be much thickened, the inner surface was of a dark- greenish color, and beneath it the tissue was deeply injected. The thickening seemed largely due to an exudation on the mucous membrane, which could not be torn away. The thickening ended quite sharply, but on some of the valvulae conniventes above a similar membranous deposit could be found. In the colon the thickening was most marked in the caecum and the rectum, and least so in the transverse colon, and the process seemed older than in the ileum. Cultures from the various organs were nega- tive. Various organisms were found in the ileum, but none that seemed to be of especial significance. The following cases and figures illustrate varieties of ileo-colitis and show how with our present knowledge it is usually impossible to diag- nosticate the especial lesions during life. The first specimen (Fig. 165) is a portion of the colon of an infant who during life had only a slight diarrhoea. The lesion is quite marked and simulates closely the hyperplasia of Peyer's patches which is commonly seen in typhoid fever; but in this case it represents merely intestinal irritation. 826 PEDIATRICS. This next specimen (Fig. 166) was found at the autopsy of a little girl, three years old, who had been under the care of Dr. Webber. The child was attacked with excessive vomiting after eating pigs' feet, and the vomiting continued until her death, five days later. The lesions were chiefly in the upper part of the colon, and consisted of a general non-ulcerative follicular inflamma- tion. ■ The hyperplasia of Peyer's patches was extreme. Fig. 165. ■ t -ft-----..- Hyperplasia of the lymph-follicles. Warren Museum, Harvard University. The following interesting specimens of lesions of colitis occurred in the hospital service of Dr. Northrup, and are now preserved in the Museum of the College of Physicians and Surgeons. New York. Fig. 167 shows an acute catarrhal follicular inflammation without ulceration. The infant, a male, two years old, had a history of diarrhoea and general debility lasting two weeks. While in the hospital he had a continued high temperature, which at one time reached 40° C. (104° F.). The symptoms were mostly of a cerebral type, and the abdominal symptoms were not severe or prominent enough to indicate the marked lesions which were found at the autopsy. The post-mortem examination showed the following conditions : Brain normal. Stomach congested. ' The small in- testine contained a large amount of thick mucus. The solitary follicles were enlarged, rather more in the upper third of the intestine. Peyer's patches were markedly Fig. 166. Non-ulcerative follicular inflammation. Simple hyperplasia of lymph-follicles. Female, 3 years old. Warren Museum, Harvard University. (Page 826.) Fig. 161 Colitis follicularis non-ulcerativa. Male, 2 years old. and Surgeons, New York. Museum of the College of Physicians (Page 826.) Fig. K)8. Colitis follicularis non-ulcerativa. (Page £ Fig. 169. Hyperplasia of lymph-follicles (solitary glands). Muc. Mem., mucous membrane ; Lym. Ts. lymph-tissues; Mus., muscle; Fol., follicles (Page 827.) Fig. 170. 4tt^ft^^^ ■*&& Muc. Mem Muc. Mem., mucous membrane ; Fol., follicles ; Submuc, submucous tissue ; Mus., muscle. (Page S27.) Fig. 171. Ileo-colitis ulcerativa follicularis. Infant. 16 months old. Museum of the College of Physicians and Surgeons, New York. (Page 827.) Fig. 172. Acute ulcerative catarrhal colitis. Female, 3 months old. Museum of the College of Physicians and Surgeons, New York. (Page 827. ) Fig. 173. Inflammation of follicles and surrounding- parts of colon. The process has gone on to necrosis. Female 3 months old. Warren Museum, Harvard University. (Page 827.) Fig. 174. Pigmented follicular ulcers of colon. Chronic catarrhal ulcerative follicular colitis. Museum of the College of Physicians and Surgeons, New York. (Page 828.) Fw. 1 Pseudo-membranous colitis. Child, Z%, years old. Museum of the College of Physicians and Surgeons, New York. (Page 828.) Fig. 176. Pseudo-membranous colitis. Female, 4 years old. Ps. M., pseudo-membrane ; M. M., mucous membrane; Subm., submucosa; Mus., muscle; Per., peritoneum. (Page 828.) Fig. 177. Nee. Muc. Mem., necrotic mucous membrane ; Inf. Muc. Mem., inflamed mucous membrane Mus., muscle ; Submuc, submucosa. (Page 828.) DISEASES OF THE INTESTINE. 827 swollen, and a few solitary follicles appeared to be ulcerated. The mesenteric lymph- glands were enlarged. The mucous membrane of the colon was swollen ; the follicles were enlarged and somewhat pigmented, but not ulcerated. Fig. 168 shows another portion of the colon taken from the same infant. The solitary follicles are very much enlarged, and in Peyer's patches, which are in the middle of the specimen, the hyperplasia is of a very high degree. Figs. 169 and 170 illustrate microscopic sections of this form of follicular inflammation. The former showed the great enlargement of the lymph-follicles ; the latter showed the inflamed condition of the mucous membrane as well as the enlarged lymph-follicles. The next specimen (Fig. 171) was taken from an infant sixteen months old. The infant before entering the hospital had had occasional attacks of diarrhoea for three months, presumably caused by improper feeding. Soon after entering the hos- pital it rapidly grew worse and died. The autopsy, made by Northrup, gave the following results : No tubercular lesions. Bronchial lymph-follicles enlarged. Small intestine showed much swelling and con- gestion of Peyer's patches, but no ulceration. The colon showed extensive follicular ulcerations. In the small intestine and the colon were found masses of strings of greenish mucus ; no blood. The next specimen (Fig. 172) was taken from a female infant, three months old. The infant on entering the hospital was somewhat rhachitic, emaciated, and fretful. There were no vomiting and no fever. It took very little nourishment, and at this time was having one large, watery, faecal discharge daily. The faecal movements were greenish yellow. The infant apparently improved for about a week. The temperature was then found to have risen, and during the next week it varied from 36.6° to 37.7° C. (98° to 100° F.). During the next week the temperature was sometimes subnormal. At the end of three weeks the infant began to fail rapidly without any discoverable cause, and died suddenly. The autopsy was made by Northrup, and showed the following lesions : the mucous membrane of the ileum was swollen, and the lymph-follicles were enlarged, but not ulcerated. The report of the examination of the colon was as follows : numerous ulcers, some round and some irregular in shape ; an increased production of mucus ; a profuse growth of connective tissue between the tubules, witn disappearance of the tubules ; necrosis of the new tissue so as to form ulcers ; the solitary follicles swollen. but not concerned in the formation of ulcers, which were simply necrotic. No amoebae found. The process was one which would ordinarily come under the head of acute catarrhal colitis. The next specimen (Fig. 1 73)- was taken from an infant three months old, in the hospital under the care of Dr. Holt. The child had no acute symptoms, but had never been well, and for some time had been losing in weight and strength. It entered the hospital for vomiting and 828 PEDIATRICS. diarrhoea. Nothing was found on physical examination. While in the hospital it had from six to eight loose greenish discharges in the twenty-four hours, and vomited occasionally. Its temperature varied from 37.2° to 38.3° C. (99° to 101° F.). It gradually failed, and died twelve days after entrance. The post-mortem examination showed extensive follicular ulcerations of the colon, especially in the lower part of the specimen, where there was a large ulcer. The tissues around the follicles are also involved, and the process had gone on to necrosis. The next specimen (Fig. 174) was taken from a male infant six months old. The infant entered the hospital in a very wasted condition, and died in a few days without any special abdominal symptoms. The autopsy, made by Northrup, showe'd numerous superficial abscesses on the body, a general bronchitis, and a beginning broncho-pneumonia. The lesions in the intestine were an inflammation of the solitary follicles of the ileum and of the colon, with small ulcerations at the apices of the follicles in the colon, no ulcers being present in the ileum. In the specimen the ulcers were pigmented, which denoted a chronic condition. The apices of the follicles are sometimes found pigmented as the result of post-mortem changes, and may simulate these ulcerations. The next specimen (Fig. 175) was one of pseudo-membranous colitis. This child, three and a half years old. a patient of Xorthrup's, entered the hos- pital in a very reduced condition following an attack of whooping-cough. It was attacked with diphtheria, and during the ten days that it was suffering from this disease there was a slight amount of diarrhoea, but no pain and no tenesmus. The autopsy showed a pseudo-membranous inflammation through the whole length of the colon, most marked in the lower third. The other organs were normal. The microscopic examination of the colon confirmed the diagnosis of pseudo-membra- nous colitis. Fig. 176 shows a microscopic section of another case of pseudo-mem- branous colitis. A girl, four years old, had always been delicate. She had pneumonia twice in her fourth year. Eight days before her death she was attacked with vomiting and diarrhoea. There was blood in the faecal discharges. The pulse was rapid. The loss of strength and the pallor were marked. The eyes were sunken, and the tongue was dry. On the last day of her life she became very feeble, and died in convulsions. Early in the dis- ease the discharges were frequent. Later, they were from four to six daily, and were accompanied by tenesmus and tenderness of the abdomen. The autopsy showed that the mesenteric lymph-follicles were not much enlarged ; the follicles in the colon were slightly enlarged. The whole intestine was injected in patches, and contained faecal masses of a yellowish color. The large intestine was filled with large quantities of faeces of foul odor and colored by bismuth. The whole surface was rough, and did not look like a mucous membrane, but rather as though a thin layer of gelatin had been poured over it. This film could be pulled away with the forceps. The solitary follicles were enlarged. The microscopic section of this specimen showed a marked fibrino-purulent exudation, forming a membrane which characterized the disease as pseudo-membranous colitis. In connection with the pseudo-membranous condition shown in Fig. 175. another specimen (Fig. 177) is of interest. DISEASES OF THE INTESTINE. 829 This specimen was taken from a child, three and a half years old, who first had whooping-cough and was then attacked with diphtheria. During the course of the dis- ease the temperature was raised continuously, at times being as high as 40° C. (104° F.). During this attack it had diarrhoea with blood in the discharges, but no pain or tenesmus and no other symptoms of colitis. The autopsy showed a broncho-pneumonia, and a normal condition of the stomach and small intestine. The colon showed an apparent exudation, which simulated that of a pseudo-membranous colitis so closely that before the microscopic examination was made it was supposed to be identical with the pathological lesions found in the case of pseudo-membranous colitis (Fig. 175). The surface appearance in the fresh specimen was identical. Under the microscope, however, the lesion proved to be only a super- ficial necrosis of the mucosa, with swelling of the lymph-follicles. This case should impress upon us how important it is not to rely upon the macro- scopic appearances of intestinal lesions without the corroboration of a microscopic examination. ANIMAL PARASITES. The animal parasites which are found in the intestines of infants and children are the same as those which occur in older patients. The only ones, however, which are common and important enough to speak of are the oxyuris vermicularis (pin-worm), the ascaris lumbricoides (round-worm), the tcenia solium, and the tcenia mediocanellata (tapeworms). Oxyuris Vermicularis. — The oxyuris vermicularis is a minute worm, which looks like a little piece of white thread. The female is from 0.6 to 1.2 cm. (I to J inch) in length. The male is about one-third as large, and has the tail rolled into a spiral. Their development takes place in the large intestine, and the mature worms deposit their eggs in the rec- tum. They enter the intestine through the mouth, and children are very apt to reinfect themselves by carrying the eggs on the fingers or under the nails to their mouths. These worms sometimes exist in large numbers, and their development is so rapid that it is often difficult to dislodge them completely. The most common symptom of the oxyuris is an intense itching about the anus. The sleep of the child is disturbed by this irritation, and various nervous symptoms develop in children who are infested with this para- site. Thus incontinence of urine sometimes results. In girls the parasite, by migrating from the anus to the vulva, may cause a vulvo-vaginitis. Diagnosis. — The diagnosis of the presence of these, as of other intes- tinal parasites, can be made, only by finding the worm or its ova in the intestinal discharges. When they are suspected, an enema of clear water should be given. If the parasites are present, they will be dislodged. and careful inspection will disclose their presence. Whenever there are symptoms of reflex irritation in the neighborhood of the anus or the genital organs, the oxyuris should be suspected and sought for. The parasites can often be found in the faecal discharges, and in some cases they can be seen by simply stretching open the anus and examining the mucous membrane of the rectum. g30 PEDIATRICS. Treatment. — Although most of the worms are in the rectum, yet they also infest the upper parts of the intestine, and therefore cannot be reached by enemata. In many cases enemata of salt-and- water are sufficient to produce a cure, but in some cases the salt, even in small amount, is so Fig. 1 Oxyuris vermicularis. Ascaris lurnbricoides. irritating that it cannot be used. Infusions of quassia may also be em- ployed as enemata. One of the most effective methods of dislodging the parasite is to give every evening at bedtime an injection of 60 c.c. (2 ounces) of sweet oil. This is allowed to remain in the rectum for five or six minutes, and a large enema of water is then used to wash out the oil, which usually carries with it the parasites from the lower colon and the rectum. Care must be taken in regard to cleanliness, so as to prevent reinfection. When this treatment is not sufficient, lozenges of santonin, 0.01 to 0.03 gramme (J to I grain), according to the age, may be given two or three times daily. Every two or three days a cathartic, such as castor oil or calomel, should be given. Care must be used in giving santonin not to produce DISEASES OF THE INTESTINE. 831 symptoms of poisoning, such as gastro-enteric irritation, dizziness, and yellow vision. This occurrence, however, will not be common if in each case the effect of the drug on the child is carefully watched. Serious symptoms, such as convulsions, have been caused by a lack of care in using this drug in young children. Under this treatment, aided by high rectal injections, the worms can in most instances be eradicated. I have, however, met with very intrac- table cases in which months and even years had elapsed before treatment of any kind was successful. In such cases temporary relief can be obtained by giving the child each night, or two or three times a week, a small . enema of oil. Ascaris Lumbricoides. — The ascaris lumbricoides is a long, cylin- drical, yellowish-white or reddish-yellow worm, pointed at both extremi- ties. The male is distinguished from the female by the fact that it is smaller and is always rolled upon itself, while the female is straight. The length of the male is from 10.4 to 18 cm. (-1 to 7 inches), and that of the female from 15.5 to 28.5 cm. (6 to 11 inches). The eggs of this worm are oval in shape, 0.075 mm. long and 0.058 mm. wide. When they are first passed they are almost transparent, but they soon become yellowish and opaque. These eggs are not developed within the intestine, but may pass out with the faeces. They are very tenacious of life, and may develop under favorable circumstances after many years. The embryos are de- veloped outside of the body, and reach the intestine with the drinking- water, where they develop into the mature worm. The habitat of the worm is usually in the small intestine. It may, however, pass through the rectum either with the faeces or alone, and may migrate into the stomach, oesophagus, or nose. Sudden death has resulted from the entrance of these worms into the air-passages. They may also at times enter the common and cystic bile-ducts, and they have even penetrated farther and caused abscess of the liver. There is no danger of their perforating a normal intestine, but when ulceration has been present perforation has occurred. Symptoms. — There are no especial symptoms produced by this worm, and we can diagnosticate its presence only by seeing it or by finding the eggs in the faecal discharges. The worm may in some instances produce a feeling of discomfort or even colic in the region of the umbilicus. Neither of these symptoms, however, can be depended upon, and an anthelmintic is required to determine whether the parasite is present. In certain cases convulsions in children have been followed by the passage of a lumbricoid worm. This, however, cannot be accepted as conclusive evidence that the convulsion was dependent upon the worm, as I have met with instances in which large numbers of these worms were found at the autopsy in children who during life showed no nervous symptoms whatever. As a rule, the presence of these parasites in the intestine, unless in very large numbers, is not especially important. 832 PEDIATRICS. Treatment. — The most efficacious treatment of this form of parasite is in the form of santonin, which should be given in the same doses and with the same caution as I have already described in speaking of the treatment of the oxyuris. Instead of santonin, the freshly prepared fluid extract of spigelia and senna in doses of 1.87 c.c. (J drachm) for a child two years old, and 3.75 c.c. (1 drachm) for older children, can be given two or three times a day, care being taken not to produce too much irri- tation. The oil of chenopodium, 0.012 to 0.018 c.c. (2 to 3 minims), on sugar, for a child two or three years old, and 0.50 to 0.60 c.c. (8 or 10 minims) for older children, can also be given. A cathartic should be used in connection with these drugs, as well as with santonin. Taeniae (tapeworms). — Two forms of taenia occur in children. One of these is the tcenia solium, the pork tapeworm. It has a slight projec- tion at the apex of its head, around which are a series of hooks, and below which are four sucking-disks. The other form is the tcenia mediocanettata, the beef tapeworm. It has a blunter hook than the taenia solium, and does not have the circle of hooks. These worms vary in length from 605 to 1512.5 cm. (20 to 50 feet). There is nothing especial to be said con- cerning these worms, and I refer to them merely because at times they occur in early life. They are never met with in nursing children when breast-milk forms the exclusive diet. There is reason to suppose that raw-beef juice may carry the eggs of the taenia. There are no especial symptoms produced by this worm, and the diagnosis is made entirely by finding the segments in the faeces. There is no especial clanger from the presence of the tapeworm. Treatment. — The treatment employed for expelling this worm is the same in children as in adults, but we should be very careful not to irritate too much the sensitive gastro-enteric mucous membrane of the young child. The child should first be treated with laxatives, so as to free the intestine. Food should be withheld from the early evening until as late as possible the next day. An anthelmintic should then be given, followed in one or two hours by a cathartic. This usually results in the expulsion of a large mass of segments. Great care should be taken to prevent the head from breaking off before it is expelled. If the head remains, the worm grows again and the treatment has been useless. The anus should be carefully dilated during the expulsion of the worm. Sitting on a vessel of hot water seems to help to prevent the head from breaking off. There is no anthelmintic which I have found especially successful in expelling the taeniae. One of the most harmless is the alkaloid pelletierine from pomegranate. The tannate of pelletierine can be given to a child from three to five years old in the dose of from 0.01 to 0.03 gramme (i to | grain). As dizziness and headache are sometimes complained of, it is well to have the child kept in bed and lying down until the effect of the anthelmintic has passed off. The oleoresin of male fern may also be used. The dose is 0.94 to 1.88 gramme (J to J drachm). The cathartic DISEASES OF THE INTESTINE. 833 which is most useful in these cases is Epsom salt, 7.5 to 15 grammes (2 to 4 drachms). It is hardly worth while to mention the other numerous anthelmintics which have been recommended, as they are usually inefficient. Pig. 179. Taenia. I., without head ; II., with head. If the head of the worm is not obtained and if a considerable portion of the segments is discharged as a result of the treatment, it is desirable to wait a few months before making a second attempt to dispel the para- site. The reappearance of segments in the stools indicates that the growth of the worm is sufficient to justify another attempt to dislodge it. DIVISION XIII. DISEASES OF THE LIVER, PANCREAS, SPLEEN, AND PERITONEUM. DISEASES OF THE LIVER. The size of the liver is in infancy very large relatively, and in early childhood somewhat larger than at a later period of life. This is of importance in making a diagnosis as to the increase or decrease of the normal hepatic area. These changes, although varying so much at dif- ferent ages from infancy to puberty, yet in the intermediate extremes of size show such slight differences that nothing definite can be stated in regard to them. In early life, however, we may say that the edge of the liver may be felt about 1.5 to 2 cm. (J to } inch) below the edge of the ribs in front, and that the hepatic dulness extends up to the fifth inter- space or rib in front, to the seventh interspace in the axillary line, and to the ninth space or rib behind. The left lobe of the liver is relatively larger in the child than in the adult. (Steffen.) In determining, however, whether or not the liver is of abnormal size we must consider that a downward displacement of a normal liver may take place from relaxation of the ligaments and of the abdominal walls in cases of wasting disease, also from pressure, as from a pleuritic effusion or from thoracic deformity as in rhachitis. Upward dis- placement also may take place from ascites and other causes of abdominal distention. Diseases of the liver are not common in infancy and childhood, as the inciting causes of hepatic disease are usually not present in early life. When hepatic disease is present, it is commonly secondary to some gen- eral disease. Congenital malpositions and malformations of the liver may occur, but those of especial clinical interest are chiefly connected with the bile-ducts, and have been described on page 308. The acquired pathological lesions which occur in the liver in infancy and childhood do not differ from those which are met with in later life. A rapid increase and decrease in the size of the liver are not infrequently met with in disease, and careful measurements have shown that even a 834 DISEASES OF THE LIVER. 835 very slight disturbance of health may cause in young children a variation of from 2 to 4 cm. (f to .1} inches) in the size of the liver. In most diseases which are accompanied by hepatic disturbance, it is much more common to have the liver enlarged than diminished in size. ICTERUS. Icterus is a symptom of a number of diseases, as well as of disease of the liver, but it so commonly occurs when the liver is either directly or indirectly affected that it is best spoken of in connection with hepatic disease. The icterus which arises at birth, either of the temporary form, such as icterus neonatorum, or from obliteration of the bile-ducts, has already been described on page 308, but it may be added to what was said regarding the former that there is some reason to suppose that it may be caused by the ductus venosus remaining patent at birth. Icterus as a symptom of acute and chronic duodenal indigestion has been described on page 799. It must not be assumed that there is necessarily hepatic dis- ease because icterus is present, as any slight mechanical disturbance in the liver produced by diseased conditions elsewhere may cause icterus. In these cases, even though the liver may be somewhat enlarged, it is not a symptom of much import, and the liver is soon restored to its normal condition, provided that the original disease has disappeared or has ceased to produce hepatic disturbance. In addition to this obstructive class of cases, icterus may also occur as a symptom in septic inflammation of the umbilical vein. In these cases the liver is apt to be enlarged and tender. Convulsions commonly occur. Vomiting, diarrhoea, abdominal swelling, pain, and tenderness are present. The temperature is high. The respirations are increased, and death usually occurs from exhaustion or from septic inflammation of the pleura, pericardium, or other parts. ACUTE YELLOW ATROPHY OF THE LIVER. It is uncommon for the liver to be decreased in size, but this occurs in the very rare cases of acute yellow atrophy at times met with in children. The disease is insidious in its onset, and is characterized by general symp- toms of malaise, with icterus and urine containing bile. In the beginning of the disease the liver is enlarged, but in the later stages it is decidedly diminished. Cerebral symptoms and vomiting are quite prominent, and death invariably occurs. CONGESTION OF THE LIVER. Although an acute congestion of the liver may occur, as from certain poisons and in the course of malaria, yet by far the most common form is the subacute or chronic condition which results from stasis in the venous system, produced by cardiac disease and certain pulmonary conditions which interfere with the circulation. There are no especial hepatic symptoms beyond enlargement o( the g36 PEDIATRICS. organ, and the treatment is that of the primary disease. This enlargement may occur from a number of causes, among which is mechanical congestion, arising in the course of cardiac disease. PATTY INFILTRATION OF THE LIVER. Fatty liver in early life is quite common, especially in infants, and does not differ pathologically from that which is met with at a later period. The liver may or may not be enlarged, and there are no especial hepatic- symptoms, such as icterus or ascites, which characterize this condition, the symptoms being those of the general disease from which the child is suf- fering. It may be found associated with a number of diseases, especially rhachitis, tuberculosis, and wasting diseases, especially with those which are associated with disturbances of digestion. When the liver is enlarged from this cause its surface is found to be smooth and there is no pain nor tenderness on palpation. The prognosis, unless the disease is dependent upon some incurable disease elsewhere, is fairly good. The treatment is essentially dietetic, hygienic, and that of the original disease. SUPPURATIVE HEP ATTCTS.— ABSCESS OF THE LIVER. Abscess of the liver is an exceedingly rare condition in both infants and children. Even when septic infection of the umbilical vessels has taken place at birth, it has been found that only in a very small propor- tion of these cases has hepatic abscess resulted. Etiology. — According to Mussers analysis of thirty-four reported cases, the average age was nine years, and the youngest one year. The causes in these cases were from traumatism, from round-worms entering the bile-ducts, from pylephlebitis in four cases, from umbilical phlebitis once, from pyaemia twice, and once each from pelvic peritonitis, dysentery, perityphlitis, malaria, and tuberculosis of the lungs. Musser therefore con- cludes that the general conditions, such as climate and habits of life, which are marked etiological factors in adults, are not of significance in children. Symptoms. — The onset, the progress, and the duration of the disease depend greatly on the primary cause. Icterus may occur, but usually is not marked, and is not of much significance. The local symptoms con- nected with the liver are the same as in adult life, and are chiefly pain, not always, however, in the hepatic region, but in different parts of the abdomen, enlargement of the liver, usually downward, and tenderness over the liver. If in addition to these symptoms a tumor is detected apparently connected with the liver, and accompanied by fever of a hectic, pyaemic, or intermittent type, with sometimes an initial chill or with irregular daily chills, abscess of the liver is to be strongly suspected. Leucocytosis is present. The symptoms are at times, however, very latent, and the diagnosis can only be determined by aspiration. DISEASES OF THE LIVER. 837 The duration of the disease is apt to be prolonged, and the child gradually emaciates and fails in strength. The prognosis varies greatly, as there are so many conditions as to the especial- cause and the especial locality of the abscess which must be taken into account and which render the chances of recovery more or less un- certain. Treatment. — The treatment is essentially surgical. Musser reports twelve recoveries out of the thirty-four cases, and in eleven of these aspiration or incision or both were employed. HYDATIDS.— BILIARY CALCULI.— NEW GROWTHS. Echinococcus cysts and biliary calculi are so rare in early life that they need merely be mentioned as of possible occurrence. Carcinoma, ade- noma, and sarcoma of the liver have in rare instances been met with in early life. Tuberculosis of the liver has been described on page 431. AMYLOID LIVER. When amyloid changes are present in the liver, other organs, such as the spleen, kidneys, and intestine, are involved. Amyloid infiltration may occur in the course of tuberculosis when there is chronic disease of the bones with extensive suppuration, in wasting diseases, and in hereditary syphilis. A very prominent symptom in this condition is an extreme degree of secondary anaemia. The liver is, as a rule, very much enlarged, and commonly more so than in any of the other hepatic disturbances. Its surface is smooth, and there is rarely hepatic tenderness or pain. Ascites is rare, and there is usually no icterus. The progress of the disease is slow. The diagnosis is not difficult if we find that the child has one of the diseases which have just been mentioned as being the causes of amyloid changes. The skin has a waxy appearance. The spleen is enlarged, and there may be albuminuria and dropsy, either from an associated amyloid condition of the kidney or from the pressure produced by the enlarged liver. When these changes occur in the liver the prognosis is very grave, and there is no treatment which will be of more than temporary benefit. The treatment, therefore, is removal, if possible, of the cause, such as a diseased joint. If the disease is the result of syphilis, anti-syphilitic remedies should be employed. Fig. 180 represents a boy seven and three-quarter years old. There was no his- tory of tuberculosis in his family. He had pertussis when he was one and a quarter years old, and measles when he was three years old. He seemed well and strong until he was about seven years old, when he became listless and began to have fever and to perspire profusely. Later he began to vomit occasionally, to complain of headache, and to cough. Although he evidently lost in weight he was not especially emaciated. His entire skin was extremely pale and had a waxy look, which was apparently not 838 PEDIATRICS. due to jaundice. His mucous membranes showed much anaemia. His tongue was heavily coated, and his breath was offensive. He was dull and apathetic. The cer- vical glands were enlarged and slightly tender, but did not fluctuate. The glands were moderately enlarged in the axillae and groins. The percussion of the right lung, espe- cially at the apex, was dull, and there were numerous rales. The area of cardiac dul- ness was not enlarged, but there was a slight systolic murmur at the apex. The spleen Fig. 180 t V 1 Amyloid liver. Pulmonary tuberculosis. Male, 7% years old. was slightly enlarged. The edge of the liver could be felt below the line of the um- bilicus. The area of hepatic dulness was increased, as is represented by the broken line in the figure. There was no hepatic tenderness, and the child did not complain of pain. The lower part of the abdomen was dull on percussion as high as the line which is drawn under the umbilicus. This was due to a slight amount of ascites. The legs were swollen. The urine had a specific gravity of 1010, and contained a slight trace of albumin, an occasional hyaline cast, and renal epithelium. The temperature had varied from 37.2° to 39.4° and 40.5° C. (99° to 103° and 105° F.). The increased size of the liver was probably due to amyloid infiltration, following what was supposed to be pulmonary tuberculosis. A few days later the child grew rapidly weaker, and died of exhaustion. An autopsy was not obtained. INTERSTITIAL HEPATITIS.— CIRRHOSIS. Interstitial hepatitis may be a lesion of a number of systemic diseases, especially of syphilis, but also of tuberculosis. The disease, however, may apparently occur without disease of any other organ. In infants cirrhosis of the liver is almost invariably of syphilitic origin. A certain number of cases seem to have followed scarlet fever and measles. Alcohol is sometimes an etiological factor in infancy and early childhood. When the disease is caused by alcohol the pathological condi- tion is, as a rule, atrophy. Interstitial hepatitis as it occurs in childhood may be atrophic or hyper- trophic. The general symptomatology differs but little from that of the DISEASES OF THE LIVER. 839 adult. In the beginning the symptoms are very apt to be confounded with those of simple congestion arising from digestive disturbances. There may be abdominal pain, slightly augmented by pressure. Diarrhoea and constipation alternate. There are usually ascites and slight jaundice, and at times dilatation of the subcutaneous abdominal veins. Stigmata com- posed of collections of dilated minute \ T eins are sometimes observed on the face. The temperature is irregular. As a rule, it is not much height- ened, and. in fact, is often subnormal. Enlargement is not common, and the symptoms are the same as in the adult, the ascites being especially prominent. Prognosis. — The prognosis in this class of cases is bad, as the progress of the disease is usually rather rapid. When the hepatitis is not dependent on disease elsewhere, and is not due to alcohol, there are no characteristic symptoms beyond the enlarge- ment of the liver. In this form the ascites is usually small in amount, and the diagnosis can be made only by eliminating the other forms of enlarge- ment. It is commonly spoken of as hypertrophic cirrhosis. Its prognosis is more favorable than that of the cirrhosis just described. Its treatment is symptomatic. Pig. 181. jf* 8 ****^- ^1 Hypertrophic cirrhosis. Female, IS months old. Fig. 181 represents a girl eighteen months old. There was no history of syphilis or of tuberculosis. She had pertussis when she was ten mouths old. and the couch lasted for several months. She had never been given alcohol in any form. She was well until she was fifteen months old, when she began to complain of pain in the 840 PEDIATRICS. abdomen and to become pale. Before entering the hospital she had diarrhoea, and her abdomen was swollen. On entering the hospital and being placed on a proper diet, the diarrhoea ceased, but the swelling of the abdomen increased. She was not especially thin, but was pale. The abdomen was much enlarged. The edge of the liver could be felt nearly as low as the line of the umbilicus. The area of dulness on percussion is marked by black lines. The lower one shows the notch between the right and the left lobe, which was distinct and easily palpable. There was no especial tenderness on pressure. The spleen was slightly enlarged. In the lower part of the abdomen there was a moderate amount of dulness and fluctuation, showing the pres- ence of fluid. There were no glandular swellings. The heart was normal, but was pushed up somewhat by the abdominal distention. The child improved in its general- health while in the hospital, and had a fair appe- tite. Physical examination showed the presence of no other disease. Without an autopsy, however, the diagnosis was necessarily held in abeyance. The child remained in the hospital for a few weeks, and improved in its general health so that it seemed quite bright. The ascites did not increase in amount, but the liver remained enlarged. The child was eventually taken away from the hospital, and its subsequent history could not be obtained. DISEASES OF THE PANCREAS. Diseases of the pancreas are practically unknown in infancy and child- hood, with the exception of the general tissue-changes which may be met with in syphilis, and which have already been described. New growths of a malignant nature have been reported. DISEASES OF THE SPLEEN. The spleen may be involved in tuberculosis, and may show amyloid changes in connection with other organs. It is frequently enlarged in the course of a number of diseases which have been described elsewhere, but there are no primary diseases of the spleen. DISEASES OF THE PERITONEUM, Diseases of the peritoneum may be of non-inflammatory or inflamma- tory origin. The non-inflammatory diseases are mostly represented by new growths. These may be of a malignant nature, such as carcinoma and sarcoma, or they may be lipomata or of a cystic character. Tumors of the omentum are rare, but cysts and hydatids may occur in this region. The differen- tial diagnosis of these various forms of peritoneal and omental growths can scarcely be made during life. The treatment is essentially surgical. The inflammatory diseases of the peritoneum are represented by peri- tonitis. ACUTE PERITONITIS. Etiology. — Acute inflammation of the peritoneum may be primary or secondary. It is a condition of great importance in infancy and early life. Infants and children of any age may be attacked. The disease may DISEASES OF THE PERITONEUM. 841 occur in the course of tuberculosis, of the infectious diseases, of syphilis, and. most frequently of all, of appendicitis. The disease in any of the above forms is exceedingly rare between the ages of six weeks and two years. A large variety of micro-organisms are found in connection with acute peritonitis. The colon bacillus is the most frequent cause. Streptococci, staphylococci, and pneumococci are sometimes found either alone or in mixed cultures. In the rare instances of perforation of typhoid ulcers typhoid bacilli may be cultivated from the abdominal fluid in conjunction with the colon bacillus and other intestinal micro-organisms. Tubercular peritonitis has been described on page 401. Perforation of some viscus into the peritoneal cavity is the underlying cause of many cases of peritonitis. Such an accident may occur from intestinal ulcers, from abscesses and cysts of the liver, gall-bladder, spleen, kidney, lymph-glands, and appendix, and from strangulated hernias and intussusceptions. Peritonitis may also be set up by extension from neighboring inflamma- tory processes, even when no direct communication has been made with the peritoneal cavity by means of perforation. Traumatic peritonitis may develop from blows, punctured wounds, and septic infection from surgical operations. Pathology. — The pathological lesions in acute peritonitis are repre- sented by reddening and loss of the normal glistening appearance of the peritoneum, soon followed by an exudation varying from a thin serum with a small number of white and red blood-corpuscles to a thick, fibrino- purulent exudate. The character of the pathological processes have been more fully described under the various forms of appendicitis with peritonitis on page 815. In the peritonitis of the new-born the charac- teristic lesions are apt to be in the umbilical region, and are not infre- quently associated with lesions of a general septicaemia. Symptoms. — The symptoms of acute peritonitis vary according as the process is general or localized. The localized form of peritonitis corre- sponds in its symptoms to what has already been described in speaking of appendicitis, which is its most frequent cause. In general peritonitis the symptoms in infants are often obscure. In children the symptoms are usually pronounced and characteristic. The child is attacked with abdominal pain and with general abdominal tenderness. The abdomen becomes distended and tympanitic, and the child assumes the position which will most relax the abdominal walls, — that is, with the thighs flexed and the knees bent. Vomiting is very apt to be present, and is augmented when food is given. The bowels are often constipated, although at times there may be diarrhoea. The temperature is usually high, 38.3° to 40.5° C. (101° to 105° F.) ; in some cases, however, the temperature may be normal or subnormal. The pulse is small and rapid. The respirations are not only accelerated, but also superficial, as deep respiration causes 842 PEDIATRICS. pain. The face has an anxious expression, and shows great suffering. When recovery takes place, these symptoms gradually subside after a few days, the tenderness, pain, and tympanites disappear, and the child's face assumes a tranquil look. When improvement does not take place, the pulse becomes weaker and more rapid, the breathing more superficial and more frequent, there is chilling of the extremities, and the child dies usually within a week. Leucocytosis is generally marked unless the severity of the infection is so great as to render a reaction impossible. Peritonitis of the New-Born. — This form generally appears within the first two or three days of life, rarely later than the first week. The onset is sudden, with vomiting, diarrhoea, pain, distention of the abdomen, and tenderness. The temperature is very high, 40° C. to 41° C. (104° F. to 106° F.). In a case reported by Quinquand it reached 42.5° C. (108.5° F.). Emaciation is rapid and the cachexia is extreme. Hydrocele, gen- erally of the right side, with oedema of the scrotum, frequently develops. Septicaemia and pyaemia may occur as complications. Death takes place in four or five clays. Acute Pneumococcus Peritonitis. — Peritonitis may be due to a primary idiopathic infection by the pneumococcus. or to a secondary in- fection from the same organism in connection with pneumonia, pleurisy, or meningitis. Netter has reported a case of pneumococcus meningitis with pneumococcus peritonitis in an infant three or four days old. Accord- ing to Comby, primary pneumococcus peritonitis is more frequent in chil- dren than in adults, and is most common between the ages of three and twelve years. In Brim's series of cases it was nearly four times more frequent in girls than in boys. Dieulafoy describes pneumococcus peritonitis as a special clinical form, which can sometimes be diagnosticated by the character of the symptoms. Symptoms. — The onset is sudden, with intense abdominal pain, diar- rhoea, and faecal vomiting. The temperature rises to 39° to 40° C. (102.2° to 104° F.), and there may be delirium. A remission of some of these symptoms then ensues, the pain subsides, diarrhoea and distention per- sist, and the picture is more like that of typhoid fever. At the end of about eight days the temperature falls, sometimes as abruptly as in pneumococcus pneumonia. The disease then passes into another stage, which resembles tubercular peritonitis. There is emaciation, cachexia, pinched features, sunken eyes, and a large and tender abdomen, usually with signs of fluid. The fluid, which is purulent, is not very movable, but shows a strong tendency to become encysted. The process may go on for several weeks and finally end in spontaneous evacuation of the pus. While recovery may take place by natural means, the danger of secondary infection and death from exhaustion is so great that early surgical inter- ference is indicated, as under favorable conditions a good proportion of the operative cases recover. DISEASES OF THE PERITONEUM. 843 Prognosis. — The prognosis in acute peritonitis is always grave. It de- pends largely upon the virulence of the exciting cause, upon an early diagnosis, and upon prompt and skilful surgical treatment. Treatment. — The treatment is essentially the same as has been de- scribed under appendicitis with peritonitis on page 819. The following case illustrates acute peritonitis : An infant, nineteen months old, previously apparently healthy, was attacked with vomiting and diarrhoea. On the following day the face was pale, the alae nasi were working slightly, the respirations were 36, and the temperature was 39.4° C. (103° F.). The respirations gradually increased to 74, and the temperature rose to 40.3° C. (104.6° F.). The abdomen became very much distended and tender, and the face pinched and anxious. On the evening of the second day from the onset of the disease the temperature rose to 41.1° C. (106° F.), the infant became very restless, the pupils were contracted, and death took place a few hours later. The autopsy showed that the heart and lungs were normal. The spleen was en- larged, and was covered with a fibrinous exudation. The kidneys were pale, and normal in size. The liver was covered with flakes of lymph of recent formation, and on sec- tion showed the acini to be red and their periphery yellowish and opaque. The mes- enteric lymph-nodes were slightly enlarged, and the smaller ones were translucent on section and presented evidence of hyperplasia. A small pocket of the larger nodes was found to have become cheesy in the central portions, and in two of these the pro- cess had extended through the substance of the gland and had broken through its peri- toneal covering. About these points of rupture there was a small zone of reactive inflammation. The pathological diagnosis was acute general peritonitis, which, from an absence of any other source, must be considered to have been caused by the rupture of the cheesy, degenerated mesenteric nodes. In this case the high temperature and the distended abdomen rendered the diag- nosis comparatively clear. The case is important on account of the cause, for there is seldom any noticeable enlargement of the mesenteric nodes under the age of three years, and these nodes seldom soften, but either retrograde or harden from calcification. CHRONIC PERITONITIS. By far the most common cause for chronic peritonitis with ascites is tuberculosis, which has been described on page 401. When an acute peritonitis is localized, the inflammatory process may subside, the fibrino-purulent exudation may become organized, and the result be fibrous adhesions binding the coils of the intestine closely to- gether and to the abdominal wall. A form known as congenital peritonitis occurs, but is of pathological rather than of clinical interest. In this form the fibrous adhesions are found in infants who have died within a few hours after birth. It is con- sidered a peritonitis of intra-uterine development, possibly through the placenta from an intra-uterine peritonitis in the mother. DIVISION XIV. DISEASES OF THE KIDNEYS, BLADDER, AND GENITAL ORGANS. DISEASES OF THE KIDNEYS. Diseases of the kidneys may be congenital or acquired. CONGENITAL DISEASES. The congenital abnormalities, such as congenital cystic kidney, absence of one kidney, hypertrophy of the remaining kidney when one is absent, anomalous shapes of the kidney, and malpositions of the ureters, are important, but are of surgical rather than of medical interest. The lobu- lated kidney, already described as a normal condition in intra-uterine life, may to a greater or less degree continue into infancy and childhood, but has no pathological significance. Movable kidneys are rare in early life, but have been reported. ACQUIRED DISEASES. Renal disease as a primary affection in infancy and childhood has been considered rare, but this view has been modified by later investi- gations, which have shown that nephritis is not uncommon in cases of general infection. Secondary renal lesions are comparatively common. The systematic examination of the urine in children in connection with the different pathological lesions of the kidney has not yet been made to such an extent that we can invariably, differentiate the especial type of lesion by the character of the urine. Clinically, the diseases of the kidney, as differentiated by the urinary examination in infancy and early childhood, are less varied than in adults. They are represented chiefly by active hyperemia and the mild and severe forms of acute nephritis following scarlet fever especially and other of the acute infectious diseases. General Etiology and Pathology. — According to Councilman, to whom I am indebted for much information on this subject, the acquired diseases of the kidney in childhood show considerable differences from the renal diseases of the adult. In childhood there is a greater liability to those acute affections, such as scarlet fever, measles, and diphtheria, in the 844 DISEASES OF THE KIDNEYS. 845 course of which nephritis is apt to appear. Children under the age of fifteen years are less subject to many pathological conditions, such as disorders of the circulation, which in the adult frequently lead to chronic lesions of the kidney. Children do not usually have those disorders of the circulation which result in granular kidney, for lesions of the arteries, especially the condition known as arterio-sclerosis, do not commonly occur in childhood. While it is true that typical examples of the small granular kidney are sometimes met with in children, these lesions of the kidney are primary, and the lesions of the circulatory system are secondary and dependent on the renal lesions. A part of the chronic diseases of the kidney in the adult is without doubt to be referred to the continuous action on the kidney of slight pathological conditions, an action from which the child's age protects it. One pathological lesion not perfectly recovered from, moreover, makes the kidney more prone to disease, and a greater effect will be produced a second time by the same cause, and chronic disease may result. In the kidney of the adult, with the advance of years there is a gradual decline in the power of regen- eration, and slight troubles are not readily recovered from. The kidney of the child, on the other hand, is an organ which possesses great power of growth and regeneration. For this reason a condition which in the adult organ is either not recovered from at all, or lays the foundation for chronic disease, may in childhood result in complete recovery. Again, the child is not exposed to certain conditions which are productive of chronic lesions, or which may lay the foundation for them. Among these may be mentioned alcoholism and excesses of various sorts. Many cases of nephritis in the adult are to be referred to causes acting not through the blood, but through the urinary tract. The child, on the other hand, is not exposed to the dangers arising from hydronephrosis and pyelonephritis, except to a very limited degree. Although the causes of renal disease are less numerous and less common in children than in adults, yet when the same etiological factor is present the same morbid condition is pro- duced in the kidney. The various cachectic conditions will lead to amy- loid infiltration in the child as they do in the adult, and amyloid in- filtration of the kidney makes up by far the larger part of the chronic cases of albuminuria in children. We may also meet with certain chronic lesions in the child 1 s kidney, such as are seen in tuberculosis, and these may lead to albuminuria and to nephritis. The acute diseases of the kidney may either lead to recovery or may of themselves prove fatal. They are not to be referred to the contin- uous action of the poison of the acute disease, but to the effect on the kidney of the lesions produced by the inflammatory process. An example of this is the condition of chronic nephritis after scarlet fever, in which the acute lesions gradually pass into the chronic. These chronic lesions are to be attributed to the disorders in the circulation of the organ brought about by the destruction of the glomeruli. 846 PEDIATRICS. General Symptomatology. — The general symptoms connected with the various forms of nephritis are so similar that it will be less confusing to mention first the common symptoms which may occur in any of the forms of nephritis, and then to describe the etiology, pathology, and urinary examination of the different forms. One of the most common signs in nephritis is oedema, which occurs frequently in acute nephritis and in chronic parenchymatous nephritis. The oedema generally appears first in the eyelids, and then in the hands and feet. There may be general anasarca. Not infrequently, however, oedema is absent or not marked. Nausea and vomiting are not infrequent in the beginning of the disease, and in some cases are, perhaps, due to the heightened temperature. It may occur later in the disease as a symptom of uraemic poisoning. In such cases there is marked diminution in the amount of the urine, or even suppression. A marked secondary anaemia giving a peculiar dull white color to the skin is commonly seen in chronic parenchymatous nephritis, and is quite striking. In acute nephritis fever is often present to a greater or less extent, but is a variable symptom. Lack of appetite, and weakness, are common in both acute and chronic nephritis. Headache is a variable symptom. It is a frequent symptom of uraemia, and sometimes the only one. Restlessness and insomnia are often met with, and attacks of dyspnoea may occur. Amau- rosis may occur as the result of albuminuric retinitis, or it may be a func- tional symptom of the uraemic poisoning and disappear later if the patient recovers. Hypertrophy of the left ventricle with a pulse of high tension is apt to occur in interstitial and chronic parenchymatous nephritis. Both diseases are, however, very uncommon in childhood. In acute nephritis following scarlet fever dilatation and moderate hypertrophy of the left ventricle are not uncommon. Transudation into the serous cavities has been reported in a number of cases, as has also oedema of the larynx. In all cases of nephritis the amount of urea excreted during the twenty- four hours should be carefully estimated from time to time, as a decrease in the urea always suggests a pathological condition, and a return to the normal amount is usually indicative of recovery unless there is a com- plication with some other disease. Any interference with metabolism, however, whether in the liver or in the lung, may diminish the amount of urea in the urine. In children during convalescence from acute ne- phritis the urea returns to or exceeds the normal amount, while in chronic nephritis it is always diminished, as it is in adults. A sudden and exces- sive diminution of the urea in acute nephritis is suggestive of uraemia. In acute and chronic nephritis the chlorides are diminished when an effusion such as ascites is increasing, and gradually return to the normal amount as the effusion is absorbed. In any attempt to estimate the functional activity of the kidney, either as regards the quantity of urine or the amount of solids excreted, it is DISEASES OF THE KIDNEYS. 847 very desirable to know the amount passed in twenty-four hours. This is practically impossible in infants and very young children, in whom it is often difficult to obtain even a single specimen. Various methods have been devised for collecting the urine in infants. The most simple and effective is a cotton ring large enough to enclose the buttocks and genitals. The ring is lined with sheet rubber, and the infant (the napkin having been removed) rests upon it comfortably, and the urine can be collected as in a bed-pan. ANURIA. Anuria is an arrest of the secretion of urine. It must be distinguished from retention of urine in the bladder, from the scanty urine passed when liquids are withheld or refused in sickness, and from diminished. secretion dependent upon a profuse watery diarrhoea. Total suppression of urine may occur in the intense congestion of acute nephritis, in poisoning by lead, phosphorus, or turpentine, or after severe injuries or operations. Anuria in the new-born may be due to malformation of the urinary tract or to uric acid infarction. Other cases in infants are evidently of nervous origin, and may last for twenty-four or thirty-six hours without other symptoms. Hysterical anuria may occur in older children. Charcot reports a case lasting for eleven days. Treatment. — The obstructive cases demand operation. In non-ob- structive cases the treatment is usually simple and satisfactory. Sweet spirits of nitre or citrate of potash given with plenty of water will usually relieve the condition. Hot applications over the kidney may be used, or large hot irrigations of the colon with salt solution. PHYSIOLOGICAL ALBUMINURIA. This condition is not infrequent, and may occur at any period of infancy and childhood, but is most common between the fifth year and puberty. It is more common in boys than in girls. The amount of albu- min present is, as a rule, less than one-twelfth per cent., and is sometimes associated with temporary glycosuria. It is not present in every micturi- tion, and in many cases seems to depend upon over-exercise, cold bathing, or a highly nitrogenous diet. The albumin is rarely present in the urine which is passed in the morning immediately after rising, and this is an im- portant point in differentiating physiological albuminuria from periodic albuminuria due to pathological causes, such as uric acid. The presence of blood-corpuscles or abnormal elements in any amount from the kidney shows that there is a pathological condition. The children who have this physiological albuminuria often seem to be in good health, but some- times they are rather delicate. The diagnosis can be made only by re- peated examinations of the urine passed at different times in the day, and by observing the effect of exercise and diet upon it. An occasional hya- line cast and albumin as high as one-fourth per cent, for short intervals 848 PEDIATRICS. may be present. The albumin often disappears for a time and returns again. Albuminuria of Adolescence. — One form of physiological albumi- nuria is that which has been called the albuminuria of adolescence. At puberty there appears to be a disturbance of the equilibrium of the renal circulation, occurring so frequently, and presenting so distinctively the characteristics of a simple hyperemia, that we are justified in looking upon it as a physiological rather than as a pathological condition. This physiological congestion of the kidney is probably closely con- nected with the development and increased activity of the uterine circu- lation in the female, and with the prostatic and genital blood-supply in the male. The importance not only of knowing that such a condition exists at puberty, but also of bearing it in mind when we are called to treat children avIio are on the border-line between childhood and adoles- cence, is too little recognized, and this want of recognition often leads to unfortunate mistakes. Prognosis. — The prognosis in these cases of physiological albuminuria is good, and, so far as I know, no cases have been reported in which the condition terminated in nephritis. Treatment. — The treatment is to regulate the diet, exercise, and gen- eral hygiene carefully. If the children are anaemic, iron is indicated. The following is one of a number of cases of albuminuria of adoles- cence which have come under my notice : A girl, thirteen years old, was brought to me for advice with the following history. She had always been somewhat delicate, but had never had any especial disease, and was considered to be fairly healthy, until she was twelve years old. She then began to grow very fast in height without a corresponding development in weight and gen- eral muscular strength. When she was twelve and a half years old the catamenia appeared, and were accompanied by severe pain. Six weeks later, the catamenia again appeared, and were accompanied by considerable pain and general prostration. The child at this time looked pale and thin, had very little appetite, and was easily fatigued. A physician was consulted, who prescribed strong food, such as meat, a tonic, and gymnasium exercise. This advice was followed implicitly, and the child was made to exercise especially the muscles connected with the abdomen and pelvis three or four times a week at the gymnasium, and by daily home exercise, such as lying on the back and raising the legs. Under this treatment the child rapidly grew worse, and the catamenia did not return in the following month. A physical examination of the child showed nothing abnormal beyond too rapid growth. The total quantity of urine in twenty-four hours was 960 c.c. (32 ounces). The color was normal, reaction acid, specific gravity 1023, urea increased, a very slight trace of albumin, sugar absent. The sediment showed a considerable amount of mucus, a little vaginal epithelium, an occasional granular and epithelial cast, renal epithelium, and an occasional blood-globule. The urine was simply one which showed a slight renal hyperemia, and the child was therefore treated as follows. She was not allowed to go to school or to the gymna- sium, but was made to rest in bed for several hours twice a day. Her diet was largely milk in considerable quantity, meat especially being withheld. She was also made to drink freshly distilled water, 250 c.c. (about eight ounces) once in six hours. She was allowed to take a slight amount of exercise out of doors, but to a very limited degree. DISEASES OF THE KIDNEYS. 849 Under this course of treatment the child began slowly to improve. She became less anaemic ; her appetite increased, and was less capricious ; she began to gain in weight, to sleep well, and to have more strength. Subsequent examinations of the urine showed a progressive improvement until, at the end of one year, the albumin had entirely disappeared and the urine became normal. HiEMATTJRIA AND HEMOGLOBINURIA. Hematuria is the term applied to the presence of red blood-corpuscles in the urine. Hemoglobinuria is the term used to describe those cases in which the haemoglobin or blood-pigment is present in the urine with- out the red- blood-corpuscles themselves. Both conditions are to be con- sidered as symptoms of some primary disease rather than distinct dis- eases in themselves. Hematuria and hemoglobinuria are, as a rule, easily recognized by the color of the urine if sufficient blood or blood- pigment is present to color it. The color is red if it is due to fresh blood, or brownish red if due to blood-pigment which has been washed out of the corpuscles. Etiology. — Hematuria is often the first indication of an acute nephritis from any cause. It may also occur as a result of scorbutus, hemophilia, pernicious anemia, and leukemia. Malignant disease of the kidney, uric acid concretions in the kidney and bladder, and trauma, are at times the direct cause of the condition. Both hematuria and hemoglobinuria, usually in small amounts, may be caused by poisons, such as carbolic acid, cantharides, and chlorate of potash, and also by infectious diseases, such as scarlet fever, typhoid, and malaria. Paroxysmal hcemoglobinuria is of rare occurrence in childhood. The cause is obscure. Some cases are probably of malarial origin ; many others seem to be dependent upon over-exertion and exposure to cold, such as may come from chilled or wet feet, or from a cold-water plunge. Symptoms. — With the onset of the attack there may be severe symp- toms of chills, fever, rapid and small pulse, and prostration. Again there may be hardly any subjective symptoms, the color of the urine alone being noticed. When the hematuria is dependent upon an acute ne- phritis, the symptoms follow the course of the primary infection. Diagnosis. — To determine the source and cause of the hemorrhage is often quite difficult, and at times is impossible. When the blood comes from the bladder it may not be uniformly diffused through the urine, and small clots are common. In addition to this there are symptoms of disturbance of the bladder, such as tenesmus and frequent and perhaps interrupted micturition. In hemorrhage from the kidney the blood is diffused through the urine. The color maybe red or brownish red. The microscopic examination shows epithelium and casts from the kidney, many of which contain red blood-corpuscles embedded in them, and are known as blood-casts, and the renal elements are stained yellow and brown from long contact with the blood. There are also normal blood- 54 850 PEDIATRICS. corpuscles, and others from which the haemoglobin has been washed out, which appear as pale rings, the biconcavity being lost. The diagnosis of hematuria rests upon the detection, by microscopic examination, of the red blood-corpuscles, either in a normal condition, or decolorized, in the urine. When these are absent and the color of the urine suggests the presence of blood-pigment, the hsemin test by glacial acetic acid will show the characteristic crystals if blood-pigment is present. Infectious haemoglobinuria has been described on page 314. Treatment. — The treatment of hematuria and hemoglobinuria con- sists in that of the primary diseases. The cause should be determined, if possible, and the indications for treatment followed. Rest in bed and a milk diet until the urine is of normal color should be enforced. CHYLURIA. Chyluria is a rare disease. Two forms are usually spoken of, the tropical and the non-tropical. Etiology. — The tropical form is caused by a parasite, the filaria san- guinis hominis, a species of round-worm. This parasite is found in the blood during the night ; in the daytime the blood is almost or entirely free from them. The parasite is found at times in the urine. The exact con- nection between the parasite and the chyluria has not yet been deter- mined. In the non-tropical form the parasite has not been found. Cases have been reported in which the parasite appeared in an individual residing in the tropics, and disappeared on his returning to a cold climate, although the chyluria continued. The chyle is supposed to get into the urine after it has left the kidney. Symptoms. — The symptoms of this .disease are shown chiefly in the urine. The urine has a milky appearance, sometimes a sour odor, and tends to decompose rapidly. The reaction is slightly acid, or neutral. Microscopic examination shows the fluid to be filled with fine granules or fat drops in suspension. The urine at times contains blood-corpuscles, and albumin is always present. The attacks are apt to be paroxysmal, lasting for days or weeks, then ceasing and again recurring. A fatty diet may or may not cause an increase in the chyluria. The individuals affected by the disease may have a healthy appearance. Coagula may at times be formed in the bladder and give rise to pain and difficult micturition. The lymph-nodes, especially in the inguinal region, are sometimes enlarged. Prognosis. — The prognosis of chyluria is doubtful. It is a disease which lasts for a long time, and may cause anaemia and emaciation from the loss of fat and albumin. Treatment. — There is no drug known which destroys the embryos in the blood. In infected districts the drinking-water should be boiled. A diet containing little liquid and little fat will cause the chyle to dis- appear from the urine, but this, of course, does not constitute a cure. DISEASES OF THE KIDNEYS. 851 The removal of the adult worms from the enlarged lymph-nodes by surgical means has been the most successful treatment. GLYCOSURIA. Glycosuria is a symptom, characterized by the transient appearance of sugar in the urine. It may result from poisoning with such substances as carbonic acid gas. morphine, or mercury, or it may appear in connection with acute infectious disease, such as diphtheria, scarlet fever, typhoid fever, or malaria. It is not infrequently dependent upon some disturb- ance of the nervous system resulting from a fracture of the skull, cerebro- spinal meningitis, or epileptiform convulsions. Glycosuria may occur in infants as well as in children, although usually not in those who are healthy. It is often associated with digestive disturbances. It may depend partly on the diet, and in these cases is called dietetic or alimentary gly- cosuria, and Koplik found glycosuria in five out of ten infants who were taking a food largely composed of sugar. The amount of sugar excreted is usually small and its appearance transient, by which the condition may be readily distinguished from the disease diabetes mellitus if the urine is examined frequently and at different times during the twenty-four hours. ACTIVE HYPEREMIA. Etiology. — An active hyperaemia of the kidneys may arise in the course of various acute infectious diseases from the elimination of irritating solu- ble toxins. Fermental diarrhoeas and acute ileo-colitis are frequent causes of active hyperaemia in children. It may also be caused by an excess of uric acid, and by such irritating drugs as turpentine, cantharides, and arsenic, lead, large doses of calomel, salicylic acid, and potassium chlorate. Concentrated urines, and urines containing bile and sugar, also act as irri- tants, and lead to a hypersemic condition of the kidneys. Irritants due to inflammations of the bladder from gonorrhceal and tubercular infections may, by extension upward along the ureters, start up an active hyper- semia of the straight or collecting tubules. When the action of these causes is very intense, or when the irritation is sufficiently prolonged, the hyperaemia may develop into a true acute nephritis. Pathology. — The pathological conditions resulting from active hyper- aemia of the kidneys are represented by degeneration and desquamation of the renal epithelium and injection of the blood-vessels. There is also to some extent an infiltration of round cells. The process seems to affect chiefly the epithelium of the tubules. Symptoms. — Unless the hyperaemia is very pronounced, there are. as a rule, no general symptoms. Urine. — The urine is clear, acid, and its color is often normal. If the cause of the hyperaemia is due to a febrile disturbance, the urine is gen- erally high-colored, concentrated, and diminished. If the cause is not febrile, the urine is often either normal in quantity or dilute. The amount 852 PEDIATRICS. is diminished. The specific gravity is generally increased. The solids are either normal or slightly diminished. There is a slight sediment, with a slightest possible trace ovalbumin. Microscopic examination shows the presence of renal epithelium and blood-corpuscles ; the latter, however, are not in sufficient number to color the urine. There are also leucocytes, and hyaline and fine granular casts, with an occasional epithelial cast and blood cast ; the last three varieties of casts, however, are not very numerous. In the severer forms of hyperaemia the albumin may for a few days be as high as one-eighth to one-fourth of one per cent. When irritation of the kidney is so active as to cause these larger percentages of albumin, the type of the disease is often called a catarrhal nephritis. In these cases the urine is smoky and the blood and renal elements are much more pronounced. Diagnosis. — The diagnosis from acute nephritis is made by the daily examination of the urine, and the relatively rapid diminution in the amount of blood and renal elements, and by the absence of dropsy, which never occurs as a result of an active hyperaemia even when severe. (Ogden.) Prognosis. — The prognosis in active hyperaemia of the kidney is good, and the pathological condition usually disappears within a short time when its cause has been removed. Treatment. — The child should be placed on a diet exclusively of milk, so as to avoid any further irritation of the kidneys, and should be made to drink a great deal of water. It should be kept quiet, and its general hygiene should be carefully regulated. Sweet spirits of nitre, potassium citrate, and cream of tartar Avater may advantageously be given to increase the flow of urine. PASSIVE HYPEREMIA. In addition to the active hyperaemia which has just been described, chronic passive hypercemia or chronic passive congestion may occur, de- pendent upon diminished arterial or increased venous pressure. This condition occurs in chronic cardiac disease with disturbance of compensa- tion, in chronic pulmonary disease, and when there is mechanical obstruc- tion to the venous circulation, as from the presence of abdominal tumors or ascitic fluid. Pathology. — The kidney is enlarged, firm, and of a deep-red color. The substance is tough from increase of interstitial tissue. The vessels are congested and their Avails become thickened in long-continued cases. The epithelium of the tubules shows granular or fatty degeneration. Symptoms. — The symptoms which occur in the course of passive hy- peraemia are only slightly referable to the kidney, and depend for the most part upon the disease which causes the hyperaemia. Urine. — The urine in this condition is high-colored, strongly acid, and often considerably diminished in amount. It has a high specific gravity, DISEASES OF THE KIDNEYS. §53 and often a heavy sediment of amorphous urates. The total solids are diminished absolutely, but owing to the concentration of the urine are relatively increased. There is a slight trace of albumin, usually under one-tenth of one per cent. Microscopic examination shows a few hyaline casts with renal cells adherent and an occasional blood-corpuscle. There are. however, very few of these elements in the sediment. If the urine is passed in larger quantities, it is not so highly colored and contains a smaller amount of albumin. Diagnosis. — The diagnosis of passive hyperaemia from active hyper- emia often cannot be made from the urine alone, owing to the associa- tion of the two conditions. The amount of blood elements in the urine is the principal test. The main reliance must be placed upon the clinical history and physical examination. Prognosis. — The prognosis in cases of passive hyperaemia of the kidney depends upon the cause of the condition. Treatment. — The treatment is to be directed to the cause or causes of the congestion. ACUTE DIFFUSE NEPHRITIS. This condition is also described under the name Acute Brighfs Disease, and also Acute Nephritis. Etiology. — The most common cause of acute diffuse nephritis in chil- dren is scarlet fever. Other diseases in the course of which it may arise are diphtheria, measles, varicella, erysipelas, typhoid fever, malaria, small- pox, meningitis, septicaemia, pertussis, and pneumonia. With the excep- tion of its occurrence in scarlet fever, diphtheria, and measles, the disease is not frequent. Cases have been reported in which it has arisen in the course of extensive affections of the skin, such as eczema. Cases of pri- mary nephritis have been reported in which no cause could be found. Although it is difficult to estimate with certainty the importance of cold as a causative factor in the etiology of acute nephritis, and although it has been denied that cold can produce this condition, yet numerous cases have followed exposure to wet and cold. In most of the diseases due to infectious fevers the lesions in the kidney are dependent chiefly upon the action of the toxins. Some- times direct bacterial infection is a cause, and the course of the disease is especially severe in such cases. Any of the causes of active hyperaemia, described on page 851, may be a cause of an acute diffuse nephritis. Pathology. — According to Councilman, acute diffuse nephritis includes a number of different pathological conditions, described as (a) acute de- generative nephritis; (b) acute glomerular nephritis ; (c) acute hemorrhagic nephritis; and (cl) acute interstitial nephritis. These forms have been described in some detail under scarlet fever, on page 549. From a clinical point of view, these various forms cannot be differen- tiated by the character of the urine even when studied in connection with the history and symptoms. It is possible that the acute degenerative form 854 PEDIATRICS. of nephritis corresponds to the condition of urine seen in active hypercemia. (Ogden.) Symptoms. — The symptoms of acute nephritis are such as have been already described under scarlet fever on page 572. In general, the symp- toms arising in cases due to other causes than scarlet fever are the same, but less severe than those described in connection with that disease. Briefly they may be stated to be, sudden onset with mild fever ; rapid development of anaemia ; swelling of the eyelids, face, ankles, and often general anasarca ; headache, thirst, nausea, and vomiting ; frequent mic- turition, but diminished quantity ; and in case of the advent of uraemia, stupor and convulsions. Urine. — The characteristics of the urine are generally described ac- cording to three recognizable stages. First or Acute Stage. — The quantity is very much diminished, at times almost suppressed. The color is dark, smoky, or blood-red. The re- action is acid, rarely alkaline from the presence of blood. The specific gravity is low or high ; it may be high from the presence of albumin. The normal solids are diminished both absolutely and relatively, especially the chlorine and urea. The albumin varies from one-fourth to one-half of one per cent. The sediment is abundant and is of a dark-brown color. There are large numbers of normal and decolorized blood-corpuscles and brown granular renal cells. Brown granular, epithelial, blood, fibrinous, and even hyaline and finely granular casts are seen in abundance. There may also be evidence of an acute pyelitis, as shown by clumps of caudate cells, round cells, and leucocytes. This stage lasts from five to ten days. Second or Fatty Stage. — In this stage the quantity of urine and solids excreted begins to increase, the albumin to diminish, and the sediment to become more dilate, with the same characteristics, but with the addition of fatty renal cells, fatty casts, and compound granule-cells. This stage lasts about as long as the first stage. Third Stage, or Stage of Convalescence. — In this stage there is a marked increase in the quantity of urine, which gradually loses its dark and smoky color and becomes pale, faintly acid, of low specific gravity, and with only a trace of albumin. The solids are nearly normal in absolute amount, but relatively are diminished, owing to the increased amount of urine. The sediment becomes slight in quantity, colorless, and shows a great diminution in the number of renal elements seen in the fatty stage. This stage may last from several months to several years, and be followed by complete recovery, especially in children. Exacerbations may occur at any time in the course of the second and third stages, and be followed by the return of the characteristics of the first stage. There is a sudden drop in the quantity of urine, with the reappearance or increase of the blood elements, especially of fresh red blood-corpuscles, the amount depending upon the intensity of the ex- acerbations. DISEASES OF THE KIDNEYS. 855 Complications. — Pneumonia, pleurisy, endocarditis, and pericarditis should all be carefully watched for, as they may occur any time in the course of an acute nephritis. Uraemia, however, is the condition especially to be guarded against. With a fall in the amount of urine and diminution in the amount of solids, as judged by a daily examination of the urea, special measures should be taken to increase the elimination of the toxic substances by diuresis, diaphoresis, or free catharsis. Differential Diagnosis. — The distinction between a severe acute hyper- emia and a mild acute nephritis is to be made by the sudden onset, oedema, and persistence of albumin, blood, and casts in considerable amounts. In the convalescent stage of an acute nephritis in which there is a large amount of urine and a small percentage of albumin, the characteristics of Fig. 182. Acute diffuse nephritis, following scarlet fever. the urine resemble those which occur in a chronic interstitial nephritis, but the history of an acute attack, the normal solids and presence of blood, and the rarity of chronic nephritis in children enable us to make the diagnosis if several examinations of the urine are made. Cardiac disease with dropsy is to be distinguished either from acute diffuse nephritis or subacute glomerular nephritis by the evidences of valvular lesions and the character of the urine in cardiac disease, which is that of a passive hyperemia or congestion. Fig. 182 illustrates the character of the dropsy which may occur in the course of an acute nephritis. The case is described on page 577. Treatment. — The treatment of acute nephritis consists primarily in the administration of a strict milk diet, rest in bed, and the free use of diuretics. The details of the treatment and of the complications which may arise, such as uremia, have been sufficiently described in connection with nephritis following scarlet fever on page 573. 856 PEDIATRICS. SUBACUTE GLOMERULAR NEPHRITIS. This condition is known also as " chronic parenchymatous nephritis." Etiology. — Chronic parenchymatous nephritis is not a common disease in childhood, and its etiology is still very obscure. Some cases have followed an attack of acute nephritis, and in these there has generally been an interval during which the urine has contained simply a trace of albumin and a few casts, the symptoms of a chronic affection of the kidney appearing later. Cases have also occurred in connection with long-continued suppurative processes in .the bones, joints, or elsewhere, arising in the course of tuberculosis or syphilis. In these cases amyloid infiltration is also apt to occur. In the majority of instances no cause whatever can be discovered. Pathology. — The kidney is enlarged, pale, slightly mottled, and of in- creased consistency. The cortex is increased in width and is pale. The markings are indistinct. The essential lesions consist of swelling and in- crease in the nuclear elements of the glomeruli, with hyaline degenera- tion of the blood-vessels. There is proliferation and desquamation of the capsular epithelium and new formation of connective tissue. Diffuse degeneration and desquamation of the tubular epithelium and oedema of the intertubular tissue occur. (Councilman.) Symptoms. — The onset of subacute glomerular nephritis, or chronic parenchymatous nephritis, is sometimes insidious. Indigestion, loss of appetite, and vomiting are early symptoms. The face becomes pallid and " pasty," and oedema of the face, eyes, and ankles develops. Palpita- tion, headache, and dyspnoea, with hypertrophy of the heart and pulse of increased tension, are present and are often early symptoms. Epistaxis may occur. Nervous symptoms of a uraemic type are often pronounced, and in the more advanced stages of the disease may end in convulsions and coma. Changes in the retina are often found, and there is always a special tendency towards the development of intercurrent diseases, such as pneumonia and pleurisy, which often lead to a fatal conclusion. As the disease advances the oedema becomes more general, and a condition of anasarca develops. The anaemia becomes more profound and the cardiac symptoms more marked. Urine. — Micturition is frequent, but the quantity of urine which is passed is small. The disease is characterized by periods of activity and quiescence. In the active stages the oedema is increased, the quantity of urine is very small, and uraemic symptoms threaten. The urine is high-colored, strongly acid, with high specific gravity, and the solids are absolutely much diminished, although relatively they may be increased. The albumin is always very large, averaging from one-half to one per cent., although it is sometimes much higher. The sediment consists of many hyaline, granular, and fatty casts, some of which contain fatty renal cells and compound granule-cells adherent. These fatty degenerated cells are also found free. In advanced stages waxy casts will be met DISEASES OF THE KIDNEYS. 857 with and are usually of bad prognosis. Signs of acute irritation of the kidney are often present and are indicated by the presence of blood elements. During the quiescent stage the dropsy becomes absorbed, and the oedema may entirely disappear. This change is associated with a marked increase in the quantity of urine, which may become normal or even in excess of the normal limit. As a result, the urine becomes pale, of a lower specific gravity, and with solids which are both relatively and abso- lutely diminished. The albumin remains high, ranging from one-fourth to one-half per cent. The sediment is the same as in the active stage, but the renal elements are less numerous. Diagnosis. — It is important not to diagnosticate this form of paren- chymatous nephritis when complicated with an active hyperaemia with the second stage of an acute nephritis, for the prognosis is very different in the two conditions. The diagnosis can only be made by attention to the history of the case and to the changes which take place in the urine. If the case is one of a subacute glomerular nephritis complicated with hyperaemia, the blood elements of the acute process will subside in the course of a few weeks. Prognosis. — The prognosis is very grave. A few very rare cases of recovery have been reported. Most cases, however, die from uraemic in- toxication or from some intercurrent disease, such as pneumonia. There may be a remission in the symptoms for a time. The duration of the disease is from one to five years. Treatment. — The treatment of chronic parenchymatous nephritis is essentially the same as in acute glomerular nephritis. The diet should be restricted as far as possible to milk. Good hygienic surroundings and as much rest as possible are indicated. The use of diuretics and the treatment of general oedema and threat- ened uraemia have been described in detail in the chapter on scarlet fever (page 573). The anaemia is to be treated with iron, especially the tincture of the chloride, but the indications for iron should be determined by the blood examination and not from the pallor. Exposure to cold must be avoided, and residence in a warm, even climate during the Avinter months is very desirable. The skin must be kept active by bathing and friction, and moderate, regular exercise taken when the child is strong enough. Cardiac dilatation is to be combated with digitalis and strychnine. CHRONIC INTERSTITIAL NEPHRITIS. Chronic interstitial nephritis (chronic Bright" 1 s disease) is very uncom- mon in childhood. It is hardly practicable to attempt to make the dis- tinction between the various forms of chronic nephritis as can often be done in the case of adults. I therefore shall not describe chronic intersti- tial nephritis, chronic diffuse nephritis of the interstitial type, and chronic diffuse nephritis of the parenchymatous type as separate diseases. 858 PEDIATRICS. Etiology. — The etiology of chronic interstitial nephritis is obscure. Hereditary tendencies and congenital syphilis play a part in the produc- tion of the disease in young children, but the common predisposing or associated conditions which are found in adults, such as gout, lead poi- soning, chronic alcoholism, and arterio-sclerosis are very rare in childhood. In some cases a subacute glomerular or chronic parenchymatous nephritis is followed by a chronic interstitial nephritis. Pathology. — The pathological conditions do not differ from the lesions as seen in the adult. The kidneys are very small and contracted with thick adherent capsules. The color is reddish, and on section the cortex is seen to be thin, the pyramids wasted, and the arteries thickened. The glomeruli are injected, and the pyramids show passive congestion. On microscopic examination the connective tissue between the tubules is much increased. The epithelium is degenerated. A general condition of arterio-sclerosis prevails. Symptoms and Diagnosis. — The diagnosis can scarcely be made from the symptoms. The disease is progressive and slow, with no character- istic symptoms. Cases have been reported in which there were headache, weakness, dyspnoea, palpitation, and disturbance of vision. Hypertrophy of the left ventricle, with a pulse of increased tension, occurs as a constant lesion. There is little tendency to oedema ; retinitis may be, present. Sometimes severe nervous symptoms are prominent, such as tremor, increased reflexes, aphasia, and psychoses. Cerebral hemorrhages may occur as in adults. Baginsky refers to the lack of development of the children in these cases, and this condition was noticed in a case of this disease which occurred at the Boston Children's Hospital. This child, a girl, twelve years old, showed the development of a child of about seven years. The only symptom until she died of uraemic poisoning was persistent headache. The post-mortem examination showed marked interstitial nephritis, hut it was not possible to determine whether it was primary or not, and no previous history could be obtained. Urine. — In chronic interstitial nephritis the amount of urine passed in the twenty-four hours is very greatly increased. It has a low specific gravity, a very slight sediment, and a trace of albumin. The microscopic examination shows a few hyaline and finely granular casts and occasional renal cells. Sometimes towards the end of the disease highly refractive homogeneous casts resembling wax appear in the urine. At this time the amount of urine may be somewhat diminished, but the specific gravity does not rise, as the excretion of urea is interfered with. Diagnosis. — The early stages are not recognizable. The cases demand careful observation for a long time and repeated examinations of the urine. The presence of cardio-vascular changes, such as cardiac enlargement and a pulse of high tension, are important. The condition must be dis- tinguished from physiological albuminuria and from passive hyperemia. DISEASES OF THE KIDNEYS. 359 The distinction must be made principally on the clinical evidence of the symptoms and of the physical examination. Prognosis. — The prognosis is very unfavorable. The children usually die of cerebral hemorrhage or of some intercurrent disease. It is impossible to predict the duration of the disease from the symptoms or from the urinary examination. The presence of marked cardio-vascular changes, of oedema from failing compensation of the hypertrophied heart, and the continued excretion of very small amounts of solids, especially of urea, are unfavorable signs. Treatment. — The treatment of chronic interstitial nephritis is essentially the same as that of subacute glomerular nephritis. The diet, however, need not be so strictly limited. It should be light and nutritious and moderate in amount. Meat may be given in small quantities. Alcohol should be prohibited. Free use of the mineral waters is beneficial. In general, the indications are to maintain the functional activity of the heart, kidneys, skin, and bowels according to the methods which have been de- scribed. When the arterial tension is high, nitroglycerin may be tried. As evidences of failing compensation of the heart develop, appropriate sup- portive treatment with strychnine and digitalis should be given. Threat- ened uraemia is to be met by the same measures which have been de- scribed in connection with acute nephritis (page 573). AMYLOID INFILTRATION. Amyloid infiltration of the kidney may occur in the kidney in connec- tion with amyloid changes in other organs, especially in the liver, spleen, and intestines. It is always 'combined with other changes in the kidney, usually those of a chronic parenchymatous nephritis, and it is not to be considered as a separate disease of the kidney. Etiology. — It occurs at times in connection with chronic suppurative processes in the bones or elsewhere, and also in tuberculosis, syphilis, and chronic wasting diseases. It is not, however, especially common in early life. Pathology. — The amyloid change usually begins in the vessels of the glomerulus of the kidney, extends to other small vessels, and finally to the walls and epithelium of the tubules. The kidneys always show signs of diffuse nephritis. Symptoms. — The symptoms are those of chronic nephritis. The char- acter of the urine, the presence of a cause, and of amyloid changes in the liver and spleen, shown clinically by enlargement, are the signs by which the diagnosis is made. Hypertrophy of the heart is rare. The urine is usually passed in large quantity when the amyloid changes are advanced. The specific gravity is low, and albumin is present to the extent of from one-tenth of one per cent, to one per cent. When the amount o( urine is not much increased, as may happen temporarily, the albumin occurs in large 860 PEDIATRICS. amount. Microscopic examination shows no characteristic sediment ; but when, as may often happen, the disease is combined with chronic nephritis, the sediment will show evidence of this latter disease. Waxy casts appear much earlier than in other forms of chronic nephritis. There are no fatty elements unless the disease is complicated. Prognosis. — On account of the usual causes of this condition the prognosis is unfavorable. Treatment. — The treatment is the same as that of chronic interstitial nephritis and of the primary disease upon which the amyloid changes are dependent. The case which follows illustrates a chronic parenchymatous nephritis with an acute exacerbation. The boy was eleven years old, and had had nephritis for one year. He had pertussis when he was three years old, scarlet fever when he was four years old, and measles and pneumonia when he was five years old. He is reported to have remained well from that time until nine months before he came under my observa- Fig. 183. Probable chronic parenchymatous nephritis with an acute exacerbation. after being out of bed five days. Male, 11 years old. Relapse tion, when, without any known cause, such as exposure to cold or sickness of any kind, his face and eyes began to be cedematous. This was followed by oedema of the legs and ankles, and was accompanied by dyspnoea. The urine was noticed to be nearly of the color of blood, and to be lessened in amount. He was kept in bed for six weeks, and is said not to have complained of any especial discomfort. During this attack his appetite remained fair. From the beginning of the attack he grew weak and pale. Six weeks before the present history the paleness and oedema about the eyes in- creased, and the urine became smoky again. This was followed by oedema of the ankles, feet, and legs, accompanied by dyspnoea. The bowels were regular, and there was no vomiting. Sleep was not disturbed. On entering the hospital his face looked pale and waxy. There was considerable oedema of the face, especially of the eyes. His tongue was slightly coated, and there was oedema of the ankles, feet, and legs. DISEASES OF THE KIDNEYS. 861 Nothing abnormal was found in the heart or lungs, and there was no evidence of ascites. He was kept in bed and given a diet of milk. Under this treatment the oedema and anaemia disappeared rapidly, and in two weeks he was allowed to be dressed and about the ward. Five days later he again had oedema of the face, and was immediately put to bed. From 750 to 900 c.c. (25 to 30 ounces) of urine were passed in the twenty-four hours. An examination showed it to have a specific gravity of 1010, an acid reaction, to contain about 9 grammes (140 grains) of urea in the twenty-four- hour quantity, to have the chlorides diminished, and to contain 0.6 of one per cent. of albumin, but no sugar. The sediment showed numerous hyaline casts of medium diameter, some of large diameter from the straight tubules, many coarse and fine granular casts, numerous fibrinous casts, and many casts with renal cells adherent ; also epithelial casts and blood casts ; an excess of renal epithelium, most of it granular or fatty ; a large amount of abnormal blood, free fat, and fatty casts. His temperature varied from 36.6° to 37.2° C. (98° to 99° F.). After remaining in the hospital for two months, with temporary periods of im- provement, he was discharged in about the same condition as when he entered. The following represents another case of the same type. Fig. 184, Probable chronic parenchymatous nephritis with an acute exacerbation. Female, 9 years old. Second week of the disease. This child had measles when she was two years old, scarlet fever when she was three years old, varicella when she was six years old, and pertussis when she was eight years old. She apparently recovered entirely from all these diseases, and was well until one week before entering the hospital, when, without any apparent cause, her face and feet began to swell. She complained of no pain, and had no other symptoms. There was marked and extensive oedema of the entire face, body, and limbs. There was also a pronounced pallor of the skin. Nothing abnormal was detected in the heart or lungs. There was no ascites, headache, nor discomfort. An examination of the urine showed the color to be pale, the reaction acid, the specific gravity 1012, and the sediment moderate ; it contained 0.25^- of one per cent, albumin, and no sugar ; the sediment contained considerable abnormal blood, some tree 862 PEDIATRICS. fat, and a number of hyaline and fine granular casts of medium and small diameter, many of them short and with fat-globules adherent. There were some fatty renal epi- thelium, leucocytes, casts with renal epithelium, and hyaline casts with a few renal cells adherent. There were also several fatty casts. The casts were not very numerous. She was treated by absolute rest in bed. bitartrate of potassium, digitalis, and a diet of milk. In about a week the cedema rapidly diminished and the urine increased in amount. An analysis of the urine at this time showed that the color was pale, that it had a specific gravity of 1010, a trace of albumin, and a slight sediment, consisting of a small amount of blood, renal epithelium, and a few casts with blood. The total amount of urine passed in the twenty-four hours was 2010 c.c. (67 ounces). An examination of the urine three weeks later showed the color to be pale, the re- action acid, the specific gravity 1014, the albumin 0.25— of one per cent. It contained hyaline and fine granular casts of small diameter, many with fat-globules and renal cells adherent : also free fat-globules, fatty and granular renal epithelium, some normal and abnormal blood, leucocytes, and squamous cells. The casts were not very numerous, and there was not much change from what was found in the urine three weeks pre- viously. At this time the urine again became scanty, and the cedema and pallor re- turned, but she did not complain of any discomfort. An examination of the urine eight weeks later showed it to be pale and cloudy, the reaction acid, the specific gravity 1018, and that it contained considerable sediment, and albumin 0.25— of one per cent. The sediment consisted chiefly of hyaline casts of medium and small diameter, many of them having renal cells and fat adherent. There were also a few finely granular casts, considerable abnormal blood, free fat, fatty renal cells, epithelium, leucocytes, and occasionally blood, epithelial, and fatty casts. ACUTE PYELITIS AND PYELONEPHRITIS. Etiology. — Pyelitis is an inflammation of the mucous membrane lining the pelvis of the kidney. After the pyelitis has lasted for a time, the sab- stance of the kidney may be involved and pyelonephritis results. The most common cause is the excretion of uric acid by the kidney, or pelvic calculi. It may also be due to an extension upward of gonorrhoea or cystitis from the ureter and bladder, or to tuberculosis of the kidney, or to malignant growths. There is also an infectious form which may appear in the acute infectious fevers, such as scarlet fever, typhoid, or malaria. Pyelitis due to a local cause is usually unilateral. The form which ap- pears as a complication in fevers is usually bilateral. An acute pyelo- nephritis not infrequently follows exposure to cold or wet. Pathology. — The acute cases show an acute catarrhal inflammation of the mucous membrane of the pelvis of the kidney. In chronic cases there is thickening of the membrane and occasionally a considerable accumulation of pus. In pyelonephritis the suppurative process extends into the kidney itself. Symptoms. — In an acute attack of the disease, such as is caused by uric acid or a calculus, there are often local pain, chills, and fever. Typi- cal attacks of renal colic, with vomiting, pain, and intermittent fever, may occur. Hematuria may be an early symptom. Micturition is frequent. If the condition be due to tuberculosis, malignant growths, or abscess of the kidney, there will be more or less cachexia and emaciation, and DISEASES OF THE KIDNEYS. 863 there may be local pain and tenderness. Pyuria is often the only symp- tom in the eases complicating acute infectious diseases. Leucocytosis is generally present. Urine. — The diagnosis is made from the examination of the urine, the characteristics of which vary according to the extent to which the inflam- mation involves the parenchyma of the. kidney. The quantity of urine excreted is small. The color is high, smoky, or blood-red, according to the amount o + " blood present. The specific gravity is generally high and the total solids absolutely diminished, but relatively increased. The quan- tity of albumin varies from a trace to one-fourth or to one-half of one per cent., or even higher, depending upon the severity of the involvement of the kidney itself. The microscopic examination shows sometimes the whole field to be filled with pus-corpuscles, at other times the pus is in clumps : there are also present small round cells with single nuclei, from the pelvis or from the kidney, and more or less blood. The diag- nostic cell of pyelitis is the ki caudate cell, 1 ' which is a small cell about the size of a renal cell, having a single nucleus and a tail. These cells come from the superficial layers of the pelvis of the kidney, and may disappear from the sediment as the inflammatory process becomes subacute or chronic. If the kidney is affected there are casts of various kinds, hya- line, granular, epithelial, and blood. The casts may be hard to find if the field is filled with pus. The presence of tubercle bacilli in the sedi- ment, shown by appropriate methods of staining, establishes the diagnosis of tuberculosis. The tuberculin test may be used with advantage. When calculi are present, they usually cause local pain and tenderness and hema- turia, and occasionally attacks of renal colic. In the freshly passed urine, uric acid is often present in the sediment in the form of irregular spicu- lated crystals. Diagnosis. — New growths are more apt to produce hemorrhages than pus. Pyelitis may usually be distinguished from cystitis by the history, acid reaction of the urine, the presence of caudate and round pelvic cells in large numbers, and the local signs. In cystitis, on the other hand, there is generally vesicle pain and tenesmus, an alkaline urine, and large numbers of squamous and prostatic cells. It may be confirmed by the aid of the cystoscope. Catheterization of the ureters in older children, when possible, is of great aid in making a definite diagnosis. Prognosis. — The prognosis depends upon the cause. In malignant, growths it is fatal. This is true to a greater or less degree when the tubercle bacillus is the cause of the disease, as in almost every case tuberculosis is present somewhere else in the body. When uric acid or a calculus is the cause,, the prognosis is more favorable under appropriate treatment. Treatment. — Uric acid, if present, should be treated by neutralizing the acidity of the urine, by placing the child upon a mild and unirritating diet, such as milk, and by making it drink freely of water. Potassium citrate should be used to neutralize excessive acidity of the urine, or benzoic acid 864 PEDIATRICS. if the urine is alkaline. Either may be given in doses of from 0.12 to 0.30 gramme (2 to 5 grains) three or four times daily in from one to four ounces of water. Operative treatment is at times called for when a calculus is present. CHRONIC PYELITIS, Etiology. — Chronic pyelitis may occur from a number of causes, such as tuberculosis, as a result of acute pyelitis from any cause, from irrita- tion of crystals and calculi, especially when the outflow of the urine through the ureter is obstructed, and from a movable kidney. Symptoms. — The symptoms depend largely upon the cause and the manner in which the. disease develops. There are often no symptoms at all. and again we may have those of acute obstruction of the urine. If there is retention of pus, fever, sweats, leucocytosis, and renal colic result, and the condition is spoken of as pyonephrosis. If the pus is discharged into the bladder, these symptoms rapidly subside, returning if the reten- tion recurs. Urine. — The urine is somewhat diminished in amount, pale, and very turbid, slightly acid in reaction, of low specific gravity, and with the normal solids diminished both absolutely and relatively. The albumin varies from a slight trace to 0.1 per cent. The sediment is chiefly de- generated pus, with possibly a few blood-globules. Casts of large diameter from the straight tubules are generally present, but are hard to find. The presence of crystals may enable us to diagnosticate a pyelitis due to calculus, but concretions may exist without the crystals appearing in the urine. In all cases of chronic pyelitis the urine should be examined for tubercle bacilli. Prognosis. — The prognosis depends upon the cause. If the cause is removable and the involvement of the kidney is not severe, recovery may be expected. Treatment. — The medical treatment is essentially the same as in acute pyelitis, but the case should be referred to the surgeon if there is a reasonable chance of removing the cause by operation. PERINEPHRITIS. Perinephritis is an inflammation in the connective tissue about the kidney. It may end in resolution or suppuration. It has been con- founded not infrequently with hip disease or vertebral caries. The most important paper on perinephritis in children was published in 1880 by Gibney, who reported twenty-eight cases. Etiology and Pathology. — Perinephritis in children may be secondary to suppuration in the kidney, such as results from calculi or tuberculosis, or to disease of the suprarenal capsules or to trauma. It is more fre- quently primary. The cellular tissue about the kidney becomes inflamed, and in the majority of cases suppuration occurs. The pus may discharge outward in the ileo-costal space, or into the pleura or bowel. DISEASES OF THE KIDNEYS. 865 Symptoms. — The onset may be acute or chronic. In the acute cases there is high fever, often with a chill. There is usually gastric disturbance, and the constitutional symptoms may be very severe. The bowels are constipated at times. There is usually local pain referred either to the hip or small of the back. The spine is painful and rigid, and the leg on the same side is drawn up as the movement of extension is productive of pain. General movements of the body are instinctively avoided by the patient. There is tenderness and resistance in the lumbar region, and later a tumor appears, in which deep fluctuation may sometimes be obtained. The size of the abscess may be very large. The cases which discharge into the pleura are usually diagnosticated as empyema. The character of the urine is rarely affected. The condition runs its course in from a few weeks to six months. Diagnosis. — Hip disease is likely to be confused with perinephritis, but the diagnosis is easy after careful examination. In hip disease the pro- cess is much more chronic, and the deformity is produced insidiously. Moreover, the pain is lower down, and there is tenderness over the joints. There is limitation of all the movements of the hip instead of extension alone. Perinephritis may give local signs similar to psoas abscess from spinal caries, but the characteristic changes and deformity of the lumbar verte- brae are absent. Perinephritis may be confused with typhoid fever when the consti- tutional disturbance is severe and prolonged and the local signs develop slowly. Prognosis. — The primary cases almost always end in complete re- covery. Peritonitis from rupture of the abscess is the most serious complication. Treatment. — The treatment is surgical. Rest in bed and hot local applications are first indicated, and later incision with free drainage of the abscess. HYDRONEPHROSIS. Hydronephrosis is a condition in which the pelvis and calyces of the kidney are dilated with fluid as a result of an obstruction to the outflow of urine. Etiology. — Hydronephrosis may be congenital, in which case it may be due to constriction of the ureter. Both kidneys may be affected, but usually only one is involved. When acquired it generally affects but one kidney, and may be caused by obstruction of urine either from above, such as may occur from an impacted calculus in the hilus of the kidney or in the urethra, or from below by the pressure from a tumor or from en- larged mesenteric glands. The effects are mechanical, and are due to the pressure on the kidney of the retained fluid, which leads to the gradual absorption of the parenchyma of the kidney. These tumors sometimes 55 866 PEDIATRICS. acquire a large size. They are frequently associated with other deformity or degeneration of the kidney. Symptoms. — The main symptom of hydronephrosis is the presence of an abdominal tumor connected with the kidney. When the tumor has grown sufficiently large, fluctuation can usually be detected, and aspira- tion gives a fluid which ordinarily contains urea. Subjective symptoms are usually absent and urinary signs are rare. If only one kidney is affected, the other performs the function of both, and the general condition of the child may remain good. When both kidneys are affected, life is usually too short for the development of a tumor, and the condition is not recognized. Prognosis. — Bilateral cases are usually fatal within a year. If only one kidney is involved operation gives the only hope of relief. Treatment. — The treatment is surgical. Total excision of the kidney has given better results than incision and drainage. MALIGNANT GROWTHS AND ENLARGEMENT. Tumors of the kidney are more common in the child than in the adult. They are almost always primary and usually malignant. The simple adenomata are probably equally common in both, but the child is much more, liable to carcinomata and sarcomata than is the adult. Sarcomata are the most common in the first five years of life, and usually occur in one kidney. Symptoms and Diagnosis. — The diagnosis depends upon the recognition of a tumor of the kidney, the hematuria, and the progressive emaciation and cachexia which arise. At times there is pain, but, as a rule, pain is absent. The urine sometimes gives evidence of a pyelo-nephritis ; hema- turia and albuminuria usually occur at intervals late in the disease, at a time when the tumor can be felt through the abdominal wall. The tumors are frequently of large size and rapid growth. They may cause symptoms by compression of the lungs, vena cava, or bowels. Ascites is sometimes present, and very rarely general peritonitis. Some of the characteristics of a tumor of the kidney are that it is located in the hypogastric and lumbar regions, is deep-seated, and is not so commonly to be felt in the umbilical region as are tumors of the retro-peritoneal glands. The tumor is irregularly rounded, and usually does not have a well-marked border, such as is found in enlargement of the spleen and liver. In these cases of sarcomata of the kidney the health at first is often not much affected, but there are progressive emaciation and enlargement of the abdomen, commonly without pain. Malignant growths of the kidney may be con- fused with hydronephrosis. Prognosis. — The prognosis is very unfavorable, although temporary relief is sometimes obtained by means of surgical interference. Treatment. — The treatment is essentially operative. The total mor- tality of the operation, including cases of recurrence with death, is over seventy-five per cent. DISEASES OF THE BLADDER AND GENITALS. 867 DISEASES OF THE BLADDER AND GENITALS. ACUTE CYSTITIS. Acute cystitis is not a common affection in infancy and childhood. Etiology. — It may be caused by a vesical calculus, by irritants, such as turpentine, and also occasionally by the extension of infection through the genital tract. It is not an infrequent complication of typhoid fever from direct infection by the bacteria which are eliminated by the urine. Gonorrhoea and infections by the pyogenic organisms are direct causes of acute cystitis. It is more common in girls than in boys. Symptoms. — The symptoms of acute cystitis in children do not differ from those which are met with in the adult. The chief symptom is fre- quent and painful micturition. This local symptom is usually accom- panied by fever, which may be high, and by general symptoms of malaise, fretfulness, and crying from vesical pain and tenesmus. The urine is passed in small quantities, and, as a rule, is of a reddish color at first, and gradually becomes of a lighter color. The specific gravity is high. When freshly passed it is acid, but it quickly becomes alkaline ; there is a heavy sediment, and it contains a trace of albumin. Microscopic exami- nation shows chiefly pus in large quantities, squamous epithelium, and some blood. To establish the diagnosis in females it is necessary to ob- tain the urine by the catheter, or first to wash out the vagina thoroughly, as the epithelium of the vagina and that of the bladder are very similar. Prognosis. — The prognosis of acute cystitis is good after the removal of the cause. Treatment. — The especial cause of the attack must be looked for, and removed if possible. The child should be kept perfectly quiet in bed, and should be made to drink a great deal of water. The diet should be of milk. In the acute cystitis occurring in the course of typhoid fever, urotropin in doses of from 0.06 to 0.32 gramme (1 to 5 grains) four times a day acts almost as a specific in from four to seven days. In cystitis due to other causes it is not so serviceable, except as a preventive of fer- mentation of urine within the bladder. Sedatives should be used freely. CHRONIC CYSTITIS. Etiology. — Chronic cystitis may be caused in children, as in adults, by a vesical calculus, by foreign bodies in the bladder, by tumors, by papil- lomata, and by tuberculosis. The nuclei of the calculi are generally composed of uric acid, upon which phosphates are precipitated in alkaline urine, and this deposition is favored by the accompanying catarrhal in- flammation. Symptoms. — Micturition is frequent and at times painful. Later there may be a constant dribbling of urine, giving rise to an offensive amiiio- niacal odor and causing irritation about the genitals. When there is a calculus in the bladder the stream is often suddenly interrupted during 868 PEDIATRICS. micturition, and the pain is more severe. Prolapse of the rectum is not uncommon with stone. In addition to these local symptoms there are general symptoms of anaemia and loss of weight. The urine is ammo- niacal, offensive in odor, and turbid, has a heavy ropy sediment, and contains a trace of albumin. The sediment should be examined as soon as possible after the urine is passed, because the ammonia which is produced from the urea disintegrates the cells. The examination will show a large quantity of pus, some blood, bladder-epithelium, and crystals of triple phosphate and urate of ammonium. Tubercle bacilli may be found in the urine in tuberculosis of the bladder, but a prolonged and careful search is often necessary. Prognosis. — The prognosis of chronic cystitis depends upon the cause, upon the length of time during which the disease has persisted, and the presence or absence of a secondary infection of the kidney. Treatment. — The urine should be diluted by giving distilled water in large amount. It may be rendered less irritating by such drugs as salol and buchu, and less alkaline by benzoate of sodium. Urotropin given by the mouth has yielded excellent results by disinfecting the urine in the bladder and checking alkaline fermentation. Washing out the bladder with weak solutions of permanganate of potash, creolin, boracic acid, or lysol is of use in many cases, and local applications may be made in tuber- culosis of the organ. Operative treatment is indicated when a calculus is causing the disturbance. At times it is exceedingly difficult to determine by the general symptoms whether or not a calculus is present in the bladder. The following case may be cited as an illustration : A boy, seven years old, began to have pain of a spasmodic character in the region of the bladder during micturition. In connection with the pain there was a sudden stoppage of the flow of the urine and a bearing-down feeling in the rectum. These symptoms simulated those of a vesicle calculus so closely as to render a differential diagnosis very difficult. The boy was of a nervous temperament, and was rather anaemic, but otherwise was well and strong. Nothing abnormal was detected about the prepuce or the rectum. The pain was so annoying and caused so much trouble that it was deemed advisable to have the bladder examined for stone. An examination was made, but nothing abnormal was detected. After this a decided improvement took place, apparently connected with the passing of the sound, and the boy recovered entirely after remaining at home from school for a few weeks and having daily exercise in the open air. VULVO-VAGINnTS. Vulvo-vaginitis is a very common affection in little girls. It arises from a variety of irritations, one of which is the oxyuris vermicularis. In a very large number of cases the gonococcus of Neisser has been found in the purulent secretion. The gonococcus was found in all of six cases lately treated at the Boston Children's Hospital. The disease may also arise in children who are very much debilitated, and is met with at times DISEASES OF THE BLADDER AND GENITALS. 869 in scarlet fever and in measles. Again, it is not infrequent in anaemic girls, in whom it occurs without any apparent cause. Pathology. — The labia are reddened and are more or less swollen. There is a thick, purulent discharge of a greenish-yellow color, usually offensive. At times there is more or less excoriation of the inner surfaces of the labia. The inguinal glands may be slightly enlarged and tender. The urethra is. as a rule, involved in the irritation, and is swollen and red. Symptoms. — There may be some fever in the early stages of vulvo- vaginitis. Smarting and burning are usually complained of, but at times the staining of the clothing first calls attention to the disease. The children commonly become pale if the disease persists for some time. Micturition is painful and frequent in some cases, and the disease is one of the many causes of dysuria. In many cases the children appear to be quite well, with the exception of the local condition. A positive diagnosis of gonorrhoea is only possible by means of a microscopic examination of the discharge after staining by Gram's method. Prognosis. — The prognosis is good, but the disease is apt to be pro- longed for several weeks or months. Complications may arise from the infection of the bladder, uterus, Fallopian tubes, inguinal glands, joints, or conjunctivae. Infection of the conjunctivae and uterus is common, infection of the other organs is much less so. Treatment. — Local applications to the vagina constitute the only satis- factory form of treatment. This is difficult in young children, but may be accomplished with a soft rubber catheter. Such solutions as boracic acid 1 to 40, corrosive sublimate 1 to 5000, or creolin 1 to 500, may be used. In some severe cases local applications of nitrate of silver 1 or 2 per cent., or protargol, may be necessary. The labia should be kept sepa- rated by absorbent cotton, and the parts kept dry and covered with some mild dusting-powder. Absolute cleanliness must be observed, to prevent infection of the eyes and of other persons. The parts should be pro- tected with compresses held in place by a bandage, which should be worn all the time, and the compresses should be frequently changed and burned. The towels used for the patient should not be left lying about, and should be carefully disinfected. Tonic treatment is sometimes indi- cated. The urine should be kept dilute, in order to avoid irritating the inflamed surfaces, and any complicating cystitis should be treated. During the active stage of the disease the child should be kept as quiet as pos- sible, and on a diet of milk. When the vulvo-vaginitis is caused by the oxyuris vermicularis, especial care should be given to eradicating the parasite from the rectum. as described on page 830. After this has been done, the vagina is readily freed from the parasite by using an injection of warm sweet oil, which is to be allowed to remain for three or four minutes, the vagina then being syringed out with warm water. 870 PEDIATRICS. ORCHITIS. Orchitis, or inflammation of the testis proper, occasionally results from direct injury, much more rarely from infection in gonorrhoea, syphilis, and tuberculosis. When present it is commonly accompanied by hydrocele. The orchitis which so commonly follows mumps in the adult is much less common in children. The treatment consists in support of the testicle by means of a suspensory or of a bandage. EPIDIDYMITIS. Acute epididymitis may be caused by trauma or by any irritation of the mucous membrane of the urethra. In this disease the whole scrotum is apt to be hot and tender, and the child is in great pain. The epi- didymis is much enlarged and exquisitely tender, and pushes the testis forward. The cord is often implicated, becoming enlarged and painful on pressure. The treatment should be energetic, as, owing to the swelling of the tissues about the testicle, there may be so much pressure that the gland will be seriously damaged, although the subsequent atrophy may not de- clare itself for a considerable time. The child should be kept upon his back in bed, the bowels freed with a cathartic, and a series of hot poultices kept upon the scrotum. In all inflammations of the testis or epididymis the scrotum should be placed in such a position that the lower end of the testicle points upward. TUMORS OF THE TESTICLE. In addition to tubercular disease of the testis, tumors may be found in infancy and in early childhood. These may be congenital or acquired. The congenital tumors are very rare, and are usually of the dermoid variety. The most common of the acquired tumors are carcinomata and sarcomata, which are very malignant. The rajpid growth and the large size of this variety usually render the diagnosis easy. PHIMOSIS. In early life there appears to be a physiological adhesion of the pre- puce to the glans penis. As the child grows older these adhesions normally disappear. When the adhesion between the prepuce and the glans remains permanent and the prepuce is very tight, the condition gives rise to various symptoms. Thus the escape of the urine may be me- chanically hindered, and the urine collecting behind the glans may give rise to irritation. Smegma is also apt to collect around the corona. In this way an inflammatory condition of the prepuce (posthitis) or of the glans (balanitis) may arise. As a result of this there is swelling, and micturition is painful and difficult. In addition to these local symptoms many secondary disturbances arise from the local reflex irritation. Among these are nervous phenomena of greater or less degree, such as insomnia or convulsions. Phimosis may lead to enuresis and masturbation. DISEASES OF THE BLADDER AND GENITALS. 871 In all cases of phimosis local treatment is indicated, and may be by dilatation, incision, or circumcision, — the latter being the most radical and producing the best results for complete relief from the morbid condition. In all cases, even if the phimosis is very slight, mechanical interference should be persisted in until absolute cleanliness can be secured, for in this way only will entire relief from the local and reflex symptoms be obtained. ENURESIS. Enuresis (incontinence of urine) is a condition in which there is an involuntary discharge of the urine. It may be continuous or periodic. It may also be diurnal, nocturnal, or both. It is of very frequent occur- rence in infancy and early childhood. It is a symptom rather than a disease, and in most cases is a true neurosis. During the first year of life the infant has not learned to assume control of the mechanism of mictu- rition, but during the second year this control is usually attained at an earlier or a later period according to the individual. Etiology. — The causes of enuresis may be organic or functional, the latter in all probability being very commonly of a reflex nature. Organic Enuresis. — The organic causes comprise such malforma- tions as small ureters, a small bladder, exstrophy of the bladder, and hypospadias. Enuresis may also be caused by central lesions of the brain and cord, such as brain tumor, idiocy, or injury to the cord. The prognosis and treatment of these organic cases of enuresis vary according to the conditions which cause them, and need not be considered here. Functional Enuresis. — In a large number of cases the children are of a highly nervous temperament, but enuresis is also often present in children who otherwise do not show any nervous symptoms. As has been stated by Rachford in an admirable paper on this subject, this condition may depend upon (1) irritable and unstable nerve-centres, (2) anaemia with malnutrition, and (3) reflex stimulation of certain nerve-centres in the lumbar cord. The longitudinal and circular mus- cular fibres of the bladder, which by their contraction empty the bladder, are innervated by sensory and motor nerves from the lumbar region of the cord, and the external sphincter in the prostatic portion of the urethra, which by its contraction prevents the escape of urine from the bladder, is also innervated by sensory and motor nerves from the lumbar cord. The researches of Von Zeissl show the manner in which reflex causes may act in starting or checking the flow of the urine. Thus, a reflex carried to the proper centre in the lumbar cord would, through the motor fibres of the erector nerve, contract the muscular coat of the bladder, and through the inhibitory fibres of the same nerve relax the sphincter vesica?. In this manner the urine which is being expelled by the contracting bladder is allowed to pass without hinderance through the relaxed sphincter vesicae. It is also to be remembered that the act of urination is in part under the control of the will. Admitting these 872 PEDIATRICS. anatomical and psychical facts, it is easily understood how the causes which produce enuresis may act in two ways : either directly on the centres in the lumbar cord, making them more irritable or unstable, and in that way increasing their reflex excitability, or indirectly through ex- aggerated reflex causes that affect both accelerator)' and inhibitory influ- ences sent to the bladder. These influences may be psychic, originating in the brain, or may be the result of external irritation originating in or near the bladder itself. There is also during childhood a lack of development of the centres of inhibitory reflex acts, and in this way the muscular fibres of the bladder, having no inhibitory restraint, are excited to action by even so slight a reflex cause as a small quantity of urine in the bladder. For this reason enuresis is a normal condition during infancy, and ceases when the child's inhibitory mechanism is more developed (Soltmann). The inhibi- tory influence of the will is in abeyance during deep slumber, and noc- turnal incontinence is therefore more frequent than diurnal. In any diseases which are accompanied by anaemia and malnutrition the reflex irritability of the lumbar nerve-centres is much increased and enuresis may result. Reflex enuresis may be caused by irritation in any portion of the genito-urinary tract, as by a vesical calculus, cystitis, vulvitis, phimosis, very acid urine, and over-filling of the bladder, as in diabetes, or by an irritation of some neighboring part, such as may arise from a fissure, polypus, or the oxyuris vermicularis in the rectum. Symptoms. — As a symptom, enuresis is simply the involuntary empty- ing of the bladder. Prognosis. — The prognosis of enuresis varies greatly, according to the cause and the individual. It is usually hopeless when it depends on disease of the brain or cord. In a large number of cases the enuresis lasts for only a short time, but in some cases it may continue throughout childhood ; almost invariably, however, it ceases between the twelfth and the fourteenth year. The cases in which enuresis does not disappear at puberty are nearly always in girls. Treatment.— The treatment of this functional form of enuresis is often prolonged and very unsatisfactory. According to my experience, in quite a number of cases the disease is intractable and is not affected by any treatment whatever, the individual finally recovering without treatment. Sometimes a habit of incontinence seems to have formed which continues after the removal of the original exciting cause. After a careful examination has shown that no malformation or central nervous lesion is present, the urine should be examined, to determine if it is abnormally acid. When this is found to be the cause of the irritation, a rapid cure can be effected in some cases by simply diluting the urine. In females, especially when there is irritation around the meatus urinarius, local applications are of great service, and in some cases dilatation of the urethra will produce a permanent cure. When phimosis is present, relief has sometimes been DISEASES OF THE BLADDER AND GENITALS. 873 obtained by circumcision. The bowels should be regulated, little or no fluid should be given after live p.m., and it is well to have the child pass its water just before going to sleep, and to rouse it in the middle of the night in order that it may empty its bladder. The foot of the bed should be raised, in order that the urine shall not irritate the neck of the bladder. There is no especial drug which in my experience can be relied upon in curing enuresis. Attention to general hygiene is important. Plenty of sleep and a simple diet should be insisted upon. Punishment of the child is usually harmful, and should never be alloAved. When the chil- dren are anaemic and debilitated, iron and nux vomica are indicated. When there is excessive irritability of the nerve-centres, belladonna and atropine are at times efficient in relieving this condition ; but in many cases they fail to produce beneficial results even when given in toxic doses. Faradism applied to the perineum or to the base of the sacrum and to the symphysis pubis is in some cases beneficial. If the bladder is contracted, daily dilatation up to the normal size with warm water may be very effectual. There is, however, no routine treatment for enuresis. Each case should be studied closely, and in many instances when the es- pecial cause of the condition has been found the enuresis can be relieved. MASTURBATION. Masturbation is one of the injurious habits of early life. It is most frequently practised during the later periods of childhood, especially be- tween the tenth and fifteenth years. It may, however, become a habit at any age, even in infants of one year. The inciting cause may be some local irritation, such as intestinal para- sites, concentrated and very acid urine, phimosis, balanitis, vaginitis, and a long prepuce. It may also be inculcated by the indiscreet handling of the genitals by nurse-maids. Not infrequently the habit is started from imitation of other children. There are no characteristic symptoms by which one can judge as to whether a child is a victim of this habit. The pallor, anaemia, dark rings under the eyes, headaches, and embarrassment which are sometimes men- tioned as distinctive signs, are common to so many other conditions that they are not sufficient evidence on which to make a diagnosis. Mastur- bation is stated by some writers to be a direct cause of insanity. The diagnosis of masturbation should only be made when the child has actually been observed to practise the habit on several occasions. The treatment in young infants consists in mechanical restraint, the hands and legs being so tied that the act becomes impossible. In older children strict surveillance should be kept. Punishment should be avoided. Moral persuasion, diversion of the mind, exercise, bathing with cold water, diet, and general hygiene are the main points in the treat- ment. In serious cases the bromides may be given. Hypnotism has proved very beneficial in many of these cases. DIVISION XV. THE BLOOD. THE LYMPH-NODES. THE DUCTLESS GLANDS. THE BLOOD IN INFANCY AND CHILDHOOD. The blood does not merely absorb the waste material from the tis- sues and carry fresh oxygenated material to replace it ; it plays a far greater part than this in the economy, and is intimately connected with many diseases, both through its corpuscular elements and its serum. An immense amount of labor has been expended on examinations of the blood, both chemical and microscopical, in adults, but our knowledge of the blood as it occurs in pathological conditions in infancy and in early life is still very incomplete and is wanting in exactness. Nomenclature. — The following nomenclature, with its accompanying plate, will explain the terms which are used in speaking of the various elements of the blood : Bed Corpuscles Normal red corpuscles (Plate XII. ) (Erythrocytes. ) 1. Haematoblasts Nucleated red corpuscles (Plate XII. ) (1) Normoblasts Size of erythrocytes, having a small deeply staining nucleus (Plate XII. ) (2) Megaloblasts .... Large nucleated red corpuscles, having a large, often fragmented, nucleus, staining faintly (Plate XII. ) (3) Microblasts Small nucleated red corpuscles. 2. Microcytes Abnormally small erythrocytes (Plate XII. ) 3. Macrocytes Abnormally large erythrocytes. or Megalocytes. 4. Poikilocytes Abnormally shaped erythrocytes (Plate XII. ) White Corpuscles (Leucocytes. ) 1. Lymphocytes Pound mononuclear cells about the size of or small mononuclear. erythrocytes, with faintly staining proto- (Basophiles.) plasm. The nucleus stains deeply, and fills nearly the whole cell (Plate XII.) 2. Large Mononuclear and Transitional Cells double the diameter of erythrocytes (Basophiles.) with oval, round, or indented (transi- tional), faintly staining nucleus filling a relatively small part of the cell (Plate XII.) 874 PLATE XII. Cul ex . ( Resting Position. ) Anopheles Anopheles. ( Resting Position.) ' i'-'Sa BK, Plasmoidium Malariae Oillmmers.REICHERTKs Ocular N?3. * # I /'■■%*.. id ®- Sfc 1*- ^ ' -3 / c?m^ LEITZOil lrnmers.% Ocular N?3. 1. Normal Red Corpuscles. 2. Haemato blasts or Nucleated Red a. Normoblasts.. Corpuscles: b. Myeloblasts. 3. Microcytes. 4. Poikilocytes. 5. Lymphocytes or Small Mononuclear. 6 Large Mononuclear: a. Transitional. 7. Polynuclear Neutrophils . 8. Polynuclear Eosinophiles.- a. Dwarf Eosinophife. 9. Myelocytes: a. Neutrophilic. b. Eosinophilic. THE BLOOD IN INFANCY AND CHILDHOOD. 875 3. Neutrophiles Considered by most observers tbe oldest or polynuclear cells. variety of the leucocytes. Tbe nucleus stains with basic stains ; the plasma stains faintly with neutral aniline stains, and the granules stain with a combination of both basic and acid stains, and hence are called neutrophiles. The nucleus is really poly- morphous, though sometimes (apparently) broken ]. (Plate XII. ) •A. Eosinophils Polymorphonuclear cells characterized by ^Oxyphiles. ) the presence of large, highly refractile granules which stain with all acid coloring matters (Plate XII. ) 5. Myelocytes Large, round, or ovoid cells with one (sel- or large mononuclear dom two) large faintly staining nuclei, neutrophiles. The plasma is filled with small granules that take (a) a neutral or (b) an acid stain (Plate XII.) (a) Neutrophilic (Plate XII. ) (b) Eosinophilic (Plate XII. ) Leukocytosis An increase in the whole number of leu- cocytes, or an increase in the proportion of any single variety. Basophilic Stained by basic stains. Acidophilic Stained by acid stains. or Eosinophilic. Neutrophilic Stained by neutral stains. Polychromatophilic Taking more than one stain. Oligocythemia Reduction in number of erythrocytes. Hemolysis Destruction of erythrocytes. Hemoglobin Coloring matter of the blood. ELemoglobixemia Presence of ha?moglobin in the serum. Hemoglobinuria Presence of haemoglobin in the urine. Plate XII., facing page 874, shows all the principal normal and abnormal cells occurring in the blood in early life. The different types of anaemia are characterized by a combination of the different cells in varying pro- portions, and by becoming familiar with their microscopic appearance, and then in a given case by calculating the percentages of the different cells which are present we have a very valuable aid in diagnosis. THE BLOOD IN NORMAL CONDITIONS. There are certain general characteristics which must be recognized when we are dealing with human beings in the earlier stages of their development. These characteristics merely impress upon us that the blood, like the various organs and tissues, changes by a process of development from the foetal to the developed condition of adult life. It is therefore necessary to take into consideration the age and stage of development of the individual whose blood we are examining before we can state that such a blood is normal or abnormal. For instance, just as it would be abnormal for the anterior fontanelle to be closed at the sixth month and unclosed at the twentieth month, so it would be abnormal for the blood of an infant in the early weeks of life to show the same ratio of leucocytes to erythro- 876 PEDIATRICS. cytes as it would in adult life, or for the leucocytes to show the percentage of lymphocytes and polynuclear neutrophiles in the same proportion as at a later period. In fact, what I have already stated concerning the different stages of physical development holds true in the case of the blood, where what can be considered normal and physiological at one period becomes, if it lasts into another period, abnormal and significant of disease. In order to understand, therefore, the diseased conditions of the blood we must remember what is normal at each period. We will next consider the normal condition of the blood at birth and its various stages of development. Amount of Blood at Birth. — Welcker states that the total amount of blood at birth is one-nineteenth of the body-weight. His opinion is based on the examination of a poorly developed infant, in which the umbilical cord was ligatured immediately at birth. Schuecking places the amount at one-fifteenth of the body-weight, from an examination of five full-term infants, without expressing the blood from the placenta, and with immediate ligature of the cord. When the cord was tied later, and the so-called " reserve 1 ' blood was expressed from the placenta, the percentage rose to one-ninth. In adults the re- lation of the blood to the body-weight is stated to be one-thirteenth. All authors agree that there is a temporary gain in the amount of blood when the cord is tied late. Reaction. — The reaction of the blood at birth is always alkaline. Color. — The color is found to be darker in the capillaries during the first few days than at any other time. Specific Gravity.- — At birth the specific gravity of the blood is about 1065, and this does not vary for the first few weeks. From this time up to the second year there is a constant diminution, decreasing in boys to as low as 1048, and in girls to 1050. It then gradually rises, till at the end of the first year it has reached the normal average of 1052 to 1055 (Hock and Schlesinger). The specific gravity does not seem to be in- fluenced by the number of red or white corpuscles, food, rest, exercise, or other causes, but depends directly upon the amount of haemoglobin. As a whole, the specific gravity is, apart from physiological variations, very constant in the same individual, and remains for weeks and months the same. Hock and Schlesinger place the greatest twenty-four-hour varia- tion at 0.00025. The appearance of the child's skin is not an index to the specific gravity of the blood or to the amount of the haemoglobin. Children often appear anaemic without any especial alteration in either of these conditions. Hemoglobin. — The haemoglobin is found to be less firmly bound to the red corpuscle in the infant at term than it is in adults. It is, however, proportionately greater in amount at birth than in adult life. The haemo- globin, like the specific gravity, which is closely dependent upon it, reaches its maximum at birth. Starting at 100 or 104, it falls rapidly to THE BLOOD IN INFANCY AND CHILDHOOD. 877 its minimum in the first three weeks of life (Hock, Schlesinger, Widowitz, Schmaltz, and Hammerschlag). The lowest percentage that has been found is about fifty-five per cent. From two weeks to six months it re- mains about the same and then rises slowly. The average figure for infants and children is sixty to eighty per cent. The percentage of haemo- globin varies greatly not only between different individuals, but also in the same individual, which may explain the great discrepancy in the figures given by various authorities. Haemoglobin is more abundant in boys than in girls. Red Corpuscles (erythrocytes). — All authors agree that there is a large number of red corpuscles at birth, and also that an increase occurs in the first twenty-four hours. As regards the actual number in the cubic millimetre of blood there is much diversity of opinion. Hayem has found a larger number at the moment of birth than in the mother's blood, and gives as an average 5,350,000 ; Shiff says 5,800,000. The increase after birth is only seeming, according to Shiff, and is due to a loss of fluid and consequent concentration of the blood. From the -second day the red cells begin normally to diminish, and fall eventually, according to Lepine, Jerrard, and Schlemmer, to 5,000,000. In infancy the average number is from 4,000,000 to 5,500,000 ; in later childhood from 4,000,000 to 4.500,000 (Hayem). There is much greater variation in size in the red corpuscles of the newly born than in those of older children or adults, and microcytes are more numerous ; the oscillations in the number of red cells within twenty-four hours are also much more marked than in adults. H^mato blasts. — Haematoblasts or nucleated red Corpuscles are nor- mally present in the foetal blood and diminish in number towards the end of pregnancy. They also occur in the blood of premature infants, and are present in small numbers in the blood of normal infants for a few days after birth and then disappear. After six months they are rarely or never found normally. Pathologically their presence may be of con- siderable importance, and the younger the child the less intense need the anaemia be which will cause their appearance in the blood. Leucocytes. — The leucocytes, or white corpuscles, are more numerous at birth than in adults and in young children. In the first twenty-four hours the number varies from 18,000 to 30,000 (Schiff, Gundobin, Hayem). This is rapidly reduced at the end of ten days to from 14,000 to 10,000. The daily variations in the early days of life are more marked than in adults, and the leucocytosis of digestion is relatively higher. The average number of leucocytes in an infant's blood after the first two or three weeks and up to six months is from 12,000 to 14,000, and from six months to one year from 10,000 to 12,000. Denis places the number of white cells from the second to the sixth year at from 9000 to 10,000. Bouchut and Debrisay found the average number of counts in children from two to fifteen years of age to be 6700. 878 PEDIATRICS. The following figures compiled by R. C. Cabot show the normal average number of blood-corpuscles at different ages in cases in which there was a loss of weight in the first forty-eight hours. TABLE *73. Normal Average Number of Blood-Corpuscles at Different Ages in Cases in which there was a Loss of Weight in the First Forty-eight Hours. Age. Erythrocytes. Leucocytes. At birth 5,900.000 21,000 (26,000 to 36,000 after first feeding. ) End of 1st day 7,000,000 to 8,800,000 24,000 " 2d t: generally increased. 30,000 • ; 4th " 6,000,000 20,000 " 7th < ; 5,000,000 15,000 10th day 10,000 to 14,000 12th to 18th day 12,000 1st year 10,000 6th year and upward 7, 500 Five varieties of white corpuscles are found normally in human blood, and these are classified as follows by Ehrlich : 1. Lymphocytes (Plate XII. , facing page 874). — These are about the size of a red corpuscle, and contain one large, round, deeply staining nucleus which entirely fills the cells. The protoplasm is not granular and stains faintly or not at all. 2. Large Mononuclear (Plate XII.). — These cells are much larger than the lymphocytes. They have one large oval nucleus with a broad margin of non-granular, almost colorless protoplasm about it. 3. Transitional (Plate XII.). — These cells are derived from the last form and are similar in size and color. The nucleus is indented on one side as the result of the beginning of nuclear division. These three varieties are sometimes called basophiles. (Hewes.) 4. Polynuclear Neutrophiles (Plate XII.). — These are round cells, smaller than the large mononuclear, having a peculiar polymorphous deeply staining nucleus. The nucleus is long, irregular or twisted, and when stained often appears segmented. The protoplasm contains fine granules which are stained by neutral stains. 5. Polynuclear Eosinophiles (Plate XII.). — These cells are usually about the size of neutrophiles and have a deeply stained polymorphous nucleus. The protoplasm contains granules which are much coarser than those of the neutrophilic cells, and which stain readily with acid stains. These cells are sometimes called oxyphiles. (Hewes.) 6. Myelocytes (Plate XII.). — These are round or ovoid cells with one, rarely two, large round or slightly bent nuclei which stain light blue. There are two varieties, neutrophilic and eosinophilic. The first has a protoplasm crowded with fine neutrophilic granules. The second con- tains coarse eosinophilic granules. Myelocytes rarely, if ever, appear in normal blood, but are much increased in some of the pathological states. THE BLOOD IN INFANCY AXD CHILDHOOD. 879 Percentages of Various Leucocytes in Normal Blood. — Concerning the percentages of the different leucocytes in normal blood, it is sufficient to say that the blood of infants differs from that of adults in that the blood of the latter contains from 62 to 70 per cent, of neutrophiles, the re- maining 40 to 25 per cent, being made up of mononuclear cells, of which about 28 per cent, are lymphocytes. The following figures illustrate this : TABLE 74. Adults. Infants. Small mononuclear 20 to 30 per cent. 50 to 70 per cent. Large mononuclear 4 to 8 " 6 to 14 " Neutrophiles 62 to 70 " 28 to 80 " Eosinophiles i to 4 " ^ to 10 " Gundobin finds very little change from the above figures until the beginning of the third year, when the blood resembles more that of adults, the neutrophiles and mononuclear elements being present in about equal proportions. In children of eight or ten years he found very little difference from the blood of adults. His conclusions are that an infant's blood is (1) richer in white corpuscles ; (2) richer in young form elements, the absolute and relative counts of the lymphocytes being three times as large as in the blood of adults, while the " overripe" elements, or neu- trophiles, are half as many ; (3) in infants the white corpuscles remain relatively longer in the " unripe," and in adults in the "overripe" stage. Variations in temperature and physical exertion seem to have no effect upon the number of white corpuscles, but digestion leucocytosis is often quite pronounced. Most authors place the normal percentage of eosinophiles between 2 and 10 per cent. It is safe to say that they may be somewhat increased, even considerably, in infants' blood without having the same significance as in adults' blood. THE BLOOD IN ABNORMAL CONDITIONS. It is recognized that all the signs by which' sickness is shown in the blood of adults are exaggerated in that of children. In my clinical work among infants I have noticed that their blood is much more sensitive to the action of adverse influences, such as poor air, improper hygienic surroundings, improper food, the inhalation of arsenic, and numerous other causes, and that anaemia is much more easily induced than in adults. This is especially noticeable in the impoverishment. of the blood which follows gastro-enteric disease. Not only is an anaemic condition of the blood acquired by these influences, but also in congenital weaknesses which may be represented by infantile atrophy, or in some other inherited diseases, such as tuberculosis and syphilis, or in such acquired diseases as rhachitis, the development of the blood may be retarded. In this class of cases the blood of a child three or four years old may show no higher degree of development than that of a healthy infant in the second year. It is also found that when certain diseases occur in young children the 880 PEDIATRICS. blood is apt to revert to a more infantile condition, and that the normal leucocytosis of infancy may represent disease at a later period. Again, the erythrocytes under certain morbid conditions may revert to an earlier type, such as nucleated corpuscles. One of the most important points to be remembered is that a physiological leucocytosis depending upon digestion is commonly met with in infancy, and to a much greater degree than at a later period of life, so that what would be a normal leucocytosis at different times of the day, in reference to the food which has been taken, must always be borne in mind. It is therefore evident that when we are considering the blood of an infant or young child in any given disease we should take into consideration what the conditions of the blood usually show in the individual. — namely, as to whether a normal condition, according to the age, was present before the onset of the disease, or whether the especial individual had already an abnormal blood from backward development or from some inherited or congenital condition. Enlargement of the spleen in infants is not so significant as in adult life, for whenever anaemia is present there is apt to be an asso- ciated enlarged spleen. A classification of diseases of the blood is as difficult to make and as unsatisfactory as that of infectious and non-infectious diseases. The one heading, however, under which all abnormal conditions of the blood may be brought is that of anaemia. It is probable that all the anaemic con- ditions of the blood will in the future be proved to be secondary, but when the causes of the pathological conditions found in the blood are difficult to find, or apparently are insufficient to cause so severe a disease as is present, we speak of primary anaemia, while we speak of secondary anaemias as those which have some obvious cause, such as rhachitis, malaria, syphilis, or hemorrhage. Specific Gravity. — In various pathological conditions the specific gravity of the blood may be increased or diminished. Its changes usually run parallel with those in the amount of haemoglobin, on which, in fact, it is largely dependent. It is diminished in all forms of primary and secondary anaemias, being most diminished in leukaemia and pernicious anaemia (1028). It is usually diminished in nephritis (1040) as a result of the small amount of albuminous substance in the serum. It is sometimes increased in cardiac affections, and especially in tubercular meningitis. Haemoglobin. — In children the variation in the amount of haemoglobin present from day to day is more marked than in adults, boys usually having more haemoglobin than girls. It is diminished in secondary anaemia and in chlorosis, and lowest in leukaemia and pernicious anaemia (15 to 20 per cent.). Red Corpuscles {erythrocytes). — A diminution in the number of red corpuscles is found in a large number of acute and chronic diseases, especially in those accompanied by a marked anaemia. Instances of these diseases are rhachitis, syphilis, tuberculosis, malaria, and chronic ileo- THE BLOOD IN INFANCY AND CHILDHOOD. 881 colitis. In leukaemia, and especially in pernicious anaemia, the number may fall to 500.000 per cubic centimetre. Certain drugs, such as arsenic, may in poisonous doses cause a marked diminution in the number of red cells. In recovery from acute anaemia the red cells regain their normal number much more rapidly than they do their haemoglobin. The red corpuscle, which normally has a size of from six- to nine- thousandths of a millimetre, may undergo changes in size or shape, and cells much smaller (microcytes) or larger (macrocytes) than the normal reel corpuscles may appear, also cells having oval, pointed, or irregular forms (poikilo- cytes). I have already spoken of the fact that nucleated red corpuscles are found normally in the blood of young infants. They also readily ap- pear in quite large numbers in anaemia. There is, however, an essential difference in their significance in adults and in young children. In the former they only appear at a late period in severe anaemia, and therefore have a grave significance, while in children they readily appear in the blood in simple anaemias which go on to recovery. White Corpuscles (leucocytes). — The white corpuscles are affected in a temporary or permanent manner by many physical and pathological conditions in the body at large as well as in the blood-forming organs. The most common change from the normal is that of leucocytosis. Leu- cocytosis was originally described by Ehrlich as the presence in the blood of a greater number of white cells than normal for the individual, or a relatively increased number of any variety of white cells, with or without an increase in the total number of leucocytes. Cabot has restricted the term leucocytosis to an increase of leucocytes in which the polynuclear cells predominate, and uses the terms lymphocytosis and eosinophilia to describe a relative increase of the lymphocytes and eosinophiles. Physio- logically, we find a leucocytosis after the ingestion of any proteid food. It is at its height about two hours after a meal, when the total number of leucocytes may be as great as from 13,000 to 30,000, according to the age of the child. Pathologically, a leucocytosis follows a consider- able number of diseases, and seems in a general way to depend upon the amount of local reaction to which the disease gives rise. We find a pronounced leucocytosis in most fevers and in most septic processes. In these cases the increase is almost Avholly composed of the polynuclear neu- trophiles, which may make up from 90 to 98 per cent, of the entire leuco- cyte count. The leucocytosis does not depend on the degree of fever, does not always occur with it, and conversely inflammatory leucocytosis may appear before the fever. Pneumonia shows generally a leucocytosis. In pneumonia the large increase in the number of leucocytes seems to follow closely the course of the pathological process, and the "blood crisis ,, is found to anticipate the "temperature crisis" by some hours. Pericarditis and endocarditis, advanced pulmonary phthisis, pleuritis, erysipelas, acute rheumatism, purulent meningitis, pharyngitis, diphtheria, septicaemia, osteomyelitis, scarlet fever, variola, tonsillitis, bronchitis. 5G 882 PEDIATRICS. peritonitis, acute nephritis, gastroenteric inflammation, rhachitis (espe- cially basophiles), some profound anaemias, whether primary or secondary, leukaemia, hemorrhage, malignant new growths, abscess of any kind, in- cluding appendicitis, and many skin diseases are among the affections that show leucocytosis. In leukaemia the leucocytes are increased more than in any other disease, they may reach 500,000 per cubic millimetre, and the proportion of the white to the red corpuscles may be 1 to 20 or even 1 to 6. Certain drugs cause leucocytosis, such as pilocarpine, antipyrin, thyroid extract, and tuberculin. The diseases in which the leucocytes are approximately normal are malaria, tubercular meningitis, tubercular and serous peritonitis, influenza, measles, typhoid fever, pulmonary tuberculosis (unless there is a secondary infection by other bacteria), rubella, mumps, and most cases of epidemic influenza. Comparing these two lists it will be seen that there are in- stances in which the leucocyte count may be of great importance to the physician in making a differential diagnosis. By its aid Ave may in some cases differentiate scarlet fever from measles, a purulent from a tubercular meningitis, and a beginning pneumonia from a tubercular meningitis or typhoid fever. We may also differentiate typhoid fever from appendi- citis, and from osteomyelitis, from ileo-colitis, and from septicaemia, also tubercular peritonitis from septic peritonitis. Lastly, we may by the leucocyte count alone be able to distinguish between sepsis and malaria in a patient whose only symptoms are malaise and returning chills, LEUKEMIA. The disease called leukaemia sometimes occurs in infancy and child- hood. Klebs, von Jaksch, and Sanger describe congenital cases. On the whole, it is a rare disease in infancy, and when it occurs it is probably always a mixed form. A pure myelogenous form of leukaemia is very rare. The etiology of the disease is obscure. Cases have been reported which followed congenital syphilis and rhachitis. It is thought by some to be an infectious disease, but the evidence is insufficient. Von Limbeck thinks that it is a disease of the lymphatic system. Others say that any anaemia or Hodgkin's disease may progress to leukaemia under certain cir- cumstances, as may also anaemia infantum pseudo-leukaemica. A number of the cases are apparently primary. Males are more prone to the dis- ease than females. The essential feature is a persistent increase in the number of the white corpuscles of the blood, associated with changes in the spleen, lymph-glands, or bone-marrow. Pathology. — Leukaemia is a rare affection in infancy and childhood, and the recorded observations of these cases in early life are very in- complete. In the splenic myelogenous form the spleen is much enlarged. The condition of the organ is one of chronic hyperplasia, often with grayish-white lymphoid tumors scattered through it. The essential change in the bone-marrow is a great hyperplasia of the red marrow, THE BLOOD IN INFANCY AND CHILDHOOD. 883 which contains large numbers of nucleated red corpuscles in all stages of development, also myelocytes and other cells. In the lymphatic form of the disease there is a general enlargement of the lymphatic glands and other lymphoid tissues as a result of simple hyperplasia. This is usually associated with a moderate enlargement of the spleen. The liver, as a rule, is considerably enlarged in both forms of leukaemia. Leukaemia is one of the few diseases which can be diagnosticated definitely from the blood examination alone. There is a more or less marked diminution in the number of the red corpuscles, the blood count ranging from 2,000,000 to 4,000,000, except in the early stages, with some irregularities in the size and shape of the corpuscles. The haemo- globin is usually much diminished. The important change is in the leu- cocytes, which are enormously increased in number, the proportion being frequently 1 to 15 of the red, and sometimes even 1 to 3. In the splenic myelogenous form the chief point of interest is the great increase in the number of myelocytes, which average about 35 per cent, of the white corpuscles, and may be even 60 per cent. The eosinophiles are some- times relatively increased. The percentage of polynuclear neutrophiles is usually diminished, and the lymphocytes show a great relative diminu- tion. Many nucleated red cells are present. In the lymphatic form the character of the blood is materially different, and the increase in the number of leucocytes is not usually so great. The increase is due solely to the lymphocytes, all the other forms being greatly diminished rela- tively. Eosinophiles and nucleated red cells are rare. Myelocytes are not present or are rare. This description of the blood applies to chil- dren as well as to adults, but there are practically no complete data as to the character of the blood of leukaemias in infancy. Symptoms. — The onset is insidious, and usually the first striking signs are progressive enlargement of the abdomen, enlarged glands, shortness of breath, and general weakness or hemorrhages from the mucous mem- branes. The progress of the disease is usually much more rapid in chil- dren than in adults. The symptoms are similar in the two types of the disease. The lymphatic form of the disease is more common than the splenic myelogenous in infants and children. The child becomes gradually pale and weak, and suffers from dyspepsia and repeated diarrhoea. The respirations are accelerated, and dyspnoea is shown on slight exertion. Fainting attacks may occur. Hemorrhage from the nose is common, and may occur from the stomach, intestine, or kidneys, or into the skin. The pulse is usually rapid and soft. There are rarely any cardiac symptoms. Headache and vertigo are marked at times. Vision may be much im- paired as the result of retinal hemorrhages or leukaemic plaques. Tender- ness over the shafts of the long bones has been occasionally observed. The urine presents no constant changes. It occasionally contains albumin and casts. A moderate degree of fever is usually present in the late stages, also oedema of the feet and general anasarca. 884 PEDIATRICS. The following table shows the average percentages of the different ele- ments of the blood in the splenic myelogenous and lymphatic leukaemias : TABLE 75. Average Percentages of the Different Elements of the Blood in the Splenic Myelogenous and Lymphatic Leukaemias. Splenic Myelogenous Lymphatic Leu- Leuksemia. ksemia. Haemoglobin 25 to 50 per cent. 25 to 40 per cent. Red corpuscles 2,000,000 to 3,000,000 2,000.000 to 3.000.000 White corpuscles 100,000 to 400,000 50,000 to 100,000 Lymphocytes 10 per cent. 96 per cent. Polynuclear leucocytes 50 " 3 " Eosinophils 5 " rare. Myelocytes 35 " usually absent. Nucleated reds very numerous. rare. Diagnosis. — A distinction is chiefly to be made between leukaemia and Hodgkin's disease, or secondary anaemia with leucocytosis, which in infancy is often accompanied by an enlarged spleen. The difference between leukaemia and pseudo-leukaemia, if such can be said to exist, is explained on page 888. The differential diagnosis of leukaemia is impossible by means of the clinical history, and can be made only by examination of the blood. The increase in the number of leucocytes is far greater, as a rule, in leukaemia than in other conditions, but the characteristic feature in the splenic myelogenous form is the presence of abnormal cells, namely, the myelo- cytes, and in the lymphatic form a great absolute and relative increase of the mononuclear cells. In Hodgkin's disease and in the secondary anae- mias with leucocytosis there is a simple increase of the normal forms of leucocytes. In some cases of Hodgkin's disease also the blood may be normal. Chronic adenitis, which might be confounded with lymphatic leukaemia, shows usually normal blood, and is thus readily differentiated. In distinguishing between the two forms of leukaemia we rely much more on the quality of the blood than on the other clinical characteristics. Prognosis. — The course is chronic and usually progressive, although recovery occasionally occurs. The great majority of cases prove fatal within a few months, although occasionally cases have been reported of three to five years' duration. Epstein and others have described an acute form with a rapid course of a few days or weeks. High fever, frequent hemorrhages, and marked oedema are unfavorable symptoms. The lym- phatic cases run a shorter course and are more uniformly fatal than those of the splenic myelogenous type. Treatment. — As in all cases of anaemia, fresh air and careful feeding are important indications. We have no specific for the disease, and the results of treatment by drugs of any kind are discouraging, although an occasional rare recovery has been reported. Arsenic given in large doses has proved the most efficient remedy. Iron is also of some value. Or- THE BLOOD IN INFANCY AND CHILDHOOD. 885 ganotherapy has been used lately with some success. Bigger, de Feo- dosia, and Whait reported cases of rapid improvement after giving bone- marrow by the mouth. A glycerin extract of the spleen has been tried with little success. The results of splenectomy thus far indicate that it is not a desirable measure. The following case of acute leukaemia occurred in the practice of Dr. Morse : The child, a girl, was three years old and was healthy at birth. Her mother had died of pneumonia when she was two years old. Her father was well. There was no tubercular or syphilitic history. She was nursed for a year and then fed from the table. She was always subject to diarrhoea, but otherwise had been well. No history could be obtained except that six days previous to being seen blood-spots had appeared on the skin and the mouth had become sore. She had also vomited blood and had passed some blood from the bowels. She looked seriously sick and was very pale, but was fairly developed and was not especially thin. Her gums were swollen, spongy, and bleeding, her tonsils were large, and her throat was reddened. There was a systolic murmur over the precordia. The lungs were normal. The abdomen was lax. The edge of the liver was felt about one inch below the costal border. The spleen was palpable below the border of the ribs to the extent of three inches in breadth and two inches in length. There was slight glandular enlargement. There were numerous petechias over the legs and abdomen. There were no evidences of rhachitis, no tenderness about the joints, nor swelling over the long bones. The temperature was normal. The blood count was as follows : Haemoglobin 25 per cent. Ked corpuscles 2,024,000 White corpuscles 87,400 Lymphocytes 83 per cent. Large mononuclear cells 11 " Polynuclear neutrophils 5 " Eosinophils 1 " There was a slight variation in the size of the red corpuscles, almost none in shape. There were no nucleated forms, and no myelocytes. A fresh liquid diet, lemon-juice, and stimulants were ordered. The bleeding from the gums and bloody discharges continued, as did the purpuric efflorescence. The child was not seen again, but died a week later. There was no autopsy. In the light of the above history and blood examination there can be no doubt as to the correctness of the diagnosis of acute lymphatic leukaemia. If the history can be accepted as correct, the onset was acute, there were subcutaneous hemorrhages and bleeding from the gums, and the duration of the disease was only two weeks. Owing to the circumstances of the child's surroundings, however, it is possible that these marked symptoms may have been preceded for a time by others less noticeable. The duration of the disease could not have been more than seven weeks. Although the glandular enlargement was not marked, that of the spleen was considerable. The great bulk of the white corpuscles was made up of lymphocytes. The large mono- nuclear forms were also somewhat increased in number. The following case of splenic myelogenous leukaemia also came under the observation of Morse at the Infants' Hospital : A boy, one year old, came to the out-patient department on April 26. His parents were Russians, and seemed well and strong. No history of syphilis or tuber- 886 PEDIATRICS. culosis could be obtained. Four other children were alive and well, two had died of some acute disease in Russia. No very definite history of his illness could be obtained. He was weaned at three months and had been fed exclusively on condensed milk for six months. He had been failing gradually for some months. His abdomen had been large for two months, and he had been unable to lie on his left side for one month. He had never had epistaxis or hemorrhages from the stomach or bowels. He had never had any eruption on the body. He vomited occasionally. His bowels were somewhat constipated, and the dejections were light-colored. The infant was markedly atrophic and anaemic. The head was large, the forehead prominent, and the anterior fontanelle widely open. There was a moderate rosary and an enlargement of the epiphyses, with slight bow-legs. There was marked enlarge- ment of the glands of the neck, axilla?, and groins. The heart and lungs were normal. The abdomen was very much enlarged, but contained no fluid. The superficial veins were distended. The dulness of the liver began at the upper border of the fifth rib in the mammillary line, and the lower border could be felt round and smooth about two fingers' breadth below the costal border in the same line. The spleen was very much enlarged. It could be felt beneath the costal margin just outside the parasternal line, and just outside the umbilicus ; it then extended beyond the middle line, and filled up almost the whole left iliac region. The notch could be plainly felt. The spleen and abdomen were not at all tender. There were hemorrhagic spots on the skin. The blood examination made at this time is given below. It was impossible to keep the child under observation, but he was seen again on May 28. He had failed rapidly during the month. His skin was very pale with a decided yellow tinge, the face, body, and extremities being thickly covered with pur- puric spots, varying in size from that of a pin's head to that of a lead-pencil. These spots had appeared two days before, at which time he developed a cough, and refused to eat. He had no other hemorrhages. The bowels were loose, the dejections were of normal color, and there was no vomiting. An examination of the chest showed a broncho- pneumonia involving the lower two-thirds of the left lung, and a well-marked bron- chitis in the right lung. The heart was normal. The abdomen was rather more dis- tended, was not tender, and there was no fluid. There was a slight increase in the size of both the liver and spleen. He was almost moribund. The usual association of leukaemia with rhachitis was present in this case, the leukaemia having probably developed subsequent to the rhachitis. The latter was un- doubtedly due to improper food and surroundings, and it seems more reasonable in the present state of our knowledge to consider the leukaemia as arising from the same cause rather than secondary to the rhachitis. The blood count made on April 26 showed 2,900,000 red corpuscles and 48,000 white corpuscles per cubic millimetre, giving a proportion of 1 to 60. The differential count of one thousand white corpuscles on slips dried and stained with Ehrlich's triple stain resulted as follows : Small lymphocytes 23.4 per cent. Large lymphocytes and transitional forms 8. 1 " Myelocytes 21.4 ' ; Polynuclear neutrophils 46. 5 " Eosinophils 6 " A slip stained with eosin and methylene blue showed numerous mononuclear and polynuclear cells with fine granulations which took the eosinophile stain feebly. A slip stained with dahlia showed the presence of very few " mastzellen." Numerous partially destroyed cells, both mononuclear and polynuclear, were found. There was a very marked poikilocytosis. a moderate number of microcytes, and numerous macrocytes, many of these being three times the diameter of a normal red THE BLOOD IN INFANCY AND CHILDHOOD. 887 corpuscle. Many of these forms lacked the normal concavity. Nucleated red cells were present in great abundance. No microblasts were seen. Many cells the size of normal corpuscles were met with in which the nucleus was smooth, feebly stained, and with little nuclear structure, the protoplasm being not quite homogeneous, ''wrinkled/' and stained a reddish violet. These may perhaps be regarded as undeveloped normo- blasts. Normoblasts were very abundant, and always with one nucleus, which showed a well-developed nuclear structure, and which occasionally presented indentations as if division was beginning. The nucleus was rarely in the centre, often on the side, some- times half-way out of the cell and occasionally free. The protoplasm was ordinarily narrow, but sometimes wide. A few cells were met with from which the nucleus had probably escaped. Megaloblasts were quite numerous and presented the same varia- tions as the normoblasts. In addition to these a number of large oval cells were seen which contained two nuclei, the long diameter of the cells being about four times that of the normal red corpuscles. In several of these well-marked karyokinetic figures were present ; these variations in the erythrocytes, of course, merely showed a severe grade of secondary anfemia. PSETJDO-LETJKJEMIC ANJEMIA OF INFANCY. Von Jaksch in 1889 and 1890 was the first to describe this disease and give it its title. Since then it has been the subject of much investiga- tion and contention, and there appears to be a great difference of opinion among those who use the term as to what constitutes the disease. Von Jaksch based his diagnosis on the following points. (1) It is a disease of infancy whose symptoms and course correspond to the picture of leu- kaemia. (2) It is characterized by a marked reduction in the number of red corpuscles and in the haemoglobin, and a marked leucocytosis, a great enlargement of the spleen with only a moderate or slight enlarge- ment of the liver, and with at times enlarged lymphatic glands. It is clinically differentiated from leukaemia by the disproportion existing be- tween the size of the liver and the spleen. The course of the disease is less rapid and the prognosis better than in leukaemia. Luzet, Alt, and Weiss give the following additional description of the blood. There is marked irregularity in the size and shape of the red cells. Many nu- cleated red cells, normoblasts and megaloblasts, many with dividing nuclei (karyokinesis), and many polychromatophilic red cells are present. The karyokinesis is regarded by some as characteristic of the disease. The leucocytosis is a polymorphous one. The eosinophilic cells vary in number and are at times much increased. Etiology. — This disease is found in infants usually between the ages of six and twenty months. It is more frequent in girls than in boys. Von Jaksch considers it a primary condition. Fischl and Epstein believe it may be secondary to many conditions, such as septicaemia, tuberculosis, intestinal infections, and syphilis. In the twenty cases reported by Monti and Berggrtin, sixteen had a history of syphilis, and one of rhachitis. Monti says it may develop from cases of severe anaemia with leucocytosis and believes it may terminate in leukaemia. Pathology. — The spleen is always enlarged ; it may attain to from four to sixteen times the normal weight, and extend to the crest of the ileum. 888 PEDIATRICS. It is firm, with rounded edges, and shows microscopically a simple hyper- trophy of the spleen pulp. The liver is enlarged in about half the cases, and much less in proportion than the spleen. Histologically it has the character of the fcetal liver. The lymph-glands have been moderately enlarged in about half the reported cases. The bone-marrow was found to be congested in some cases. Symptoms. — The chief features of the blood in pseudo-leukaemia have been already noted. The reduction of the haemoglobin often reaches as low as 30 per cent. The specific gravity ranges between 1040 and 1035. The proportion of white to red cells is usually 1 to 100 or 1 to 75, in severe cases reaching 1 to 20 or 1 to 12. The red cells usually number between 2,000,000 and 3,500,000, sometimes 1,000.000 or less. The leucocytosis ranges from 30,000 to 100,000. The onset is always insidious, sometimes with gastro-enteric disturb- ance and the usual signs of anaemia ; marked pallor and weakness develop slowly. The child becomes apathetic, but does not appear to suffer, and often remains plump and well nourished. Sometimes a slight cedema of the dependent portions of the body appears. The abdomen becomes prominent, and sometimes uniformly distended, again only in the region of the spleen, which becomes very large and easily palpable. Digestion is impaired. The urine is usually normal, but occasionally a slight al- buminuria appears. There may be occasional elevations of temperature, even in the absence of any complication. The course of the disease is a chronic one, lasting several months or a year, not longer. It is not neces- sarily fatal ; recoveries have been reported by von Jaksch, Monti, Comby, and others. The infants are so feeble, however, that they are very apt to be carried off by intercurrent diseases. Cases have been reported by various authors which apparently developed from an ordinary severe simple anaemia, and others have been noted in which the blood gradually developed all the characteristics of leukaemia. In fact, certain observers have regarded the pseudo-leukaemic anaemia of infants as an early stage of leukaemia. Diagnosis. — This disease is to be especially distinguished from simple anaemia with leucocytosis on the one hand, and from leukaemia on the other. In the first the leucocytosis is smaller and the splenic enlarge- ment much less. In leukaemia the leucocytosis has a different character, and there is less reduction in the red cells and in the haemoglobin ; there is also a proportionately greater hepatic enlargement and a relatively un- favorable course. With reference to the status of this disease, it is still an open question whether the pseudo-leukaemic anaemia of infants can be considered as a distinct disease. The descriptions of the disease given by various authors are far from being identical ; in fact, they vary so much that it is hard to see why the same title is given to them. Some authors consider it always primary, and would rule out all cases developing with rhachitis, syphilis, THE BLOOD IN INFANCY AND CHILDHOOD. 889 or tuberculosis, while others would include them. Among the cases reported under this name have been unquestionably included some of leukaemia, pernicious anaemia, and secondary anaemia with leucocytosis. The condition of the red cells is not characteristic. It may occur in any severe anaemia. The leucocytosis is not characteristic of the disease, it is simply a question of degree. Cases of ordinary secondary anaemia which have been closely observed appeared to develop into pseudo-leuksemic anaemia, and von Jaksch claims to have seen pseudo-leukaemic anaemia develop into a leukaemia. In short, it is held by leading authorities, such as Raudnitz, von Limbeck, Ebstein, and Fischl, that there is nothing in the etiology, clinical history, or blood to justify its classification as a separate disease, and that the majority of the cases reported under this title are simply severe types of secondary anaemia. We must look to the future to decide these questions. Prognosis. — The mortality has not been over 20 per cent. The prog- nosis should always be guarded, but not hopeless, and if the leuco- cytosis remains moderate and no complications occur, an arrest of the morbid process may be expected. Treatment. — The combination of arsenic with iron is most valuable in this disease. The arsenic is best given in the form of Fowler's solution in drop doses repeated several times a clay after feeding. The general treatment is the same as in secondary anaemia. The following case of pseudo-leukaemia was treated in my wards at the Children's Hospital : A boy, three years of age, had never had any disease, with the exception of a questionable malaria, from which he had entirely recovered two years previously. Since his second year he had been pale. He entered the wards on October 4. He was then of a waxen color, and the mucous membrane of the lips and nails was nearly white and had a livid tinge. The skin was almost translucent. There was not much emaci- ation. The spleen was considerably enlarged and could easily be felt about two inches below the border of the ribs. The liver was slightly enlarged and palpable. The glands in the neck, axillae, and groins were enlarged to the size of peas. On percus- sion the heart showed no enlargement. Aloud systolic murmur was heard overall the cardiac orifices. The action of the heart was very rapid but regular. Its impulse was in the fifth interspace inside of the mammiliary line. Auscultation and percussion of the lungs showed that they were normal, with the exception of some sibilant rales. The respirations were 30 to 44 in a minute. The temperature at entrance was 38.8° C. (101° F.), and afterwards varied from 39.5° C. (103.8° F.) to 38.3° C. (101° F.). The pulse varied from 125 to 150. Diarrhoea was present when the child entered the hos- pital, and at first there were from four to six very offensive movements daily. For three or four days preceding death the movements were more frequent, but not so offen- sive, and contained mucus. Vomiting occurred at times. The infant was treated with modified milk, bismuth, and stimulants. An examination of the blood. October 13, resulted as follows : Ked corpuscles 1,295,000 Haemoglobin 15 per cent. "White corpuscles 64, 500 890 PEDIATRICS There were numerous poikilocytes, microcytes, and megalocytes. A number of the corpuscles were pale and many of them contained very little haemoglobin. There were numerous nucleated red corpuscles, chiefly normoblasts, and in many of them the nuclei were undergoing subdivision. The eosinophiles were absolutely and relatively increased. No myelocytes were present, and the leucocytes were largely of the poly- nuclear form. The child died October 20 and a partial autopsy was obtained. A mi- croscopic examination showed no evidence of leukaemia in the liver, spleen, kidneys, or lymph-glands. There was no evidence of syphilis or rhachitis, nor of any inflamma- tion which could have caused the leucocytosis. PRIMARY ANAEMIAS. Pernicious Anaemia. —This is the most severe form of primary anae- mias, and is characterized by quite constant changes in the blood, usually developing without evident cause, and a progressive course, leading to a fatal termination in the majority of cases. Etiology. — This disease is much less frequent in children than in adults, the proportion of cases being about one to seventeen. It is less common in infancy than in later childhood. Of twenty-five reported cases, four were between the ages of three months and two years, four between three and five years, eight between six and ten years, and nine between ten and fifteen years. In the majority of cases no definite cause has been discovered. In some, the following etiological factors have been noted : syphilis, severe rhachitis, especially with splenic enlargement, and intesti- nal parasites, such as taenia, ankylostoma, and bothryocephalus. The best theory for the explanation of the condition seems to be that of a toxic haemolysis. There are evidences of increased destruction of blood- cells in the urine, blood, and tissues, and also of a compensating hyper- trophy in the blood-forming organs. There is considerable evidence that the alimentary tract is the source of the unknown toxins causing hae- molysis. Pathology. — The body is not often emaciated. The skin usually shows a lemon-yellow tint. There is marked anaemia of the organs at times, with many capillary hemorrhages into the organs and skin. The heart is large and flabby, and shows intense fatty degeneration. The liver is fatty and sometimes enlarged. The kidneys and blood-vessels show fatty changes. One of the most characteristic features is a deposit of iron in the liver tissue and often in the intestinal mucosa. The spleen is hard and somewhat increased in size as a result of overgrowth of the fibrous tissue of the pulp. Some of the lymph-nodes are often enlarged. The bone-marrow is " splenified," — that is, returned to its embryonic state. Symptoms. — Blood. — The red corpuscles are much diminished, usually to one million, sometimes even to five hundred thousand. The haemo- globin is diminished per bulk of the blood, often to twenty-five or thirty per cent., rarely to twelve or fifteen per cent., but owing to the greater reduction of red cells it is often relatively increased per corpuscle (the color index is high and sometimes greater than normal). This is exactly THE BLOOD IN INFANCY AND CHILDHOOD. 891 the opposite condition to that which occurs in chlorosis. The red cells show great variation in shape and size, many oval or rod-shaped or irreg- ular corpuscles are present, which take stains in an uneven way. A majority of the red cells are larger than normal (megalocytes). Many nucleated red cells are present, both of normal size (normoblasts) and of larger size (megaloblasts). The megaloblasts are the more numerous of the two. Many of the nuclei are found in a process of division (karyo- kinesis). The leucocytes are normal in number, or somewhat diminished, — eight thousand to four thousand. In the more severe cases there is fre- quently a relative increase of the lymphocytes with a corresponding dimi- nution of the polynuclear cells. A few myelocytes are not infrequently found. The general symptoms are those of severe anaemia, increasing pallor and prostration, usually without emaciation. The onset is insidious, and the clinical course does not differ from that of adults. There is fre- quently more or less gastroenteric disturbance, vomiting, nausea, or dyspnoea. Hemorrhages occur into the skin or from the nasal and other mucous membranes. (Edema often appears in the dependent portions of the skin, less frequently in the cavities of the body. Haemic murmurs are usually heard in the cardiac region. The pulse is full and soft. It is to be noted that hsemic murmurs are less frequent in the anaemia of infants than in that of adults. The urine is scanty and of low specific gravity. The temperature is variable ; at times it may be normal, and at others an irregular pyrexia may run for a considerable period. The course is a chronic one, but varies in length. The disease may be completely devel- oped in some cases in two or three months, and in others only after ten or twelve months. In most instances it progresses steadily to a fatal termination. Diagnosis. — The diagnosis from other forms of anaemia is made chiefly by the blood examination. The characteristic features are : (1) Great diminution in the number of red cells. (2) Relative increase of haemoglobin per corpuscle, — high-color index. (3) Irregularity of distribution of haemoglobin in the red cells. (4) Marked irregularity in form and size, and a general increase in size of the red cells. (5) An excess of megaloblasts over normoblasts. (6) A normal or diminished leucocyte count. Prognosis. — The prognosis is almost absolutely fatal, except in those cases associated with intestinal parasites or rhachitis, although lately, when arsenic has been given, the proportion of recoveries has increased. The blood examination is a valuable index to the prognosis. The pres- ence of many normoblasts is hopeful, pointing to a regeneration of the bone-marrow. The presence of a large excess of megaloblasts indicates a more malignant case. Treatment. — Arsenic is more useful than iron in this form of anaemia. 892 PEDIATRICS. It is usually well borne, and should be given in small doses, gradually increased to the limit of tolerance. A child of ten years can usually take 2 c.c. (30 drops) of Fowler's solution in the twenty-four hours. Arsenic may also be given in pill form. Active exercise should be pro- hibited and replaced by massage, which is of great value and never to be neglected. Rest in bed, either absolute or for the greater part of the time, is essential. Small, frequent, and regular meals should be given, of light, nutritious food. Bone-marrow in the form of a glycerin extract has been recommended, but has thus far proved of doubtful value. The free administration of oxygen day and night for several weeks is Avorthy of trial, if expense is not to be considered. I have had one case in which the red cells had fallen to 1,088,000 and the haemoglobin to 20 per cent. Rapid improvement in the blood followed this treatment when carried out for over four weeks, and the blood eventually became normal. The case is still under observation. The following case, probably one of pernicious anaemia, though the result of the blood examination is not conclusive, was seen in consulta- tion with Dr. C. P. Putnam. The infant was healthy at birth, and up to the time of its present sickness had never had any disease. For several months it had grown progressively pale, its appetite had decidedly lessened, it had not lost materially in weight but had grown weak, and its mental hebetude had been so noticeable that a suspicion had arisen that it was lacking in cerebral development. On inspection the infant seemed moderately fat, but the muscles were soft and the' skin was of an extremely pale and waxen tinge. It was evidently very weak. On physical examination nothing abnormal was detected about the head, thorax, or abdomen. All the organs seemed to be of natural size. The blood examination showed the following : Red corpuscles 1,571,000 Haemoglobin 22 per cent. White corpuscles 19, 100 Small mononuclear 42 per cent. Large mononuclear 18 " Polynuclear 40 " The child died a few days later without showing any other symptoms. Chlorosis. — Chlorosis is a primary anaemia of unknown cause, char- acterized by a marked diminution in the haemoglobin in the blood with- out a corresponding loss in the number of red cells. It is not a dis- ease of infancy or of young children, but appears in girls, especially blondes, between the ages of twelve and seventeen years. The essen- tial cause is unknown. It is chiefly seen in overworked girls living amid poor hygienic surroundings. Psychical disturbance, such as grief, worry, and fright, are important factors. Clark has stated that the condition is a copraemia due to toxic absorption (ptomaines and leucomaines) from the intestine. THE BLOOD IN INFANCY AND CHILDHOOD. 893 Pathology. — Chlorosis is rarely fatal. In some cases hypoplasia of the heart, large vessels, ovaries, and uterus have been found, also con- siderable fatty degeneration of the heart and of the intima of the vessels. Gastric ulcer has been occasionally associated with it. Symptoms. — The essential change in the blood is a marked loss, in the individual red corpuscle, of the haemoglobin, which is often only 40 per cent., and in severe cases below 30 per cent. The specific gravity of the blood may be reduced to 1025, although usually not below 1035. The red cells in a few cases are normal ; in the majority they are reduced to 4.000.000 or may be even lower. The red corpuscles may be very irregu- lar in size and shape in severe cases, and may have an average size which is less than normal. Nucleated red cells are often seen, usually normoblasts, rarely megaloblasts. Leucocytosis is not present. The onset of chlorosis is gradual, the course chronic, and relapses are common. The symptoms are those of a simple anaemia. The patient complains of shortness of breath on exertion, and attacks of palpitation and syncope are common. The appetite is poor or perverted, and there is a craving for unusual and indigestible articles of diet. Gastric hyperacidity is often .present, and constipation almost always. Enteroptosis is not uncommon. The patient frequently complains of headache or neuralgic pains. Hysterical manifes- tations may occur. The menstrual function is often disturbed ; the flow is scanty, irregular, and sometimes painful. The patient is usually plump and soft, and the skin has a peculiar greenish-yellow tint which gives the disease its popular name of "green sickness." Systolic murmurs are frequently heard over the heart in the pulmonary or mitral region, and also a venous hum, the "bruit de diable," in the veins of the neck. Palpitation is occasionally seen in the jugular veins. There is a tendency to venous thrombosis, which most often occurs in the femoral veins. The pulse is full and soft. Occasionally there is some puffmess of the face, and often oedema of the ankles. The spleen may be slightly en- larged. The urine rarely contains a slight trace of albumin. Gastric ulcer sometimes occurs as a complication. Diagnosis. — The age and sex of the patient, the well-nourished con- dition, the pearly sclerotics, the color of the skin, and the character of the blood form a striking clinical picture which easily distinguishes chlo- rosis from other forms of anaemia. Prognosis. — The prognosis is almost always good. The disease often lasts a year and relapses are common. Chlorosis is rarely fatal, except when complicated by tuberculosis or gastric ulcer. Treatment. — There are few therapeutic measures in medicine more satisfactory than the use of iron in chlorosis. In infants the iron can be given in the form of the saccharated carbonate, 0.12, 0.18, or 0.24 gramme (2, 3, or 4 grains), or of the tartrate of iron and potash. Lactate of iron can also be* given to older individuals in doses of 0.06 to 0.12 gramme (1 to 2 grains), gradually increased to 0.24 to 0.36 gramme (4 to 894 PEDIATRICS. 6 grains), three times a day. The administration of iron is usually fol- lowed by a rapid increase in the number of red cells to the normal or even above it. The haemoglobin, however, increases more slowly. When iron is not tolerated, arsenic can be given in the form of Fowler's solution. When the iron causes constipation, it should be accompanied or followed with a saline or with some preparation of rhubarb. A change of scene is often beneficial, and later an out-of-door life and moderate exercise. SECONDARY ANJEMIAS. Under the title of secondary anaemia Ave include anaemia resulting from many kinds of pathological processes in the body which occur out- side of the blood-forming organs. Etiology. — Almost every disease of any organ in the body may produce a secondary anaemia, and it is of high or low grade according to the severity of the disease. There are two important factors in the process, — namely, an insufficient production of blood on account of poor food or poor assimi- lation, and the increased destruction of blood as it occurs in many wasting diseases. The anaemia of infancy may be either congenital or acquired. The congenital forms are inherited from delicate or anaemic parents, or from a mother who has suffered with syphilis, tuberculosis, or malaria during her pregnancy. Of the acquired anaemias, a comparatively small number of cases occur after hemorrhage, as in epistaxis, haemophilia, purpura, or scorbutus. The more frequent causes of anaemia in infants and young children are disturbances of digestion and assimilation, such as are represented by inanition and chronic indigestion resulting from im- proper quantity and quality of the food. Anaemia may also result from chronic diarrhoea, ileo-colitis, constitutional conditions resulting from unhygienic surroundings, bad air, close confinement, general debility, rhachitis, and also from malignant disease. Another cause is found in the drain on the albumin of the blood occurring in chronic suppuration, nephritis, and effusions, and still another in the toxaemia produced by mineral poisons, such as arsenic or lead, or by infectious diseases, such as septicaemia, diphtheria, scarlet fever, syphilis, malaria, and tuberculosis. Symptoms. — Luzet divides the anaemias of infancy into two classes, — those with splenic enlargement and those without, — and states that the first form is more severe, and that the blood in these cases contains a larger number of nucleated red cells. This classification is not a very satisfactory one, for we find very severe anaemias without splenic enlarge- ment, and also marked splenic hypertrophy in many cases of mild anae- mia. Monti and Berggriin propose another classification, which is more satisfactory. They divide all secondary anaemias into four classes : (1) Mild ancemias. (2) Mild ancemias with leucocytosis. (3) Severe ancemias. (4) Severe ancemias with leucocytosis. THE BLOOD IN INFANCY AND CHILDHOOD. 895 In the mild anaemias there is a moderate diminution in the specific gravity of the blood, in the haemoglobin, and in the red cells, and the latter show practically no changes in size and in shape. In the severe anaemias there is a marked diminution in the specific gravity, haemoglobin, and red cells, and the latter show considerable changes in size and form (poikilo- cytes. normoblasts, megaloblasts). The difference between these two types is one of degree. Either form may be associated with leucocytosis, and the forms with leucocytosis are much more common than those without, and are almost invariably the more severe. In all but the mild anaemias with- out leucocytosis the spleen may be enlarged. The number of red cells varies from normal, in the mild cases, to two million in the severe, the spe- cific gravity from 1056 to 1035, the haemoglobin from eighty to thirty per cent., the white count from normal to sixty thousand. In secondary anae- mia the reduction in the total amount of haemoglobin is almost always proportionately greater than in the corpuscles (chlor-anaemia). In gen- eral, the more severe the anaemia the lower is the specific gravity of the blood, the greater is the variation in size and shape of the red cells (poi- kilocytosis). and the more numerous the nucleated red cells. These last are much more abundant in children than in adults with a corresponding grade of anaemia. In these cases we have the familiar clinical picture of pallor, soft muscles, digestive disturbance, fretfulness, headaches, insom- nia, fatigue, and breathlessness on exertion. Occasionally epistaxis is associated with the signs and symptoms of the primary disease. Haemic murmurs are usually heard over the heart and the vessels of the neck. (Edema is more common in older children than in adults. Diagnosis. — In the diagnosis of these anaemias the recognition of the cause is very important. The diagnosis from the so-called primary anaemias is sometimes quite simple, by means of the blood examination, especially in older children ; in young children it is often very difficult, as a result of certain factors which have already been mentioned, — namely, the frequency of splenic hypertrophy in all forms of anaemia, the ease with which a leucocytosis is developed, the frequent occurrence of abun- dant myelocytes and nucleated red cells, and the fatality of all severe anaemias in children ; in short, the exaggeration of all blood changes in infants and young children. Prognosis. — The prognosis depends on the age, cause, and condition of the blood. The course of the anaemia is usually several months. Traumatic cases, which are rare in childhood, are the most benign, since in these cases the blood is readily restored to its normal condition. The group of cases which depend on toxaemia or a drain of the albumin of the blood, such as in suppuration, fever, or from other causes, are diffi- cult to treat, unless the cause can be removed. The severe cases may develop into a pernicious anaemia or a leukaemia, but death occurs more commonly as a result of some complicating disease rather than of the anaemia itself. The prognosis is naturally less favorable in cases in which 896 PEDIATRICS. the haemoglobin is reduced to 30 per cent, or less, and the red cells to half their normal number, with marked poikilocytosis. The cases with leucocytosis are graver than those without. Treatment. — It is of the first importance to treat the cause, as. for in- stance, cases which are secondary to malaria, syphilis, or rhachitis ; or to remove the cause, if possible, in cases of inhalation or ingestion of poisons, such as arsenic, impure air. or improper food. The general treatment in infants and young children is usually far more important than the use of drugs. The treatment of infants is. above all, prophylactic, with the object of protecting them from such unfavorable influences as may interfere with their health and proper development. The question of feeding or of adapting the food to the child's digestion is of great importance, and fresh air. in the country if possible, is indicated. The best forms of iron to be used in the secondary anaemias of infants and young children are the saccharatecl carbonate and the tartrate of iron and potash. At times arsenic in the form of Fowler's solution can be used. The following case of secondary anaemia, occurred in a child suffer- ing from rhachitis with splenic enlargement, and is represented in Fig. 86, page 337. The child was three years old and fairly well nourished. It had, however, en- larged epiphyses, a rhachitic rosary, a square, rhachitic head, and marked bowing of the legs. On physical examination there was no indication of enlargement of the liver or glands. The spleen was very much enlarged, its outline showing the notch as indi- cated in black. The blood examination gave the following result : Red corpuscles 2,686,250 Hemoglobin 35 per cent. White corpuscles 13,000 There were poikilocytosis and a marked pallor of the corpuscles. (Wentworth.) The following is a case of secondary anaemia occurring in connection with congenital syphilis with enlarged spleen, and is represented in Fig. 121. page 536. The infant was three months old, and was nursed by its mother. It was healthy at birth, and remained so until three months old, when it showed marked syphilitic symptoms, which later became very characteristic. It was faiily well nourished. The skin was of the waxen pallor characteristic of the higher grades of grave anaemia. There was a moderate enlargement of the liver, which, on palpation, was found to be hard and somewhat tender. The inguinal lymph-nodes were slightly enlarged. The post-aural lymph-nodes were enlarged. The spleen was much enlarged, and extended from the fifth rib to the left inguinal region. It had a peculiar tongue-shaped outline, and was hard but not tender. There were no other glandular enlargements." An ex- amination of the blood gave the following result : Nov. 17. Nov. 20. Red corpuscles 3.387.000 3,300,000 Hemoglobin 47 per cent. 45 per cent YVhite^eorpuscles 20.000 20.000 There was considerable variation in the size of the red blood-corpuscles, which were pale and showed a moderate degree of poikilocytosis ; there were also some microcytes THE LYMPH-NODES IN INFANCY AND CHILDHOOD. 897 and megalocytes. The mononuclear elements predominated. The eosinophiles were not numerous. (Went worth.) THE LYMPH-NODES. Pathological conditions of the lymph-nodes may be primary or second- ary. The primary forms are represented by simple inflammations of the lymph-nodes (simple acute adenitis), caused by the colon bacillus and other micro-organisms from the mouth and gastro-enteric tract. Among these organisms the tubercle bacillus holds an especially prominent place. The secondary forms are due to tuberculosis, syphilis, and anaemia, and have been considered under these diseases. SIMPLE ACUTE ADENITIS. Etiology. — The place of invasion of the infection which produces simple acute adenitis is either the skin or the mucous membranes, the bacteria or their toxines reaching the nodes by means of the lymphatics. The cervical nodes may be infected from a number of sources, such as irritation or lesions of the scalp, the ears, eyes, nose, throat, gums, or teeth. The bronchial nodes may be infected from inflammation of the trachea, bronchi, and lung tissue, such as in bronchitis and pneumonia. The mesenteric nodes may be infected from such conditions of the intestine as cholera infantum and ileo-colitis. Axillary adenitis may result from lesions of the arm, such as are pro- duced by vaccination ; and in a like manner inguinal adenitis my follow lesions of the foot and leg or inflammatory conditions of the genitals. Acute adenitis is also a frequent complication of the acute infectious diseases, especially scarlet fever, measles, and diphtheria. Infection and enlargement of the superficial nodes demand special consideration, as they are of frequent occurrence and are easily detected. Inflammation of the deeper nodes had best be described in connection with the organs with which they are especially connected, as their clinical recognition is so often impossible. Thus, when there is an acute inflam- mation of the bronchial or mesenteric nodes, general symptoms of cough and diarrhoea are usually referred to the lung or intestine, unless, as may occur in extreme cases, distinct symptoms of pressure in the thorax or palpable tumors in the abdomen are present. Pathology. — The affected nodes show a condition of acute congestion and hyperplasia, but do not become cheesy, except when the infection is tubercular. The process may end in suppuration or resolution, according to the severity of the infection. Suppuration is especially frequent in infants and young children, and the pus usually begins in the second or third week from the onset of the morbid process. Periglandular cellulitis is common when the inflammation is acute and severe. 57 898 PEDIATRICS. Symptoms. — There is very little or no constitutional disturbance in non-suppurative adenitis. The nodes are enlarged, hard, and tender, and if periadenitis is present, immovable. Lymphangitis and fever may be present. The swelling usually subsides slowly after a few months. In the suppurative cases there may be quite severe general as well as local disturbance, with fever and chills. The nodes, if opened, usually heal quickly and completely. Diagnosis. — The diagnosis of simple acute adenitis of the superficial lymph-nodes is not difficult, if some local condition can be found to ac- count for it. The differential diagnosis from tubercular adenitis is de- scribed under tubercular lymph-nodes, on page 390. Treatment. — The first effort in undertaking the treatment of these cases should be to seek for and remove the peripheral source of irritation which exists in most cases. Decayed teeth should be extracted, eczema of the scalp should be treated, and in all cases as much as possible should be done to diminish any irritation in the area of surface drained by the cervical lymphatics. During the active stage of cervical adenitis it is better not to make any application to the glands, but to treat any general disturbances, such as anaemia or debility, which may be present. If the glands suppurate, they should be freely opened, when the pus has pointed, and be treated with antiseptics. If there is much broken- down tissue, the abscess cavity should be curetted. SIMPLE CHRONIC ADENITIS. In cases of simple chronic adenitis . the enlargement of the nodes is due to a simple hyperplasia. Both the superficial and deep nodes may be affected, but for the same reason stated in speaking of acute adenitis, the affections of the superficial nodes only will be spoken of here. Chronic adenitis is much less common than acute adenitis, and rarely occurs except in infants and young children. It usually occurs as a re- sult of several attacks of acute inflammations or of chronic affections of the skin or mucous membranes. The nodes are usually more uniformly enlarged, but the swelling is not so great as in either the acute or tuber- cular forms. There is no constitutional disturbance referable to the nodes themselves. The course is slow, and may extend over a period of months or years. There may be an associated hypertrophy of lymphoid tissue elsewhere, as in that of the tonsils and in adenoids. Diagnosis. — From Tubercular Adenitis. — Simple chronic adenitis is most frequently confounded with tuberculosis. The chief points in the differential diagnosis are found in its usual occurrence in very young chil- dren at an age when glandular tuberculosis is uncommon, in the evidence of a primary cause to which the chronic adenitis is secondary, in the ab- sence of caseation, suppuration, and periadenitis, and, finally, in the greater influence of general tonic treatment. From Hodgkin's Disease. — Simple chronic adenitis is distinguished less THE DUCTLESS GLANDS IN INFANCY AND CHILDHOOD. 899 easily from Hodgkin's disease, but in the latter the enlargement of the nodes is greater and more generally distributed, the secondary anaemia is more pronounced, and the disease is of rare occurrence as compared with chronic adenitis. From Syphilitic Adenitis. — The absence of other signs of late syphilis, such as are described on page 536, and the negative results of anti-syphi- litic treatment make the exclusion of syphilitic adenitis comparatively easy. From New Growths. — New growths are usually to be distinguished by their greater size and by the absence of an exciting cause, more positively by the microscopic examination of a portion of the node excised for the purpose of diagnosis. Treatment. — In the treatment of simple chronic adenitis, the primary exciting cause should be removed if possible. Local applications should be avoided, and general tonic treat- ment instituted by means of cod-liver oil, Fowler's solution, the iodide of iron, good food, and out-of-door life. If these measures fail, the treatment becomes surgical. Fig. 185 represents a case of chronic cervical adenitis in which the cervical lymph-nodes were enlarged to such an extent that they had become a deformity. Nothing else abnormal nor any symptom of tuberculosis was discovered about the child. DISEASES OF THE THYROID GLAND. The function of the thyroid gland is not definitely known, but it is generally believed to secrete certain nutritive or antitoxic substances which are necessary for normal metabolism. Disturbance in the func- tion of the gland, resulting either in hypersecretion or diminished secre- tion, gives rise to different types of symptoms. Such disturbances may be produced by simple hyperemia, hypertrophy, atrophy, new growths, or as a result of excision of the gland. GOITRE (Bronchocele). Enlargement of the thyroid gland is commonly called goitre. True goitre consists in the enlargement of the old and in the formation of new alveoli, in the cells of which a greater or less amount of colloid degenera- tion takes place. The colloid abnormalities of goitre are rarely present in children (Rex), in whom the thyroid enlargement seems to be little Chronic cervical adenitis. 900 PEDIATRICS. Fig. 186. more than a continuation of the natural growth and a true hypertrophy or an excessive development of normal tissue. Usually the enlargement of the gland is the only symptom. Infants have been born with an en- larged thyroid. The disease is endemic in Switzerland, in certain parts of France and Italy, and in Michigan. The enlargement may be purely vascular (hyper- emia of the thyroid), parenchymatous, or cystic. In places in which the disease is endemic the cause in many cases seems to be due to the drinking-water. It has a certain relation to the congenital form of myxoe- dema, or cretinism, the nature of which has not been fully determined. A woman with goitre may, on removal to a place in which the disease is endemic, give birth to a cretin. Although a simple goitre generally gives rise to no symptoms other than those of pressure, symptoms of myx- cedema may develop. The inference is that this complication is due to the interference with the function of the gland, as a result of which its secretions are either diminished or entirely checked. When myxoedema does not develop, as it does not in the majority of cases of goitre, we may account for the fact on the supposition that the enlargement of the gland has not affected its function as a secreting organ. Hypereemia of the Thyroid. — Between the ages of twelve and fifteen years in girls, about at the time of puberty, an active hyperemia of the rich vascular tissue of the thyroid oc- curs, leading at times to a consider- able and rapid enlargement of the gland. Anaemia, especially chlorosis, palpitation, accelerated pulse, and various nervous symptoms are not uncommon at this same period, and when noted in connection with the hyperemia and enlargement of the thyroid may give rise to the belief that the condition is the beginning of the much more serious disease ex- ophthalmic goitre. This enlargement of the thyroid does not usually persist, however, the disease generally subsiding under appropriate treatment of the anemia and galvanization of the thyroid, and the diagnosis is readily made. Fig. 186 represents one of these physiological disturbances in the thyroid due to an active hyperemia. Hyperemia of 13 years old. The girl, thirteen years old, was first noticed to have a swelling of the thyroid gland two or three weeks before coming under observation. The swelling was at that time THE DUCTLESS GLANDS IN INFANCY AND CHILDHOOD. 901 becoming more prominent. The catamenia had not appeared. The girl was well and strong, but was more fretful and capricious than seemed consistent with her usual temperament. The tumor was elastic, did not fluctuate, and was neither red nor tender. MYXCEDEMA. Myxoedema is a constitutional affection, generally associated with atrophy of the thyroid gland, and characterized clinically by a thickened and dry condition of the skin and subcutaneous tissues, and later by mental failure. The symptoms are supposed to be caused by a diminished or total lack of secretion of the thyroid gland due to its atrophic condition {athyrea). The disease may be congenital or acquired. Acquired myxoedema is seen most commonly in adults, and will not be especially described. Operative myxoedema, or cachexia strumipriva, is a condition closely resembling ac- quired myxoedema of adults, and follows the removal of the thyroid gland by operation. The form of myxoedema which is especially related to in- fants and children is that which is known as cretinism, or congenital myxoedema. Cretinism (congenital myxoedema,). — Two classes of cases are recog- nized : one, known as endemic cretinism, represented by the cretins of Switzerland, Italy, France, of the great lakes (Michigan) of America, and of other places ; and a second class, known as sporadic cretinism, repre- sented by individual cases which may be met with anywhere. Pathology. — There may be a congenital absence of the thyroid gland, or atrophy may occur, as after one of the specific infectious diseases. The head in sporadic cretinism is usually brachycephalic,— that is, it is contracted in its antero-posterior diameter. Virchow was the first to observe in these cases a premature ossification of the spheno-basilar bone. The sphenoid and basi-occipital bones should remain separate until about the fifteenth year, and their early ossification explains, according to Virchow, the changes which take place in the form of the cretin skull and face. Occasionally the thyroid gland in a cretin is enlarged, as in a simple goitre, but its function is absent, as shown by the symptoms characteristic of athyrea. There are certain characteristics of the bones in cretins, consisting of an enormous overgrowth of cartilage, an arrest of growth at the distal ends of the bones, and a premature ossification of the shaft. Fig. 82, II., page 329, represents a section of the tibia of a sporadic cretin child. It is distinguished anatomically by an almost entire absence of the zone of proliferation (Whitney). Symptoms. — In sporadic cretinism the symptoms of the disease usually develop in the first year of life, sometimes not until the second or third year or even later. The body is dwarfed. The anterior fontanelle re- mains open until the eighth or tenth year. The face is full, stolid, and expressionless. The nose is broad and flat ; the eyes are small, wide 902 PEDIATRICS. apart and half closed by the swollen lids. The mouth is open, the lips are thick, and the tongue protrudes. The cheeks are swollen and bloated. The hair is coarse and straight, and usually light-colored. The teeth are rough, irregular, and liable to early decay. The voice is rough and harsh. Spinal curvature is apt to be present, and is much more apt to be in the nature of a lordosis than of a kyphosis. The extremities are short and stunted, and the hands and feet are pudgy. Normally at birth the legs are about 43 per cent, of the total height, and at four or five years about 50 per cent. In cretins this percentage is lessened to between 35 and 40 per cent, of the total length. The skin is everywhere dry, thick, and bloated, and does not pit on pressure. Perspiration is scanty. The muscles are weak and flabby, and the motions slow and clumsy. The neck is short and thick, and the abdomen large and pendulous. Fatty tumors are not infrequently to be found in the supra-clavicular regions. The genitals are small and undeveloped. Habitual constipation is com- mon. The temperature is frequently subnormal. The temperament of cretins is placid, and their expression stupid or even idiotic. Their mental and physical development is very backward ; they learn to talk late or not at all. Diagnosis. — The appearance of a cretin is so characteristic that a diag- nosis is rarely difficult. Fcetal or early and severe rhachitis may give rise to marked deformities suggestive of cretinism, but do not show the other physical signs and the mental symptoms. Treatment. — The recognized specific treatment of all forms of myxe- dema is the administration of preparations of the thyroid gland. The success of this method is one of the most brilliant triumphs of modern experimental medicine. The results of treatment for several months are remarkable, as the entire appearance of the child is changed. The thick- ening of the skin disappears, the idiotic expression is lost, and the growth and development of both body and mind progress rapidly. A large num- ber of cases have been reported illustrating the effects of the thyroid treat- ment. The question whether the improvement will continue indefinitely and go on to complete and permanent recovery is one for the future to decide. The dried powdered gland or the glycerin extract are the most conve- nient means of administration. The dried thyroid extract may be given in tablet form in doses of 0.03 to 0.06 gramme (J to 1 grain) three times daily. Unpleasant effects from the treatment are rare. A decided rise in the temperature indicates that the use of the thyroid extract should be suspended for a time. The earlier the treatment is begun the better are the results obtained. When the normal condition of the body has been restored by the use of fairly large doses of the thyroid extract, it will be necessary to continue the treatment indefinitely with doses small enough to maintain the equilibrium of the metabolism of the body. It should be remembered that these THE DLTTLESS GLANDS IX IXFAXCY AND CHILDHOOD. 903 children are especially susceptible to cold, and should be kept in an even temperature or taken to a warm climate during the winter. Fig. 187 represents a case of sporadic cretinism. Fig. The child was a girl, five and a half years old. Her parents were healthy Ameri- cans, not blood relations, and did not have goitre. She was born after a severe labor ; it was a head presentation, and no instruments were used. Nothing especially abnormal was noticed about her until the twelfth month, when she did not seem so bright as is usual at that age. When four years old she was brought to the hospital. She could not speak, and her mental condition was much enfeebled. She could scarcely stand, and looked as though she were about one and a half years old. She had never had any convulsions, but had always had incontinence of urine and of faeces. When seen a year later she appeared to be in good general condition, but her mus- cles were large and flabby and she had not improved mentally. The circumference of her head was 46.05 cm. (18^ inches). The measurement from the occiput to the root of the nose was 34.4 cm. (13J inches), and across the head from external meatus to external meatus 29.3 cm. (11 h inches). The circumference of the thorax was 40.3 cm. (15f inches). There were no irregularities about her head. The forehead was overhanging, and this was ren- dered more striking on account of the sunken bridge of the nose. The lips were thick, and the tongue, which seemed enlarged, was pro- truded between them. The hearing was said to be good, and the sight was good. She had been able to sit alone since she was one year old, hut could stand only with support, and could not walk. She was bow-legged, and the bones were somewhat enlarged about the epiphyses. The hands and feet were large and puffy, but did not pit. The feet were bright red, the hands less so. The trunk was stout and thick; the spine was straight; the lungs and heart were normal, and nothing abnormal could be detected about the abdomen except an umbilical hernia. The tendon reflexes were normal. Sensation was normal. The thyroid gland could not be felt. The teeth were good. There was a general condition of infiltration of the skin like myxcedema. Hebetude was marked. The treatment of this child was with an extract made from the thyroid gland of a sheep, 0.06 c.c. (1 minim) of the thyroid extract being given three times daily, which was gradually increased 1 minim every two days unless the rectal tem- perature rose above 37.7° C. (100° F.). There was a slight improvement of the symp- toms before the child left the hospital, but her parents did not return with her to report the subsequent progress of the disease. Myxcedema. Female, 5% years old. Fig. 188 represents a case of sporadic cretinism which occurred in the practice of Northrup, of NeAv York, who describes it as follows : 904 PEDIATRICS. ' • The parents of the child were healthy Americans from Western Pennsylvania, and they were not consanguineous. The father was forty-five years old ; the mother was thirty-nine years of age, had had several miscarriages and four healthy children, two of whom had died of some acute disease. This little girl, who is now nine years old, is the fifth child. The mother first noticed that the child could not sit up when it was nine months old, that it practically ceased to grow, and now at nine years it is men- tally no older than it was at nine months, and physically it has merely thickened. The first impression one gets on look- ing at the child is that it is an idiot. Its hands are large and broad. Its color is peculiarly sallow. The hair is thin, long, dry, and without lustre. The eye- brows are present, and are not remark- able in any way. She has the character- istic flattening of the bridge of the nose, diffuse swelling of the under lid and puffiness of the upper lid, and pendulous cheeks. She has thick, pale lips, with a protruding tongue, which is swollen and pale. The lips and tongue have a ten- dency to dryness. There are fourteen teeth ; all of them are of the first set. Those in the upper row are eroded, and appear only at the bottom of a series of ulcers in the upper gums. The lower teeth are in nearly the same condition, and the gums are suppurating. An of- fensive odor is always present in the mouth. The arms, legs, feet, and hands are unnaturally thick. The abdomen is prominent, and there is, as you see, an umbilical hernia. The hand which is resting on its mother's black glove shows the dry, wrinkled condition so characteristic of myxoedema. Perspiration is absent. The skin is pale, and has a peculiar mottled appearance. The soles of the feet and the palms of the hands are dry. There is marked lordosis. The surface of the child does not suggest the feeling of oedema, nor does it pit. The feeling is that of puffiness and flabbiness. The child cannot sit alone. It can, however, stand when once bal- anced and allowed to grasp some fixed object. The supraclavicular ' pad' of tissue so commonly found in these cases is present. The thyroid gland seems to be present, and is possibly enlarged. Hebetude is shown to a marked degree, and the delayed cerebration is very evident, although the child never speaks except to say, with infinite slowness, ' da — da. ' "The rectal temperature four days before treatment was begun was 36.4° C. (97.5° F.) in the morning, and 37.5° C. (99.5° F.) in the evening. The child was treated with the thyroid extract prepared so that each drachm represented one thyroid gland of a yearling. Of this preparation 0.06 c.c. (1 minim) was given three times a day until the fourth day, when the temperature rose above 37.7° C. (100° F.), and the treatment was stopped for a day. At this time the appetite had improved, and the breath was not so offensive. Two days later the treatment was begun again, and on the eighth day the tongue was found to be considerably smaller. During the next week the Myxoedema. Female, 9 years old. Slight improve- ment after eighty days' treatment with thyroid extract. THE DUCTLESS GLANDS IN INFANCY AND CHILDHOOD. 905 temperature remained under 37.7° C. (100° F.). It then rose above 37.7° C. (100° F.), and the treatment was suspended. The first tooth, a canine, was cut at this time. The largest dose which was given during the treatment was 0.24 c.c. (4 minims) three times a day. The child was treated eighty days in this way. The improvement was very slight, but the countenance was brighter, the tongue became much smaller, and the skin less dry. She lost somewhat in weight while under treatment. The constipation, which was marked when the treatment was begun, disappeared, and she was willing to take a much greater variety of food. "' The next case represents one of sporadic cretinism which came under the observation of Osier, of Baltimore, when she was four years old. The parents were healthy, and there was no hereditary taint on either side of the family, none of whom had had goitre. She was the second child ; the labor was easy, and she throve well. She had never had any diseases. Nothing especial was noticed about the child until its second year, when it was observed that she did not attempt to walk or talk, and that she seemed unnaturally quiet and dull. She did not cut her first teeth until she was two years old. In her third year her skin became very pale and waxy, and her face and limbs seemed puffy and swollen. She had developed very little mentally, and could say only one or two words. The other symptoms indica- tive of a disturbance of -the function of the thyroid gland gradually appeared, such as the myxedematous condition of the subcutaneous tissues and the development of the supraclavicular pad. The thyroid gland could not be felt. The examination of the blood showed a moderate increase of leucocytes and some irregularity in the size of the erythrocytes. When three and a half years old she was 75 cm. (29f inches) tall, and her head measured 52.3 cm. (20^ inches). She had been under treatment with tonics for a year, and was reported to take more notice and to look more intelligent. She was then treated with the thyroid extract, and improved markedly in both her mental and her physical condition. The tongue, which had been thick and protruding, rapidly became smaller, and she began to walk and talk. EXOPHTHALMIC GOITRE. Exophthalmic goitre occasionally, but rarely, occurs in childhood, in- dependent of the physiological disturbance which has been described under hyperemia of the thyroid gland on page 900. Etiology. — According to Sachs, heredity plays a much more important part in children in the production of the disease than the emotional ex- citement, fright, cardiac disease, and severe constitutional disorders which so frequently underlie the condition in adults. Epilepsy, chorea, and chronic alcoholism in the parents predispose to the development of the disease in children. Exophthalmic goitre is considered by some writers to be due to a pure neurosis, by others to central lesions in the medulla oblongata. The more recent views attribute it to hypersecretion of the thyroid gland, to which the name hypertkyrea is given, as opposed to the athyrea of myxe- dema, in which the symptoms are supposed to be due to deficient secre- tion. Symptoms. — In some cases the onset is acute, in others subacute or chronic, and is characterized by the cardinal symptoms of tachycardia, exophthalmos, muscular tremors, enlargement of the thyroid, and by 906 PEDIATRICS. general symptoms of anaemia, indigestion with a special tendency to pro- fuse diarrhoea, slight fever, loss of weight, and many other symptoms of a neurasthenic character. Tachycardia. — The pulse-rate is increased to 90. 100. 120. or even 200 per minute, the rate being increased in states of excitement and low- ered when mental and physical rest is enforced. There is no evidence of an organic lesion in the heart. All the arteries throughout the body pulsate with unusual distinctness. Owing to the increased blood-tension, hemorrhages may occur from the nose, stomach, or intestines. Upon palpation of the goitre a distinct thrill may be felt. Exophthalmos. — The protrusion of the eyeball is not accompanied by disturbance in vision. Limitation of the field of vision with ulceration of the cornea from want of protection of the lids may occur. Graefe's symptom, a failure of the upper lid to follow promptly a downward move- ment of the bulb, Stellwag's symptoms of a dilated palpebral fissure, and Moebius's symptom of defective convergence of the axes of the two eyes are signs to be noted in connection with the exophthalmos, but are not always present. Thyroid Enlargement. — The thyroid is almost always enlarged, but the increased size may follow rather than precede the other cardinal symp- toms. The enlargement is usually bilateral and symmetrical, the tissues are vascular, hyperplastic, and may show fibrinous degeneration. Muscular Tremors. — The muscular tremors are usually rhythmical, and at the rate of about eight to the second. Throbbing of the blood-vessels and free perspiration are unpleasant symptoms, adding to the discomfort and nervousness of the patient. In- tense pigmentation of the skin, resembling Addison's disease, may rarely occur, or areas of leucoderma, or of urticaria. Very rarely myxcedema has developed towards the end of the disease. Marked diminution in the electrical resistance is present, and may be due to the profuse sweating. Glycosuria and albuminuria are occasional complications. Diagnosis. — The diagnosis is made by the recognition of the cardinal symptoms. Physiological hyperaemia of the thyroid at puberty should not be diagnosticated as exophthalmic goitre. Prognosis. — The course is generally chronic and of several years' duration. Some cases recover, but if the disease is once well developed it is apt to be prolonged, death often ensuing from some intercurrent affection. Treatment. — Absolute rest in bed. avoidance of all excitement, and careful regulation of the diet are essential. Digitalis and strophanthus are sometimes useful. Good results have been reported from the use of belladonna and of atropine. The galvanic current is also recommended. The thyroid extract has proved of no value in these cases. When the gland is so large as to cause symptoms of pressure, partial extirpation is to be considered. The operation has been done in adults with good results in a certain number of cases. THE DUCTLESS GLANDS IN INFANCY AND CHILDHOOD. 907 ACUTE THYROIDITIS. Acute inflammation of the thyroid is not very common, but may occur from a variety of causes. It may result in the formation of abscesses of various sizes or in the production of new connective tissue. Acute thyroiditis is rarely primary, being commonly a metastatic affection occurring in the course of some febrile disorder. It has been noticed among children as a complication of measles, typhoid fever, diphtheria, and parotitis, and the process in a majority of these recorded cases, in- stead of retrograding spontaneously as it did in others, caused an inflam- matory condition in which abscess-formation occurred. On opening the abscesses the pus was found to contain numerous micrococci. Symptoms. — The symptoms of acute thyroiditis are swelling, redness, and tenderness of the gland. Symptoms of pressure, such as dyspnoea, hoarseness, painful deglutition, and neuralgic pains, are sometimes present with fever and general malaise. The duration of the disease is from two to three weeks. Treatment. — The treatment is essentially expectant, but some previ- ously intractable cases seem to have been benefited by the application of iodine. The patient should be carefully watched, and, if there are indi- cations that suppuration has taken place, an incision should be made at once, as recovery then usually occurs quite quickly. TUMORS OF THE THYROID GLAND. Malignant growths are extremely rare in the thyroid. Gummata have been found in a certain number of cases of congenital syphilis and miliary tubercles in connection with general miliary tuberculosis. DISEASES OF THE THYMUS GLAND. The thymus gland may persist after the sixteenth, and even after the twentieth year, without especial pathological significance. A considerable number of cases of what is termed thymic asthma has been reported. In this condition infants and young children, many of whom were supposed to be healthy, have had severe and often rapidly fatal attacks of dyspnoea, which at the autopsy have been found to be dependent upon great enlargement of the thymus gland. Death in these cases is supposed to have been due to pressure of the gland upon the trachea, upon the great vessels, or upon the pneumogastric nerve, causing spasm of the glottis. Many of these cases have occurred in children with rhachitis. Minute multiple hemorrhages are not infrequently found in the thymus gland in new-born infants who have died of asphyxia. Primary inflammation of the thymus gland has been reported, but is extremely rare. Multiple abscesses of the thymus gland have been reported by Dubois 908 PEDIATRICS. in a number of cases of congenital syphilis. Chiari believes that these supposed abscesses were necrotic areas or cysts. Gummata are rare. Tuberculosis is rare, but when it occurs it is usually either one of the lesions of a general miliary tuberculosis or it is secondary to a tubercular pneumonia. The gland may be enlarged, but rarely, in kukcemia, sarcoma, cancer, and myo-Upoma. According to Reich, the absolute dulness of the thymus, as determined by light percussion, is irregularly triangular in outline, the base being made by the line connecting the two sterno-clavicular articulations, the blunt apex situated at the level of the second rib or slightly below it, and the sides a little beyond the edges of the sternum. The larger half of this triangle of dulness usually falls to the left side. When the limits of dulness, as given above, vary by one or more centimetres, or obscure the pulmonary resonance between the upper line of cardiac dulness and the lower lateral limits of thymus dulness, an enlargement of the thymus is probable. The thymus dulness is present until the end of the fifth year, after which it is inconstant. Diagnosis. — The diagnosis of diseases of the thymus gland is very diffi- cult and generally impossible. Symptoms of dyspnoea and pressure upon the pneumogastric nerve, without any other appreciable cause, associated with an enlargement of the area of thymus dulness as just described, render the diagnosis of some affection of the thymus probable. Reich states that swollen lymph-nodes in the anterior mediastinum do not cause dulness, but that cheesy lymph-nodes do. Treatment. — There is no treatment other than the control of symp- toms by appropriate means. DISEASES OF THE ADRENAL GLANDS. Hemorrhages into the adrenal glands are not uncommon, and are espe- cially likely to occur in the new-born. Cancer has been found in rare cases. Neither of these conditions is of clinical importance. ADDISON'S DISEASE. Etiology. — Addison's disease is even more rare in children than in adults, only about twenty cases having been reported. The cause of the disease is still an open question. The same symptoms occur when differ- ent pathological conditions are present. The adrenal glands are supposed to furnish an internal secretion which is necessary for normal metabo- lism, and a loss of this secretion is considered by some writers to give rise to the symptoms, while others believe that the disease is dependent upon changes in the ganglia of the sympathetic nervous system of the abdomen. Pathology and Symptoms. — The onset is usually insidious. Progressive loss in strength, with symptoms of secondary anaemia entirely out of pro- THE DUCTLESS GLANDS IN INFANCY AND CHILDHOOD. 909 portion to the degree of anaemia present, and a characteristic discoloration of the skin are the conspicuous symptoms of the disease. The pigmentation varies from a light yellow to a deep bronze. It is usually diffuse, and is most intense on the exposed parts of the body, such as the head and hands, and in the flexures, around the nipples and about the genitals. The mucous membranes of the mouth and vagina are like- wise pigmented, but the palms and soles remain free for a long time. Small areas of leucoderma may appear. Vomiting and diarrhoea are especially common when the disease occurs in children. Nervous symptoms are sometimes marked, and are of the same character as those we see in cases of severe secondary anaemia. The blood, however, shows only a slight degree of anaemia. There is no emaciation except in the later stages. The course of the disease is progressive, with occasional remissions, the duration varying from a few months to one -or two years. Death occurs from exhaustion or from the development of an intercurrent affec- tion, which may appear as some form of tubercular disease in other parts of the body. On autopsy the adrenal glands are frequently found to be tubercu- lar, but may present no changes. Diagnosis. — In the diagnosis of Addison's disease other causes of pig- mentation of the skin must be excluded, such as may arise from arsenic, lead, nitrate of silver, paluclism, and abdominal growths. The tuberculin test is often of value as an aid in the diagnosis when the cause is due to tuberculosis of the adrenal glands. Prognosis. — The disease is nearly always fatal. A few recoveries have been reported. Treatment. — The adrenal glands of the sheep have of late been used frequently in the treatment, and in a few cases with improvement in the symptoms. The remedy is worthy of a trial, but the results are usually very disappointing. The glands may be given raw or slightly cooked, in the form of a glycerin extract, or as a dry extract in tablets. From one- half to one gland may be given daily, or one-grain doses of. the dried extract three times a clay. General treatment and measures directed to the control of the symptoms are indicated. DIVISION XVI. DISEASES OF THE NERVOUS SYSTEM. We are much more likely to meet with nervous phenomena of the most diverse varieties in children than in adults. In like manner we meet with the most widely differing clinical symptoms. Symptoms which if occurring in adults would be significant of serious lesions of the ner- vous system may arise in children from simple reflex conditions which only simulate and do not represent actual disease. Children are much more apt to become unconscious, to have convulsive attacks, and to show disturbance of the functions of important nervous centres from reflex irritation, than are adults. The whole cerebro-spinal system in infancy and early childhood is so impressionable, so excitable, and so hypersensitive to even slight grades of irritation, that diseases of a nervous type, whether primary or secondary, dominate all others. Reflex phenomena are so much more numerous than those which arise from organic lesions, and are so irregular in their manifestations, that, from a diagnostic point of view, they are most important. They also enter into all disturbances of the nervous system, Avhether functional or organic, to such a degree that what we have learned concerning cere- bral localization in the adult becomes of much less value in the young subject. The reader is referred to especial works on the nervous diseases of children for the details of examination and cerebral localization, and I can recommend particularly the "Nervous Diseases of Children," by Sachs. Instability and irritability of the nervous system, both peripheral and central, are characteristic of the early periods of development, making certain nervous diseases of children peculiar to them as compared with adults. Many weeks are required before the peripheral nerves have ac- quired their complete function, and the brain and spinal cord do not attain their full development, for months and years. A simple heightened temperature or increase of vascular pressure in the brain and cord may cause such irritation of the nervous centres that the most varied symp- toms, such as delirium, somnolence, and twitching, may arise. On the other hand, serious nervous disturbances may in childhood follow the acute infectious diseases, and again there may be a complete arrest of 010 DISEASES OF THE NERVOUS SYSTEM. 911 development of the central nervous system, which may be temporary or permanent. As stated by Sachs, childhood is exempt only from the diseases due to senile deterioration from degeneration and sclerosis of the brain and spinal cord, and is relatively free from those due to toxic agents, such as alcohol, metallic poisons, and acquired syphilis ; the effects, however, of such diseases in the parents are shown by inheritance in the children. CONVULSIONS.— ECLAMPSIA INFANTUM. Attacks of motor disturbance represented by continuous rigidity or contractions of one or more groups of muscles, lasting for a variable time and usually accompanied by unconsciousness, are designated con- vulsions. A convulsion is a symptom and not a disease. Convulsions may be divided, as to their type, into (1) clonic and (2) tonic; as to their form, into (1) general and (2) partial ; and as to the seat of irritation which causes them, into (I) central and (2) peripheral. The clonic convulsion is an active spasmodic contraction of the mus- cles followed by immediate relaxation. The convulsions of epilepsy are illustrative of this type. The tonic convulsion is a more or less continued spasmodic rigidity of the muscles. This type is seen in tetanus neonatorum. The seat of irritation which produces the convulsion is very varied. It may be a lesion of the central nervous system or of the peripheral nerves ; in the former case the convulsions are spoken of as central, in the latter they are termed reflex. Convulsions are much more apt to occur in infancy than in later childhood and in adult life, probably be- cause the power of inhibition is not developed in the former. We there- fore not only meet with convulsive attacks more frequently in very early life, but, as a rule, we are led to look upon these convulsive attacks as of much less import than in the older subject. The reason for this is that the causes of reflex convulsions in infancy are innumerable, and, as a rule, do not result seriously, while in older children and in adults con- vulsions are almost always representative of some serious central lesion. % Convulsions are so common in infancy that they have been compared to the chill which occurs in the initial stage of many diseases arising in adults. The various acute diseases accompanied by high temperature, such as pneumonia and the exanthemata, are very commonly preceded by a convulsion, and a chill is rare under these conditions in infancy. We must, however, not be misled by the frequency and comparatively benign character of convulsions in infancy and by the rule that they are not fatal. The convulsions of infancy may represent just as serious con- ditions as they do in later life, and are to be looked upon as a grave symptom until Ave can be sure, by eliminating serious organic lesions as a cause, that we are dealing with one of the common and mild forms of this phenomenon. The convulsion does not in itself show us whether 912 PEDIATRICS. it is the result of serious or of benign disease, and the convulsions which occur from some organic lesion, such as cerebro-spinal meningitis, may differ in no way from those which arise from some simple cause, such as indigestible food. General Symptoms. — We are frequently called to see infants in convul- sions where the convulsion is the first and only manifestation of the dis- ease. After a few signs of uneasiness the infant suddenly becomes rigid for a second or two, makes a sound as though choking, the eyes turn up- ward and become fixed, there maybe strabismus, the skin becomes some- what cyanotic, and then the convulsive movements begin. The eyelids open and shut ; the face and usually the head are drawn to one side ; the fingers are clinched, and the arms and legs move up and down. The back may at times be somewhat arched and the head retracted. The infant is apt to foam at the mouth to a greater or less extent : it is perfectly unconscious, and the breathing soon becomes stertorous. These symp- toms, after lasting for two or three minutes, are followed by complete re- laxation, an apparent state of coma, and sleep. The child on awakening may be bright and well, or the convulsion may recur and continue for a much longer time, as in one of my cases, in which an infant had fifty-two convulsions in twenty-four hours and yet recovered. There may be in- voluntary discharges of urine and faeces. The convulsive movements may affect the entire body and limbs, including the face, or they may affect only certain groups of muscles. Thus, they may be localized, as in one limb, or they may be unilateral or bilateral. Convulsions of Central Origin — The most important, on account of their serious nature, are those convulsions which are of central origin. Convulsions of this nature may occur in any disease which is represented by a high temperature, such as insolation, meningitis, the exanthemata, pneumonia, or other diseases. In these cases the convulsions are pro- duced either by the action of the high temperature on the motor centres of the brain, or by the direct action of the special toxic agent which is producing the disease. These convulsions, as a rule, are general, and are produced by the diffuse action of the poison. In this class of cases it is probable that there is an extremely hyperaemic condition of the blood- vessels of the central nervous system. The convulsions may also, in contradistinction to the supposed theory of active hyperaemia of the blood- vessels and the high temperature, be produced by vascular stasis and a normal or subnormal temperature. This form may occur in the course of pertussis or of cardiac disease. Again, central convulsions are sup- posed to be caused by an anaemic condition of the blood-vessels of the brain, such as may arise from loss of blood or from exhausting diarrhoea. Such toxic agents as are represented by drugs of various kinds, as bella- donna, may produce general clonic convulsions. Mental disturbance, such as sudden fright, has also been known to produce a convulsive DISEASES OF THE NERVOUS SYSTEM. 913 attack. In all these classes of cases the convulsions may be partial and clonic instead of general, although, as a rule, they are general, owing to the diffuse character of the irritation. In addition to these convulsions which arise from a diffuse cause are others in which a local lesion having occurred in the brain from morbid growths, embolism, thrombosis, hem- orrhage, or any other cause, a disorganization of a portion of the brain has resulted. As these lesions are generally focal in their distribution, the convulsions are apt to be localized and hemiplegic in character as in cerebral paralysis. A number of diseases can by their direct effects, irrespective of the temperature which accompanies them, produce convulsions. Thus, con- vulsions occur not uncommonly in the course of nephritis, in which they are usually called uraemic, also in malaria and in other diseases. Direct pressure from tumors of the brain or from hydrocephalus may in like manner cause convulsions of either a localized or a general form. Finally, we may have these nervous explosions in epilepsy. It will be well to remember that this entire class of central convulsions emanates from the brain ; and also that when the convulsions are unilat- eral or localized we should suspect a central rather than a peripheral origin. Convulsions of Peripheral or Reflex Origin. — The other class of convulsions spoken of as of peripheral origin, and which are called reflex, have so many causes that it would scarcely be advisable to attempt to enumerate them all. Convulsions of this class may arise from almost any source in infants whose nervous system is so easily irritated that the slightest cause may produce a nervous explosion. The disease which most commonly gives rise to convulsions of the reflex form is rhachitis. Rhachitic children seem to be predisposed to spasmodic attacks of all kinds, and a general clonic convulsion in children with rhachitis corre- sponds to the spasmodic contractions in the larynx which occur in rha- chitis, and which is spoken of as laryngospasmus. It is probable that there is no special lesion, in connection with the rhachitis, which necessarily gives rise to convulsions, but that all the tissues in this disease are especially sensitive to causes which may produce reflex explosions. The most common cause of reflex convulsions in infants is improper food. Convulsions from this cause arise not only when manifestly indi- gestible articles are given to young children, but even in infants who are being fed from the breast. In the early clays and weeks of life, before the breast has acquired its normal functions connected with the elaboration of milk in which the solids are in proper proportion to each other and to the water, it is not uncommon for the infant to have convulsions produced by a disturbance of the mammary function. In cases of this kind it is usually found that the percentage of the proteids is high, and that the con- vulsions will continue until this high percentage has been lessened, it' the 914 PEDIATRICS. infant is allowed to continue to nurse. Whether the teeth of themselves during their development are a source of sufficient irritation to produce convulsions has been questioned by many observers. It is, however, evi- dent that during the different periods of dentition reflex convulsions are more apt to occur than when a tooth is not disturbing the infant's nervous system. In addition to the convulsions arising from improper food in the stomach during the dental period, foreign bodies in the intestine, whether in the shape of food or in that of intestinal parasites, may cause reflex convulsions. Foreign bodies in the nose and in the ear have been known to produce convulsions, as has also an inflamed tonsil in the initial stage of a follicular tonsillitis. Hot baths are so often given to infants when they are in convulsions that they should be spoken of as a source of con- vulsions, for they have been known to produce this result when care has not been taken to test the temperature of the bath before the infant is put into it. Mental disturbances, such as arise from fright and other causes, are also etiological factors in reflex convulsions. Prognosis in Convulsions. — The prognosis in infantile convulsions varies with the especial cause. On recovering from the attack the infant may show signs of some serious central lesion, such as paralysis, or may be left apparently perfectly well. A single convulsion followed by per- fect recovery is of slight consequence, but when the convulsive attacks recur frequently and last longer than in the attacks which have just been mentioned, the prognosis becomes more grave. Even though no central lesion be present, continued convulsions may, by the shock to the infant's vitality, finally cause death from exhaustion ; or death may occur from spasm of the glottis. Numerous convulsions, however, do not necessarily lead to a fatal issue. We must, therefore, irrespective of the cause or the apparent result of a convulsion, always look upon it as a grave symptom and endeavor to prevent its recurrence. Treatment. — When summoned to treat an infant who is in con- vulsions, we should first see that the bath, in which we usually find that it has been immersed, is not too hot, and should order the infant to be taken out of the bath before it becomes conscious, or it may be so frightened as to excite again the reflex spasm. The thorax should be quickly examined for pulmonary and cardiac lesions, and inquiries should be made as to the history of the case, with special reference to the infant's diet. The temperature should be taken, and the fontanelle be examined for bulging or depression. Having obtained this information, we can eliminate a number of causes for the attack, such as the onset of one of the exanthemata if the tempera- ture is normal, and reflex convulsions from food or from foreign bodies in the nose or the ear. If the convulsions arise from exhaustion, stimu- lants should be given at once, and if the convulsions continue, the gen- eral treatment which is indicated for all forms of convulsions is indicated. The treatment should be directed to the especial cause of the convulsion, DISEASES OF THE NERVOUS SYSTEM. 915 if any can be determined. As, however, it is often impossible when the convulsion is present to determine whether it is of central or of periph- eral origin, it becomes necessary to endeavor to control the attack at once by general treatment. For this purpose the inhalation of ether in small amounts, and the emptying of the bowels by means of enemata, are in- dicated. When the convulsions are of a very severe type, continuing with perhaps intermissions of only a few minutes, and the infant's life is evidently in danger from the continuous shocks which are taking place to its nervous system, a rectal injection of from 0.18 to 0.48 gramme (3 to 8 grains) of bromide of potassium and from 0.06 to 0.30 gramme (1 to 5 grains) of hydrate of chloral in 30 c.c. (1 ounce) of warm water, repeated if necessary every hour for three or four closes, is indicated. If the con- vulsions still continue and a fatal issue is anticipated, a subcutaneous injection of sulphate of morphine, beginning with 0.001 gramme (j\ grain), should be tried. In most cases of infantile convulsions, of whatever form, the warm bath at a temperature of not over 37.7° C. (100° F.) can be used, for, although it is not in any sense curative, it tends to quiet the nervous ex- citability and to lessen the muscular strain produced by the continuous spasmodic muscular contractions. The class of cases in which this is contraindicated are those which are caused by a loss of blood, an anaemic condition, diarrhoea, and cardiac disease, and those in which venous stasis is present with a lowered temperature. In these cases stimulants are in- dicated. When there are symptoms of the diseases which I have already spoken of which are accompanied by high temperature, the reduction of the tem- perature by the bath and the administration of an antipyretic are indi- cated. The treatment of convulsions caused by definite diseases is simply symptomatic while the convulsions continue, and later appropriate treat- ment of the primary condition. The following cases represent eclamptic attacks from various causes : A little girl, six and one-half years old, was healthy at birth, and had never had any disease. When three and one-half years old she had from time to time convulsions, clonic in type. When in the convulsions she did not bite her tongue. The first con- vulsion occurred when she was three years old ; the next when she was four years old ; the next when she was four and one-half years old ; and the last one when she was five years old. As all these convulsions were apparently produced by the same cause, it will only be necessary to describe them in a general way. They were characterized by sometimes continuing much longer than is usual in infantile convulsions, one of them having lasted for one hour and a half, during which time the hands were clinched, the eyes were rolled up, and the entire body and limbs were convulsed. Previous to each attack the child for a number of days had indefinite symptoms, which she could not describe accurately, connected with the abdomen and accompanied by a feeling o\: weakness and slight muscular twitching. 916 PEDIATRICS, At the time of the earlier attacks her mother found that these symptoms could be dissipated and a convulsion apparently prevented by giving her a dose of castor oil about once a week. After the third convulsion she passed a lumbricoid worm. From that time whenever she showed the premonitory symptoms of a convulsion she was treated with santonin followed by a cathartic, a lumbricoid worm each time was passed, and the symptoms disappeared. When she was five years old she was thoroughly treated for these lumbricoid worms with santonin, and after a large ascaris had been passed the nervous symptoms ceased entirely. The child when last seen had not had a con- vulsion for over a year. There had been no reappearance of the parasites. This child represents the class of cases described as reflex convulsions, the cause of the peripheral irritation being an intestinal parasite. Another case was that of an infant, four months old. Her mother, who was strong and well and apparently had plenty of good breast-milk, nursed her at birth. When she was three months old she began to have convulsions, which occurred almost every hour. Suspecting that the proportion of solids in the breast-milk was too high for the infant to digest, and that it was producing a peripheral irritation which was the cause of the reflex convulsions, I had an analysis of the milk made, and found that the pro- teids showed a percentage of from 4 to 5. The infant was then fed with a carefully modified milk in which the percentage of the proteids was made 1. Within a few hours the convulsions ceased, and they have never returned. A case similar to the one just described was that of a boy three weeks old, previ- ously healthy and strong, and digesting his mother's milk perfectly ; he was weaned and given by mistake a mixture containing a total proteid of 3.50. He then began to have convulsions, which continued until a new mixture was givsn, in which the total proteid was 1.50, when they ceased. CHOREA. - SYDENHAM'S CHOREA. Chorea is a disease characterized by irregular and involuntary mus- cular movements without loss of consciousness, and affecting the muscles of volition. The disease is rare in infancy, but may occur in the early months of life. It seldom begins after puberty. It is most apt to begin and is most marked in its symptoms during the period of the second dentition, — that is, during the period of active growth, from six years to puberty. The greatest number of cases is found among the female sex and among those who do not receive sufficiently nutritious food. A sharp distinction should be made between the disease chorea, with its characteristic chorei- form symptoms, and the same choreiform symptoms resulting from other diseases, sometimes represented by central nervous lesions, sometimes by purely reflex causes. It will save much useless reading of the literature of chorea and much profitless discussion as to its etiology and pathology if this distinction is borne in mind. Eliminating those forms of chorea which are due to gross lesions of the nervous system, such as the post-hemiplegic and congenital forms, we can at once very materially reduce the cases of true chorea. In like manner we should separate from true chorea those cases of peripheral irritation in which the partial choreiform symptoms are evidently reflex and can be cured by removal of the cause. Examples of these reflex choreiform symptoms are the facial chorea from naso-pharyngeal irritation and the partial choreiform DISEASES OF THE NERVOUS SYSTEM. 917 movements occasionally arising from errors of refraction and ocular in- sufficiency. The consideration of these anomalous forms of chorea belongs with the diseases in which they occur. Etiology. — Chorea can be brought about by other diseases, such as measles, although this, in my experience, rarely occurs, and even then chiefly among the poorly cared-for. A certain number of cases have so directly followed intense fright that we must acknowledge acute mental conditions as a cause. The disease which is most frequently associated with chorea is rheumatism. The percentage of cases, however, in which this association takes place is difficult to determine. This difficulty arises from the want of uniformity in the reported cases of different observers, due to their different ideas as to what constitutes rheumatism. If only the cases of acute articular rheumatism are to be classified under rheuma- tism, very few cases of associated chorea need be spoken of; while if all the flitting aches and pains of childhood are considered to be rheumatism, the number of choreic cases caused by rheumatism rises to fifty per cent., or possibly more. The truth will in the future probably be found to lie in* some intermediate number, for in certain cases a close connection exists between chorea and rheumatism. The difficulty becomes still greater when we examine the relationship between chorea and endocar- ditis. When there is a rheumatic element in the case we should expect a cardiac lesion to arise which may be dependent on the rheumatism. In certain cases, however, we find chorea with endocarditis entirely irre- spective of rheumatism. This occurs to such an extent that in chorea we should watch for cardiac lesions just as carefully as in acute articular rheumatism. Heart-murmurs of a haemic nature may occur in chorea as in any other disease of a debilitating nature. They should, however, always be looked upon seriously, as possibly indicating an insidious form of organic endocarditis, which, instead of being evanescent and passing off entirely with the recovery of the chorea, may either seriously disable the heart or lead to a fatal issue. A special microbic cause for chorea, as for rheumatism, must be thought of, but as yet has not been proved to exist. An hereditary tendency to nervous explosions of a choreic type has long held a prominent place in the etiology of chorea. This tendency does not manifest itself, however, unless the children are poorly nourished, badly cared for, or exposed to nervous excitement during their school life. Overtaxing of the central nervous system during the school year has so often been shown to result in an attack of chorea in the spring and in a recurrence in the autumn on returning to school, that it should be recognized in considering the etiology of the disease. Strain of the ocular muscles has been considered an exciting cause of chorea, but beyond causing in some cases choreiform symptoms it cannot be considered as being an inciting cause of true chorea. Pathology. — There are a large number of cases of chorea in which 918 PEDIATRICS. the disease is found to have no apparent pathological lesion. Its symp- toms, however, show us that the morbid process is located in some part of the central nervous system. Whatever the nature of the lesion, it is represented by a profound excitement of the motor centres, presumably due to their inanition, and is accompanied by a temporary inability of these centres to recover themselves. Many lesions have been described as occurring in chorea, but in the pure cases (Sydenham's chorea) which have just been described, and which really represent the disease, there is no lesion which with our present knowledge we can say is characteristic. Symptoms. — Chorea may be in its distribution general or partial : in its course acute, subacute, or chronic. In many cases the disease is exceed- ingly mild in its symptoms and is of a benign type ; in others it assumes a severity which seems to threaten life. The beginning, although at times sudden, as from fright, is, as a rule, gradual, at first a few muscles only being affected. The child becomes fretful and impatient. Its irritability must carefully be differentiated from bad temper, for which the symptoms are apt to be mistaken by the family. The clinical picture of the disease is a jerky, irregular, involuntary contraction and relaxation of the mus- cles, which usually begins in the fingers, hands, and face. There is an irregular, uncertain action of the part affected, and efforts of the will only partly control the movements. As the disease progresses, the vol- untary control of the muscles diminishes more and more, and at times disappears entirely. The movements ordinarily cease during sleep, but in severe cases they continue and even interfere with it. At times the child is unable to walk, on account of weakness. The speech may become slow and indis- tinct, from the affection of the muscles of the tongue and of the larynx, and even mastication and deglutition may become difficult. In very severe cases the difficulty in speech may be enhanced by the mental con- dition, which may be represented by dulness and apathy. The tendon reflexes are lessened in severe cases. The muscles grow weak and soft, and there is considerable emaciation. There is usually loss of appetite, and the bowels are often constipated. The urine and its urea have been found to be increased during the course of the disease. The dynamom- eter usually shows impaired muscular poAver. In certain cases the muscles of the extremities on one side of the body are principally or alone affected (hemichorea). These cases do not differ from the ordinary bilateral cases in any way except in this respect. In very severe cases there may be involuntary evacuations of the faeces and of the urine. The disease is distinct from epilepsy, and there is little danger of the patient becoming epileptic unless the disease hap- pens to develop in an individual who is predisposed to that condition. Prognosis. — Chorea is very apt to show relapses and to recur for several years. Although often obstinate in the persistency of its symp- toms, yet it may be said to be self-limited, and, as a rule, to recover, pro- DISEASES OF THE NERVOUS SYSTEM. 919 vided no complications, such as of the heart, arise. The time which elapses before complete recovery is very variable, but well-marked cases usually extend over a period of three or four months. Although chorea is considered, as a rule, a benign disease, yet we must always look upon it as a serious disturbance until we are sure that we are dealing with the usual mild form of the affection. The following case illustrates how care- ful we should be to give a guarded prognosis in the early stages of acute chorea : A girl, nine years old, reported by Cook and Beale, began to have choreic move- ments, which constantly became worse. Delirium developed, with a slight fever, a rapid and feeble pulse, and a quick and interrupted respiration. Death suddenly oc- curred one hundred and thirty hours after the onset of the disease. The autopsy revealed extreme anaemia of the pons and medulla, but no other changes of note in other parts of the body. We must allow that even uncomplicated chorea is a varying disease as to the severity of its symptoms and their persistence for a longer or a shorter time. We also know that there is a marked tendency to relapse, and that the number of relapses varies to a great degree. . The length of the attack and the response to treatment may differ much. Bearing these facts in mind, we can understand the rapidity with which certain indi- viduals are attacked or the quickness with which they recover. Some cases recover rapidly under only hygienic treatment, while others are apparently unaffected by any drug whatever. When heart-murmurs, evidently representing organic disease, appear, it is often a cause for com- ment at the comparatively slight discomfort which the cardiac lesions entail. At times, again, it is surprising how rapidly . fatal are some cases which are complicated by cardiac disease, and how they are uncontrolled by any treatment Avhatsoever. The disease is variable in its duration whether treated by drugs or not. Treatment. — There cannot be said to be any specific treatment with drugs for chorea, but of the many remedies that have been used, arsenic has, in my experience, been the most beneficial. It should, however, be used with care, and on the appearance of any evidence of the physiologi- cal action of the drug, such as nausea or oedema of the eyelids, it should at once be discontinued. It should not, as a rule, be given in very large doses, as cases have occurred in which it has produced a multiple neu- ritis of many months' duration. When any special cause can be found for the attack, such as rheumatism, appropriate treatment directed to that cause should be employed. It is manifest, however, in the uncom- plicated cases that our main reliance must be placed on hygiene and food. Fresh air, nutritious food, tonics to control the anaemia and general pros- tration, kindness, seclusion to secure mental quiet, stimulants if there is much resulting weakness, and the bromides for insomnia and over-excite- ment, are the means which I have found most valuable in managing this 920 PEDIATRICS. disease. I have seen well-marked cases get well in from sixty to seventy- days where good food and a small amount of stimulant constituted the entire treatment. If the attack is very severe, skilled nursing is a very important ad- junct in the treatment. The child should be protected from harming itself by means of a padded bed, and light but well-padded splints to control the movements during sleep are indicated occasionally. The following cases illustrate the different phases of chorea : A girl, six years old, represented one of the milder forms of chorea. There was no history of nervous or cardiac disease or rheumatism in the family, and the child herself had never been sick before. She first complained of pain in her left hand and arm, and later the muscles of the arm began to twitch. Soon after the whole body was affected in the same way. Somewhat later it was found that the child could not talk plainly, and it was with some difficulty that she could feed herself. She seemed nervous and peevish, and showed constant irregular incoordinate movements, chiefly of the face, mouth, and upper extremities. The legs were slightly affected, and sometimes the muscles of the trunk. There had been no paralysis of the muscles. The eyes were normal in their reaction. She was treated chiefly without drugs, and especial attention was paid to giving her a nourishing diet, baths, gentle massage, and rest in bed in a quiet room. A physical examination showed nothing abnormal in connection with the heart or other organs. An examination of the urine showed it to be normal. Marked improvement was shown after she had been treated for two weeks, and at about the forty-second day from the onset of the disease she had recovered completely. Another girl, thirteen years old, represented one of the milder forms of recurrent chorea. She had a number of diseases preceding her first attack of chorea. When she was two years old she had diphtheria, when five years old, measles, when seven years old, scarlet fever, and when eight years old, rheumatism. When nine years old she had her first attack of chorea, which occurred in the spring of the year, and lasted for a num- ber of months. This was followed in the spring of the next year by a second attack. In the spring of the following year she had a third attack of the disease ; at this time the incoordinate movements were not so marked as in the previous attacks, but the debility was greater. When she was examined during this attack, it was found that the heart, although weak and somewhat irregular, presented no evidence of murmurs. The pulse was 84, the temperature was normal, and there were no signs of any other dis- ease. She was treated at the hospital, and recovered in a few months. In the spring of the next year she had a fourth attack of chorea. At that time nothing abnormal beyond the choreic movements was noticed. She was treated with from 0.18 to 0.36 gramme (3 to 6 minims) of Fowler's solution three times a day, and in a few months left the hospital apparently well. In the spring, one year from the beginning of the fourth attack, she entered the hospital with a fifth attack. On this occasion, after using Fowler's solution for a few weeks and not obtaining any special benefit, iron and nux vomica were given. She gradually improved under this treatment. There remained for some time, however, incoordinate movements, which appeared especially when she was embarrassed by the DISEASES OF THE NERVOUS SYSTEM. 921 observation of the people who were around her. It was a case in which a good prog- nosis sould be given, as there were no cardiac or other complications. The following case illustrates recurrent chorea with the development of a functional disturbance of the heart, resembling organic disease. A boy. nine years old, was subject to attacks of chorea for nearly four years. The attacks usually came on in the spring with considerable severity, and continued for nearly six months, gradually diminishing in intensity until the symptoms were scarcely noticeable. The child had a history of rheumatism, not, however, of a high grade. The attack began four months previous to entering the hospital, and was quite a severe one. so that he had been unable to control the movements of his hands and face during the day ; they were, however, quiet at night. On entering the hospital a physical examination showed a marked systolic mur- mur, heard most distinctly at the apex and transmitted to the axilla. The area of car- diac dulness was not especially enlarged. The urine was normal, and nothing else abnormal was detected about the child. He was at first treated with Fowler's solution, 0.12 gramme (2 minims), three times a day. After four days the choreic movements became less marked and the car- diac souffle less distinct. Two days later, however, the Fowler's solution had to be omitted, as it caused nausea and vomiting. At this time there was a double souffle, heard most distinctly over the left third interspace, close to the sternum. A few days later Fowler's solution was renewed, but as it caused gastric disturbance, again had to be omitted, and it was found that it could not be given for more than two days at a time without causing puffmess of the face. The treatment, therefore, consisted chiefly of rest in bed, good food, bathing, massage, and the administration of iron in the form of the citrate of iron and potassium. One month later the choreic movements had decidedly lessened, and the cardiac murmurs disappeared. Two months from the time he entered the hospital he was free from all symptoms of the disease. The next case illustrates a severe case of chorea, following an attack of influenza, and terminating fatally, without the development of any complication : A boy, ten years old, had always been delicate, but had had no especial disease, such as rheumatism, until six weeks previous to the time when I saw him, when he was said to have had an attack of epidemic influenza. He recovered completely from the disease in ten days. Three or four days later he began to show symptoms of chorea. These symptoms gradually increased in severity, and finally were continuous, except when he was asleep. After he had had* the chorea for one week he was unable to articu- late, and began to have trouble with deglutition. He soon lost the control of his limbs, grew very weak, and was confined to his bed. There was considerable insomnia. In the second week of the attack the choreic movements became so violent as to endanger his falling out of bed. The temperature up to the time when I saw him, in the fourth week of the attack, was normal. The pulse varied from 140 to 150, and the respira- tions from 35 to 40. When I saw him, at the end of the fourth week from the beginning of the chorea, his mind was perfectly clear ; he had a little pain in the hands and shoulders, appar- ently from the continual movements. He was unable to articulate clearly. There was difficulty in swallowing, and he was considerably emaciated. Nothing abnormal was found in the lungs. The heart was beating tumultuously. The area of cardiac dulness was very slightly enlarged, but there were no cardiac murmurs. Although in 922 PEDIATRICS, many of these severe cases of chorea no evidence of cardiac disease can be obtained on physical examination beyond a slight dilatation of the left ventricle, yet some dis- ease of the endocardium or valves may often be found at the autopsy. In these cases, however, the temperature is, as a rule, raised. In this case the continuous normal temperature and the absence of any signs of cardiac disease beyond a slight dilatation from the apparent weakness of the ventricular muscles seemed to indicate that it was a case of simple chorea without disease of any of the organs. Although the child was carefully nursed and remedies of various kinds were em- ployed to strengthen the action of the heart and to support his general strength, he failed rapidly, and died of exhaustion a few days after I saw him. In the following case (Fig. 189) we have an example of acute articular rheumatism with endocarditis, in the course of which chorea developed with other complications, which terminated fatally : Fig. 189. Kheumatic arthritis. Endocarditis. Cardiac enlargement. Chorea. Female, 8 years old. The child was eight years old. She had been subject to attacks of rheumatism. She had not had any especial diseases, with the exception of an attack of measles when she was three or four years old, until she had an attack of rheumatic arthritis when seven and one-half years old. At that time she was confined to bed with fever, and with pain, tenderness, and swelling in all her joints, especially of the knees and fingers. Although she recovered from the acute symptoms of the rheumatism, she had since then never been able to use her arms and hands, nor able to walk much. There was no record of the condition of her heart during the attack of rheumatism, but there was no history of previous cardiac disease. During the course of the rheumatism there were no other especial symptoms noticed, except that her disposition was evidently much changed and she became peevish and fretful. One week before entering the hospital she began to have choreic movements. They were moderate in degree, but incessant. A few days later the incoordination of the muscles was also noticed when she endeavored to speak or to swallow. There were continual choreic movements of the eyes, face, and fingers, and, although seemingly she could understand what was said, she was unable to speak clearly. She was much emaciated. Incoordinate movements of all the muscles of the face, eyes, head, neck, body, and extremities were present. The peculiar look which occurs in these cases, expressive of embarrassment, was clearly shown. Although the case was a severe one, the mind was not affected beyond a slight degree of hebetude. On physical examina- tion the lungs were found to be normal. On examining the cardiac region the impulse of the heart was found to be outside of the mammillarv line and in about the sixth DISEASES OF THE NERVOUS SYSTEM. 923 interspace. On palpation the contractions of the heart were clearly felt, but were irreg- ular and not so strong as normal, suggesting irritability and incoordination of the car- diac muscles. On percussion there was normal resonance to the right of the sternum and under its upper part as far as the third right interspace. There was dulness under the sternum, beginning at the second left interspace, extending across to the third right interspace, and involving the lower part of the sternum. The area of cardiac dulness is marked in black in Fig. 189. It extended upward to the left of- the sternum as far as the second rib, then to the left and downward outside of the mainmillary line until it reached the impulse of the heart in the sixth left interspace. On auscultation a murmur was heard most distinctly with the first sound at the apex of the heart, and was transmitted to the axilla and to both sides of the back. This murmur was trans- mitted to the base, but gradually lessened as the area of the large vessels at the base of the heart was reached. Nothing else abnormal was detected on physical examina- tion. This was a case in which during the course of a rheumatic attack an endocarditis had developed. This endocarditis had been followed by enlargement, mostly repre- sented by dilatation of the left ventricle. During the course of the rheumatism and of the cardiac complication the chorea had developed. The prognosis in a case like this must be very guarded. In some instances the disease, or rather combination of diseases, grows rapidly worse, and the child dies seemingly from exhaustion. In cases of a milder form the child gradually recovers from its chorea and from its rheumatism, but is left with an organic disease of the heart from which it never recovers. The cardiac disease, however, can in most cases be much benefited by careful treatment, especially by rest in bed. In these cases the dila- tation grows decidedly less, while the heart becomes stronger, and, as the chorea passes away, may show a normal area of dulness. We may at any time expect in place of gradual improvement a decided increase in the severity of the symptoms. The val- vular lesion of the heart may become much more extensive, assuming the ulcerative form which is usually so fatal. The pericardium may become affected, and broncho- pneumonia occur as a complication. The treatment in this case was with milk and stimulants, it was impossible for her to take solid food, and the milk was with the greatest difficulty introduced into her mouth. The subsequent history of the case was as follows : The temperature rose to 40° C. (104° F.), and was accompanied by precordial pain and a pericardial friction-rub, but no physical signs of effusion. There was dulness under the left clavicle, but at first, beyond rather indefinite signs of bronchitis, nothing abnormal was detected in the lungs. The liver was somewhat enlarged. The axillary lymph-nodes were enlarged. There was great atrophy of the muscles. There was diarrhoea and incontinence of urine. The hebetude increased. Areas of dulness and diminished respiratory sound were detected. There was dyspnoea and rapid failure in strength. The child died on the thirty-seventh day from the beginning of the disease. The autopsy showed the following lesions : Chronic pericarditis and mediastinitis ; acute ulcerative endocarditis ; thrombosis of the innominate and left jugular veins ; broncho-pneumonia ; passive congestion and oedema of the pericardium. I have tried various methods of administering the milk and stimulants in these cases, but have found that the jaws close so spasmodically when- ever a spoon is introduced between the teeth that the milk is usually spilled before it enters the mouth. The method which I have found to be most successful is by a feeding-cup with a rubber nipple fitted to the neck of the cup. The rubber nipple is perforated with a large hole. 924 PEDIATRICS. The soft rubber does not incite the choreic movements of the jaw to the degree that anything hard would do. The Breck feeder (page 272) is also useful in these cases. CHOREIFORM DISEASES. Hereditary or Hunting-ton's Chorea. — This form of chorea differs from Sydenham's chorea chiefly in its hereditary character and in the much greater degree of muscular incoordination. It almost invariably appears between the ages of thirty and forty. It need merely be men- tioned in connection with children on account of its hereditary character. Habit Chorea. — This condition is common in children. It includes simple incoordinated movements, usually of the eyes, mouth, shoulder, or thighs. They have been called " habit spasms 1 ' or "tics." Imitation is probably a strong factor in the etiology. It may follow from true chorea. These habit spasms may become chronic and persist throughout life. The treatment consists entirely of discipline of the child, and the earlier this is begun and the more strictly it is enforced the better it will be for the child. Chorea Electrica. — This is a very rare condition occurring in child- hood and adult life, and seen chiefly in Italy. It is characterized by violent spasmodic movements of the neck and head and sometimes of the extremities. In the course of a few months paralysis occurs in the affected muscles with marked atrophy and loss of faradic irritability. Myotonia Congenita. — Myotonia congenita (Thomsen's Disease) is characterized by an inhibition of the voluntary movements. This disturb- ance of movement is due to a stiffness and tension of the muscles occur- ring at the beginning of motion. The most important etiological factor in the disease is that it is hereditary. In almost every case it begins in early childhood. An examination of sections of muscle taken from cases of this dis- ease has shown an enormous hypertrophy of all the muscular fibres, great proliferation of the nuclei, and a slight increase of the perimysium. The disease appears to be a congenital affection of the muscular fibres. Symptoms. — The symptoms are noticed only during voluntary move- ments, the contraction of the muscles responding very slowly to the will, and persisting for a little time after the individual has willed the muscular movement to cease. After a period of quiescence, the muscles become stiff and respond to the will only with difficulty. A tap upon the muscles causes a slow, tonic contraction, which relaxes slowly. Long-continued rest, heat, cold, and excitement cause an exaggeration of the symptoms. The muscles of the arms and legs are those usually implicated. Sen- sation and the reflexes are normal. The muscles are apparently enlarged, giving at times the appearance of hypertrophy, but the strength of the muscle is not proportionate to its size. Erb has described a charac- teristic electrical reaction, called the myotonic reaction, in which the con- DISEASES OF THE NERVOUS SYSTEM. 925 tractions caused by either current attain their maximum slowly and relax slowly, and wave-like contractions pass from the cathode to the anode. Diagnosis. — The diagnosis is made by the peculiar contraction which follows a slight tap on the muscles and by the presence of the myotonic reaction. Treatment. — Although at times it may recover temporarily, the disease is incurable, and there is no known treatment which is of much benefit, although active exercise is indicated and is in most cases desirable. Congenital Paramyotonia. — Congenital paramyotonia is a rare con- dition sometimes resembling myotonia congenita. It is an hereditary affec- tion characterized by tonic spasms lasting from several minutes to several hours and coming on soon after birth. There is no myotonic reaction. Paramyoclonus Multiplex (myoclonia). — The principal symptom of this condition is a clonic spasm of the muscles of the extremities, the face generally being exempt. The condition is very rare in childhood. The attacks occur at intervals. Symmetrical muscles are affected, and there is but slight myotatic irritability. EPILEPSY. Epilepsy is presumably an organic disease of the nervous system in which the pathological lesion has not yet been determined. The characteristic symptoms are attacks of unconsciousness Avith or without convulsions, with a great liability to a recurrence of these attacks through a long period of time. The transient loss of consciousness with- out convulsions which occurs in epilepsy is called petit mod, while the loss of consciousness with general convulsive manifestations is called grand mal. Convulsions precisely similar to those occurring in true epilepsy may occur in organic cerebral disease as the result of external trauma- tism or from other causes ; such convulsions have been termed epileptiform. The term Jacksonian epilepsy is applied to localized convulsions which are the result of organic cerebral affections. These latter forms must not be confounded with true epilepsy. It is important that a sharp distinction should be made between the convulsions of true epilepsy and the many reflex convulsive attacks which come from a variety of causes and arise from the hypersensitive condition of the infant's nervous system. These reflex convulsions so closely resemble the convulsions which occur in epilepsy that the great importance of distinguishing between the two diseases can hardly be ex- aggerated. In the infant's rapidly growing brain the irritability of certain motor centres is physiologically far greater than in later childhood and in adult life. This irritability is the source of nervous explosions pro- duced by many causes, often slight in their nature, and it is impossible to differentiate these explosions by their clinical symptoms alone from the convulsive attacks of epilepsy. Etiology. — It is usually granted that the initial lesion of true epilepsy 926 PEDIATRICS. lies somewhere in the cortical motor centres of the brain, and that the epileptiform convulsion is an irritation of these centres. True epilepsy may, of course, originate in early infancy, and does so in a large number of cases. Whether, however, infantile convulsions may be the cause of epilepsy is a very different question. The fact is that we do not as yet know what produces epilepsy. The various etiological factors which are usually cited, such as fright, injury, and dentition, probably have nothing more to do with the production of the disease than to precipitate its de- velopment in an individual who is already predisposed to it. Inheritance as a cause of epilepsy will presumably, in the future, hold a much less prominent place than has been granted to it in the past. There is no good reason for believing that reflex convulsions in them- selves ever lead to true epilepsy. It is of considerable importance that we should be able to allay the natural alarm of parents by telling them, after the convulsions have ceased for a sufficient time to allow us to say that they are not epileptic, that there is no chance of their having pro- duced an epilepsy which will develop later. Symptoms. — Epilepsy may begin in infancy or at any time throughout childhood, but a frequent time for its development is at puberty. Petit Mai. — The petit mal may exist in different degrees of severity. In the mildest form, which may often pass unnoticed unless the attendants are especially on the watch for it, the child stops for a moment in its occu- pation, whether speaking, eating, or playing, while its eyes become fixed and it assumes a vacant expression. This condition may last for only a few seconds, when the child assumes its former occupation as though it had never been interrupted, and usually is not aware that anything has happened. In other cases this condition lasts a little longer, and slight twitching of the lower part of the face and of the extremities may occur. In other cases, again, the attacks are more severe, the child complains of being dizzy, staggers, has slight convulsive movements, and turns pale, this condition lasting for a minute or more, and being quite marked, but without any total loss of consciousness. Momentary attacks of stagger- ing sometimes occur alone in place of the attacks above described. At times these attacks of petit mal are the only manifestations of the dis- ease, but in severe cases they are apt to be accompanied by occasional attacks of grand mal. They may occur as often as twenty or thirty times a day, or, on the other hand, they may be noticed only once in four or five days, and sometimes they are absent for longer intervals. Grand Mal. — In the grand mal the attacks are of much greater severity. They are sometimes preceded for several hours by a feeling of malaise or general discomfort, but this is not ahvays present. Patients sometimes have notice of the sudden onset of the attack, and such notice immediately preceding the convulsions and forming part of the attack itself is called the aura. This aura may be of different kinds. It is most commonly a sense of fulness or oppression in the epigastrium, from which DISEASES OF THE NERVOUS SYSTEM. 927 something- seems to rise into the throat, and unconsciousness supervenes. It may be. however, a pain or a sensation of numbness, tingling, or other form of paresthesia in various parts of the body. Sometimes tinnitus is the first symptom. Frequently the patient has no warning whatever of the attack, but falls unconscious with or without a cry. The face be- comes congested, and the eyes usually turn upward so that only the whites can be seen. After this follows the stage of tonic convulsions, which is sometimes so short that it is overlooked. Then come the clonic convulsions, which in typical cases are general, although the limbs on one side of the body are sometimes more affected than those on the other side. The movements of the limbs are apt to be very violent, the hands are clinched, the thumbs being flexed on the palms and the fingers closed over them. In many cases the patients froth at the mouth. In the more severe cases the children bite their tongues and pass their urine involun- tarily. The duration of such attacks is usually five or ten minutes, but one attack may succeed another with little or no intermission. When the attacks follow one another in this way for several hours the patient is said to be in the epileptic status, and his condition as regards life is very serious. After the convulsion ceases the child's breathing becomes stertorous and the limbs are relaxed. Later, and before consciousness fully returns, the child often falls into a deep sleep, and on waking has no recollection of the attack, but complains only of headache and of mental confusion. Attacks often occur in the night, and in this way may be overlooked, the only evidence of them being that the child has wet the bed. In certain cases, when only nocturnal attacks have been present, we often have reason to believe that the disease has existed for considerable periods before its presence was suspected. In some cases in connection with the attacks there is a desire to walk or to run, so that the patient must be closely watched. In this condition children may walk straight against an obstacle, though they are more apt to stop when something comes across their path. Sometimes they walk or run in circles. The cases of paroxysmal running described by Bullard are at times the early manifestations of an epilepsy which will develop later, although they may also be only the symptoms of hysteria, chorea, and organic cerebral disease. Epileptic children are liable to bursts of ungovernable anger and vio- lence lasting for hours, in which they may tear and destroy things, bite the mother or nurse, and are apparently for a time under the influence of illusions and hallucinations. The condition of patients between the attacks is in the lighter cases and in the beginning of the disease usually quite normal. As the disease progresses, however, there is a tendency to mental impairment, and in the more severe cases, in contrast to the lighter ones, we are apt to find some enfeeblement of intellect, which at times may go on to an advanced dementia. 928 PEDIATRICS. It has been considered by some observers that those cases in which petit mal exists in connection with the more severe attacks are more liable to mental impairment than those in which the grand mal exists alone. Diagnosis. — As the convulsive attacks occurring in epilepsy cannot be distinguished clinically from similar attacks due to other causes, we are forced to differentiate epilepsy from other diseases by carefully eliminating other causes for the convulsions. We must also wait to see whether the attacks will continue indefinitely, in which case they are more likely to be epileptic. The diagnosis of epilepsy is made from a continuance of the attacks after a considerable period without evidence of any organic disease or reflex irritation. When the child bites its tongue during the attack and goes to sleep after the convulsion, or when there is temporary mental impairment after the convulsion, we have good reason to state that the convulsions are due to true epilepsy, especially if no symptoms of organic brain disease coexist. Epileptic are easily distinguished from hysterical convulsions by the presence of consciousness in the latter, at any rate to a considerable extent. Hysterical convulsions in children are not very common, and almost never exist without the presence of other symptoms of hysteria. Prognosis. — The prognosis of epilepsy for life is, on the whole, favor- able, and epileptics may live for many years. As regards cure, the prognosis in cases beginning in early infancy is very serious. When the disease begins at the age of ten years or later a certain number seem to recover, at least temporarily. Many authorities consider that true epilepsy is never cured, yet undoubted cases exist in which no convulsions take place for years. Treatment. — The child should be treated at once, in order to avoid continuous shocks to its nerve-centres. Much benefit results from early attention to general hygienic conditions, to diet, and to protection from nervous disturbances. The management of these cases demands constant watchfulness and tact, so as to regulate the surroundings of the child in such a way as to avoid all source of irritation and nervous excitement. The diet must be regulated according to the especial indications for each patient. A slight gastric irritation apparently produces more serious consequences in epilepsy than irritation of any other part of the body. A vegetable diet is usually indicated, but when the child does not thrive on this it is advisable to give a certain amount of meat. Eggs are usually well borne. The bromides in some form are, in my experience, the most useful drugs. It is often advisable in giving the bromides to change from one bromide salt to another, a greater effect being thus produced than by the constant use of one of them. Efficacious medical treatment depends for the most part on the graduation of the doses, on the selection of the time DISEASES OF THE NERVOUS SYSTEM. 929 for changing them, and on the determination of the intervals for adminis- tering them. The best results in using the bromides are obtained by diluting the dose with a large quantity of water, 120 c.c. (4 ounces). As a rule, bromide of potassium has been found to be the most efficient and active of the bromides in cases of epilepsy. In giving the bromides it is well to begin with small doses. 0.12 to 0.24 gramme (2 to 4 grains), three or four times in the twenty-four hours, for the first year, and to double this amount for the second year. The dose should be increased gradually until the physiological action of the drug is noticed. This treatment, at intervals of one or two weeks, should be carried on for long periods, and from six months to a year after the convulsive attacks seem to have ceased. The following case represents epilepsy in a girl three years old : She was healthy at birth, and remained so until she was two months old. At that time she began to have slight convulsive attacks, the cause of which could not be accounted for. During the earlier attacks she appeared to be frightened. She would then scream, and become rigid and unconscious for about fifteen minutes, after which she would sleep three or four hours. These attacks occurred at all hours of the day and of the night. They continued at irregular intervals, but were not so frequent after the first year and a half. During the first year she seemed as bright as any infant of her age. and developed normally. She was treated with the bromides, and they seem to have been of some benefit, but did not produce a permanent cure. In the third year her mental condition was much affected. She had never been able to sit alone or to bear her weight on her feet. She could not feed herself, and she understood very little that was said to her. Her head was about the normal size. Her face and eyes had a vacant expression, and she had to be taken care of as though she were an infant in the early months of life. In this case there was no history of epilepsy or of any especial nervous disorder in the family, nor of traumatism or of any serious disease which could have produced this nervous disturbance. It was a case of chronic epilepsy starting from some un- known cause and resulting in permanent idiocy. INSANITY. Insanity in children is very rare. In the ordinary forms of insanity no definite pathological lesion has been found which would account for the symptoms presented. Such changes as have been detected come very late in the disease and seem to be secondary. In paretic dementia, how- ever, we find a special form of cortical interstitial encephalitis. Instances of mania and melancholia at times occur. Hallucinations, which are a common symptom in the insanity of adults, occur in children usually in connection with the delirium of fever, or more rarely with epilepsy. Insanity is met with in children at any age ; it is extremely rare before puberty, but then becomes more frequent. The prognosis of insanity in children varies according to its form. Acute mania and melancholia are said to recover generally. True paretic dementia is never known to recover. 59 930 PEDIATRICS. IDIOCY.— IMBECILITY. Idiocy is a condition in which there is a complete and permanent im- pairment of the mind. Imbecility is a slighter grade of mental deficiency. Both conditions occur in brains which are not fully developed in contra- distinction to dementia, in which the faculties are lost in a fully developed brain. Etiology. — Idiocy may be congenital, arising from intra-uterine dis- ease, or it may be hereditary in families in whom the parents have had such nervous manifestations as insanity, hysteria, epilepsy, and chorea, or who have been syphilitic or alcoholic. The acquired form may be caused when there is a predisposition to mental disease or to a cerebral lesion pro- duced by traumatic conditions, such as pressure on the head at birth, injury to the head by falls or blows, long-continued convulsions, and intracranial hemorrhages. Idiocy is in some cases also associated with hydrocephalus and microcephalus ; it may also be a result of epilepsy, especially when the epilepsy develops early in life and the attacks are frequent. Acute infectious diseases, especially epidemic cerebro-spinal meningitis, are often responsible for the development of idiocy. Pathology. — Idiocy is rarely a primary disease, but usually presents the terminal lesions of many different diseases of the brain. The result of these pathological conditions is usually atrophy, which may be local or general, and may be of intra- or extra-uterine origin. Various congenital deformities, as those of the lips, palate, mouth, hands, and feet, are fre- quently associated with idiocy. Symptoms. — The symptoms of idiocy vary according as the individual represents a high or a low grade of this condition. An idiot may have a large head from hydrocephalus, or a small head from cerebral non- development or from cerebral atrophy. Again, idiots may have normally developed crania both as to size and as to shape, In the lower grades there is often some physical malformation in connection with the mental impairment. In the more severe cases of idiocy there is considerable incoordination of the limbs, . and the movements of the child are awk- ward and irregular. In many cases the speech is almost unintelligible. The idiot does not take notice of surrounding objects as does the normal child, and even when the sight and hearing are perfectly norma] the im- pressions made on the senses are deadened. Epileptiform convulsions very commonly accompany idiocy, and play a most important part in the general condition of the patient. The symptoms which are usually met with, and which enable us to diagnosticate a pronounced case of idiocy, are the vacant expression, the occasional presence of strabismus, the drooping head, the drooling, and the lack of all idea of cleanliness. The teeth are usually decayed. Sometimes the child is so limp that he is unable to bear his weight at all, or will stand DISEASES OF THE NERVOUS SYSTEM. 931 held by the hands, with his feet apart, his knees bent, and his trunk leaning forward. The whole body sways to and fro with an oscillating movement and absence of equilibrium. When able to walk alone he walks in a staggering, uncertain way, and falls easily. In many cases, however, the child cannot even sit up alone. The muscles of the neck are often so weak that the head falls over on one shoulder or forward on the chest. The vertebral column fails to support the trunk and bends to a marked degree, and all the muscles are feeble and comparatively useless. Lack of power of attention and lack of memory exist in all cases, and in the higher grades are often the most prominent symptoms. A special type of idiocy has been described under the term agenesis corticalis, in which the size and weight of the brain are normal, but in which abnormalities of development of the fissures of Rolando, of the interparietal fissures, and of the cortical nerve-cells have been recognized. This form of idiocy is associated with blindness and terminates in ma- rasmus. Diagnosis. — We should be careful in very young children not to con- fuse slow or retarded mental development with idiocy. There is so much variation in the time at which children walk and talk, that a delayed de- velopment of these functions must not be considered to represent a con- dition of mental impairment. Some children develop so slowly, both bodily and mentally, that they appear very backward in comparison with others of the same age. Children in the first year of their lives may be so seriously affected by some grave disease that their development is pre- vented from advancing normally, and in comparison with other children of the same age they may be far below the usual grade of intelligence. If, however, we examine this class of cases carefully, we see that, although they are very backward in their development, they are gradually devel- oping, and that they do not represent the condition of complete arrest of development which exists in idiots. It is well to remember that in rhachitis we are apt to have not only- retarded mental development, but a weakness of the extremities simulating paralysis. When both these conditions occur, such cases may sometimes be mistaken for idiots. Treatment. — The treatment of idiots is essentially comprised under the question of their education. The education of this class of cases should be begun early, usually from the fourth to the sixth year. Much can be done to improve the various' defects which exist in each individual. He can usually be iaught to co-ordinate his movements, and by attending to his general health his physical condition can often be much improved. In many cases if convulsions are present they can be more or less con- trolled. Malformations or paralyses can be treated with benefit by appa- ratus or by operation. The best results in these cases will be attained by placing the children in institutions devoted to the training of idiots. Parents can be told that the association of their children with others who 932 PEDIATRICS. are feeble-minded is not a disadvantage, while it is often a great disadvan- tage for the children of sound mind in a family to be associated with one who is idiotic. In the large majority of cases, however, they will always have to be supervised during their lives, and, in most instances, after they have advanced to a certain point they are liable to retrograde. MICROCEPHALOUS. When the head is under a certain size it is called microcephalic. The size which is usually accepted as representing a microcephalic head is from 40.5 to 43 cm. (16 to 17 inches). According to Broca, microcepha- lus exists when the brain weighs 1049 grammes (35 ounces) in the male, and 907 grammes (30 ounces) in the female. It is generally considered that this microcephalic condition is due to a lack of intra-cranial pressure. Together with the lack of development of the cranial bones there exists in these cases a lack of development or atrophy of the brain, which may be considered either as the cause of the lack of intra-cranial pressure or, as is still believed by some writers, as the result of the external pressure caused by a premature synostosis. Microcephalic children are feeble- minded and usually present the symptoms of a somewhat low grade of idiocy. They not infrequently show signs of weakness of the limbs. MIRROR WRITING. An unusual and somewhat striking symptom which at times occurs in severe and, as a rule, chronic cerebral disease is one which is called " mirror writing," which is a condition represented by the individual writing in such a way that the letters can only be deciphered when they are reflected in a mirror. This symptom is usually found when there is cerebral degeneration or among the feeble-minded. The actual pathology of the affection has not yet been determined. HYSTERIA. Hysteria is a functional disturbance of the cerebral centres represented, according to Mobius, by a state in which ideas control the body and pro- duce morbid changes in its functions. The name is a misnomer, but it has been adopted so generally that we must use it for the present. Etiology. — We know very little about the etiology of hysteria. Well- marked instances of the disease occur in early life, usually in the middle and later periods of childhood. An inherited nervous organization or highly exciting surroundings, combined with a lack of proper home disci- pline, appear to present as likely a field for the disease to develop in as any conditions, such as fright, which apparently, at times, directly lead to it. It is a rare disease in children. Symptoms. — The mere presence of emotional or imaginative conditions in children does not constitute hysteria. For the existence of the disease it is necessary to have definite symptoms, either a markedly disorganized mental state, paralysis, anaesthesia, or some serious loss of function. DISEASES OF THE NERVOUS SYSTEM. 933 The symptoms are innumerable. Convulsions and paralysis are quite common, while dysphagia, amaurosis, and anaesthesia are met with only in the very severe cases, and are not often seen in America. Anaesthesia is especially interesting as representing a pure type of the disease, and is usually on one side of the body. Children perhaps only two or three years of age affected by hysteria will sometimes allow themselves to be pricked on the anaesthetic side of the face without wincing. Hysteria in children as usually seen in America is marked by the emotional conditions of the child, and by the presence, in many cases, of a fixed idea relating to its own physical condition. The child believes that it cannot perform certain actions or functions, and hence does not perform them. There probably has often been in the beginning some real difficulty or disturbance of the performance of these functions, such as pain, which has passed away or which is not sufficient to produce the present condition. The most common symptoms, aside from the mental condition, are convulsions, paralysis, and anaesthesia. The convulsions are distinguished from those of epilepsy by the absence of loss of consciousness. The patient never seriously injures himself in falling, and does not bite his tongue. He does not sleep after the attack. The paralysis is often of the spastic form, and may be either hemi- plegic or paraplegic. In this form the limbs are rigid and the knee-jerks are exaggerated. It may, however, be of the flaccid variety, with the knee-jerks diminished or absent. It is distinguished from the organic forms of paralysis by the normal reaction of the muscles to electricity, by the absence of atrophy, by the absence of any affection of the sphincters, and at times by the presence of anaesthesia. When anaesthesia occurs it is usually irregular in distribution, occur- ring in patches, or else it has the same distribution as in cerebral organic disease. It is often variable, changing more or less from day to day. Although almost any symptom may occur in hysteria, yet the lack of uniformity in the grouping of the symptoms, and the combination of symp- toms which belong to entirely different diseases, are of great aid in making the differential diagnosis from these diseases. We sometimes meet with an exaggerated hysteria in children. The attacks are represented by screaming, running, jumping, and a feeling of being pulled about ; they may last for hours, or for days ; their duration, however, is usually long, — at times, with intervals, over a year. No signs of organic disease are found in these cases ; they seldom injure them- selves, and are finally cured by moral influence, change of scene, and good hygienic surroundings. Hysteria occasionally causes children to present symptoms of serious disease of the spine and joints. This most often follows some slight injury, but may occur spontaneously. 934 PEDIATRICS. Prognosis. — The prognosis in cases of hysteria is, as a rule, favorable. Diagnosis. — Generally, the diagnosis is not so difficult as in adult life, because the child is not able to control its sensations of pain and fear so completely as is possible with adults. In surgical cases, however, in which hysterical affections simulate most closely organic disease of the joints, the diagnosis is often attended by extreme difficulty. The applica- tion of strong currents of electricity will usually show that the anaesthesia is not real. Treatment.— The treatment of hysteria is to break up at once the harmful home surroundings, if such exist, and by means of gentle but firm compulsion to make the child understand that its symptoms are unreal. The various local symptoms connected with the digestion and general health of the child should be carefully treated, as the hysterical symptoms are often largely dependent on conditions of this nature. The following case represents hysteria in a girl ten years old : The history of the case was that her parents were living and well, and that there were a number of other healthy children in the family. This child had always been well until eighteen days before she entered the hospital. At that time she complained of headache, and on going to school returned feeling sick and apparently unable to speak. She was said to have been unconscious at times, to have had spasms, and to have been very restless at night. She evidently had had great lack of care in her home life, and had been given only poor food. She showed the evidence of this lack of care in the condition of her skin and her digestion on entering the hospital. A physical exami- nation showed nothing abnormal in connection with the thorax and abdominal organs. The pupils were slightly dilated, but were equal and reacted to light. The knee-jerks were decreased. There was no ankle-clonus. She was apparently unable to walk, and she lay in bed taking no notice of anything, but winked her eyes if anything was thrust towards them. Her hearing did not seem to be especially impaired. She lay in a very limp condition, with the legs drawn up in various positions. Her head kept rolling from side to side, and occasionally was retracted. When asleep her head was retracted so as to make nearly a right angle with the body. It was difficult to feed her, and she would not swallow. Her temperature was 37.2° C. (99° F.), her pulse 66, and her respirations 16. When being examined she cried out a great deal. She was given plenty of good food, and in three or four days her condition was much improved. She took her food well, but was apparently unable to feed herself. A few days later she showed more intelligence, and on being taken up and dressed it was found that she could sit alone and could walk a little with support. On beginning to walk she threw her legs about wildly, but after being scolded she walked much better. At one time when she was sitting quietly in a chair the visiting physician came into the ward, and she immediately allowed herself to slip from the chair and roll onto the floor, but evidently was careful not to hurt herself. She at this time cried out a great deal, but stopped when no notice was taken of her. She was still unable to speak, and, although she could sit up in a chair, apparently noticed nothing. Nineteen days after entering the hospital she appeared much brighter, and began to take a slight notice of what was going on about her. When questioned, she moved her lips as if about to speak, but made no sound. She continued to improve slowly, and a few days later said " sister,' 1 understood what she was told to do, and attempted to do it. She also walked three steps without being assisted. Some days later it was found that she would repeat almost any word that was said to her, but in a whisper. After this she improved rapidly and began to articulate fairly well, but slowly and with DISEASES OF THE NERVOUS SYSTEM. 935 an effort. She also spoke voluntarily two or three times. She could not walk without assistance, as she would put her foot too far forward. She had been very much con- stipated through the whole attack, but at this time the constipation grew less. A defi- nite training of the arms and legs was then begun by means of passive movements and massage. Under this treatment she greatly improved, and on the thirty-fifth day from the time when she entered the hospital, recovered completely. HYPNOTIC STATE. The hypnotic state is an artificial mental condition which can be pro- duced in children as well as in adults. It is supposed to be a temporary abeyance of the powers of the higher cerebral centres. In the ordinary cases the child is thrown into a condition in which the consciousness of his external surroundings is lost. This condition in outward appearance closely resembles sleep, but is produced artificially and can be artificially removed. Thus, the sensation of pain can be temporarily abolished, at least to a considerable extent. For this reason it has been supposed that it might be useful in the treatment of cases requiring minor surgical oper- ations. It has also been advocated by some physicians as a form of treat- ment in various diseases ; but our experience at the Children's Hospital has proved it to be inefficient. CATALEPSY. Catalepsy is only a symptom. It denotes a condition, apparently of cerebral origin, in which, together with total or partial loss of conscious- ness, the limbs assume a peculiar form of rigidity called waxy, and remain for a considerable time in any position in Avhich they may be placed. It occurs at all ages, but is very rare in childhood. The youngest case that I know of is that of a little girl three years old, reported by A. Jacobi. The prognosis and treatment are those of the primary disease. There is no especial treatment for a single attack. SIMULATED DISEASES. On the boundary-line between children Avho evidently are suffering from the need of judicious discipline and those who may be said to have the definite disease hysteria, is a class of cases in which simulation appears to play an etiological part. These children are usually in the later period of childhood, and seem to have such perverted functions of their nervous centres as actually to represent pictures of diseases which are easily proved not to be present. Deafness, blindness, pains of all varieties, palpitation, dyspnoea, vomiting, spasmodic attacks of various kinds, and many other symptoms arise, and may persist for long periods. The best treatment for these cases is at once to show the child that its symptoms are unreal and of no importance. INSOLATION. Heat-insolation, or heat-stroke, is a condition apparently represented by a functional disturbance connected with the cerebral circulation and 936 PEDIATRICS. produced by heat. This affection in varying degrees is of somewhat fre- quent occurrence in children, and is supposed to be accompanied by a hyperemia of greater or less intensity of the meningeal blood-vessels, with general venous congestion throughout the body. It is met with most com- monly in the middle period of childhood, because at that age the child is most likely to be exposed to the influences which produce it. Symptoms.- — The clinical picture of this class of cases is, as a rule, quite characteristic. The child has perhaps been playing on a hot summer's day somewhat more vigorously than usual, possibly romping with an older child of more highly developed nervous resistance, getting intensely ex- cited, and greatly overtaxing its muscular strength. It may be that it has been exposed to the direct rays of the mid-day sun. or it may have been playing in some covered but heated and stifling place. The child's nurse, noticing the extremely flushed condition of its face and head and its excited, sparkling eyes, takes alarm and hurries it to its home. Intense headache soon comes on, and in a few hours delirium may supervene. The skin is hot, dry, and reddened ; there may be vomiting in the begin- ning ; the carotids and temporal arteries throb perceptibly. The heart's action is violent, and the temperature is raised to 38.9°-39.4°-40° C. (102°-103°-104° F.); the pulse is much accelerated, perhaps 140 to 150, and is full, but usually rhythmical. The conjunctivae are congested and the pupils contracted. Photophobia to a greater or less degree is almost invariably present. Beyond this there may be no symptoms ex- cept a slight amount of muscular twitching, and in some cases a convul- sion may occur if the temperature runs as high as 40° to 40.6° C. (104° to 105° F.). The temperature, however, in accordance with the rule in this disease as in others which occur in children, does not always produce the same or equally severe symptoms. Convulsions may occur as a very common form of nervous explosion when fever and disturbance of the cerebral circulation are present, but, as a rule, this symptom is absent. Prognosis. — We should be careful as to the prognosis given in these cases. Although they often simulate closely a beginning meningitis, yet they are very amenable to treatment, and should therefore be carefully differentiated from that disease. In very severe cases the children may, of course, die of insolation. Diagnosis. — -The diagnosis from meningitis is based upon the history, the milder grade of the symptoms, except the headache, and finally, in doubtful cases, on the rapid recovery and speedy disappearance of the fever. Treatment. — The treatment of heat-insolation should be prompt and vigorous. A stimulating enema of salt, one teaspoonful to a quart of water, should first be given. The child should then be placed upon a bed protected by a rubber sheet in a cool, darkened room ; a warm mustard pack should be applied to the lower extremities, and the neck and chest gently sponged with water at 25° C. (77° F.) for fifteen minutes out of DISEASES OF THE NERVOUS SYSTEM. 937 every hour. Letter's coil should be applied to the head with water at 5 C C. (41° F.) : bromide of potassium should be given, 0.3 gramme (5 grains) every hour for four doses ; a little iced milk may be taken if the child cares for it, not more than one or two ounces at a time ; and complete rest and quiet for at least twenty-four hours are usually indicated. The child should be watched carefully for some days and not allowed to play actively enough to get heated. Great care should be taken for the rest of the summer to protect the child from the direct rays of the sun, as after one attack the cerebral circulation remains in a very sensitive condition for a considerable period. CONCUSSION. By concussion we mean clinically a group of symptoms following some physical shock, with its resulting traumatic irritation of the nervous centres. I have met with a number of instances of this nervous phe- nomenon. One was the ease of a boy, four years old, who fell from a table to the floor. I saw him an hour later, and found that his skin was cool, his pulse about 60. He was nauseated and had been vomiting. No evidence of traumatic injury or proof of an organic lesion could be found. After a few hours the symptoms gradually im- proved, and he was perfectly well on the following day. These indefinite symptoms are usually ascribed to the brain as the seat of irritation. The treatment of a case of this kind is simply by perfect rest and quiet in a darkened room, with hot applications to the feet and abdomen, and small and repeated closes of stimulants given by enemata until the stomach is able to retain them, the treatment being continued until the circulation is normal and the pulse strong. TEMPORARY AMNESIA. The following case of temporary amnesia represents a class of nervous disturbance the pathology of which we know nothing of and the causes of which are manifold : A boy, thirteen years old, while running struck his head against a tree. I saw him three hours later. He had walked home, but was a little nauseated, and was put to bed. I found that he had partial loss of memory and was drowsy, but that he had no especial pain. He was perfectly well on the following day. TEMPORARY APHASIA, An instance of suspension of the cerebral function connected with the elaboration of words is illustrated by Demme's case. A child, six years old, previously well and bright, suddenly lost the power of speech. This phenomenon occurred during an operation for talipes, which was being performed without an amesthetic. After the operation the child was perfectly well, but was unable to elaborate words until the ninth day. when she began to use the one 938 PEDIATRICS. word "mamma" for everything that she wanted to say. She then gradually increased her vocabulary until the twenty-first day, when her aphasia disappeared entirely, and she developed mentally and physically in a normal manner. ARRESTED PSYCHICAL DEVELOPMENT. Arrested psychical development is a term used in speaking of an ap- parent lack of mental growth which is sometimes met with in infancy. So far as we know, it is a functional and not an organic condition of the brain. Infants with this affection develop both mentally and physically for a variable period, perhaps five or six months, and then continue to develop physically but cease to develop mentally. This condition lasts for a variable period of months, when their mental development begins again, and, although for some time they are backward in comparison with other children of their age, they finally show no trace of an abnormal mental condition. In some cases the arrest of cerebral development is associated with a condition of physical weakness, so that the power to sit and to walk at the usual age is delayed to a much later period, as the third or fourth year. Arrested psychical development seems to be rather commonly asso- ciated with rhachitis. and may also occur in the course of severe illnesses, but nothing else is definitely known concerning it. RETARDED SPEECH. When during the second year the power of speech does not develop with the usual rapidity, it is spoken of as retarded speech. This lack of power to speak may be from a simple lack of develop- ment of certain portions of the brain, or from organic or functional cere- bral disturbance. It may also arise from abnormal conditions outside of the brain. The cases which are caused by a lack of development may be of congenital origin, or may be due to an arrested cerebral develop- ment produced by a number of causes. These causes are usually con- nected with some serious interference with the cerebral growth, such as a severe illness. Organic aphasia is like that produced by some organic lesion of the brain such as exists in cases of cerebral paralysis. It may also be connected with the condition of idiocy. The functional aphasia I have already described. It may be produced by many causes, among others the infectious diseases. A child may for a time during a severe illness, and after convalescence has been established, apparently be unable to use the words that it was accustomed to before the illness. I have in a number of cases, however, noticed that the child speaks better than it did before the illness. Retarded speech may also be caused by such physical defects as dis- ease of the ear resulting in deafness, and from such a physical malforma- tion of the mouth, palate, or vocal cords as to render articulation impossible. In this connection stammering may be spoken of as a cause of retarded speech. When called upon to decide why the child is unable to speak, DISEASES OF THE NERVOUS SYSTEM. 939 the previous history should be carefully investigated. In this way organic disease of the brain can be eliminated by means of the absence of the usual symptoms of such disease, especially hemiplegia, and by ascertain- ing that the child has not had any disease sufficiently severe in its char- acter to interfere with the development of the centres of speech. After determining that the child is not an idiot, the ear and mouth should be examined. If the child is deaf, there is a good reason for his not being able to speak. Even when young children have learned to speak fairly well, if they later become deaf from a disease like scarlet fever, they are very apt to become mute also. When a lesion of the ear has occurred before the child has learned to speak, he almost invariably is found to be a deaf-mute, although there may be no defects in articulation or in his mental condition. It is seldom that any defect in the mouth or throat is found which interferes with articulation, except in cases in which very extensive lesions are present, such as cleft palate, and sometimes enlarged tonsils combined with a high-arched palate and a large adenoid growth. The tongue-tie which the parents usually consider to be the cause of the retarded speech is seldom present. When no symptom of organic, functional, or developmental cerebral disease exists, when there is no physical deformity, and when the child hears well and seems bright and well developed in other ways, the parents, as a rule, may be assured that the speech is merely retarded and will probably develop later. HEADACHES. When pain in the head occurs in early life it is to be regarded more seriously than at a later period, as it is more apt to indicate some grave central lesion. The various forms of organic headache which arise in children can be spoken of best as symptomatic of the various diseases in which they occur. There also appears to be a type of headache which occurs in the later years of childhood irrespective of any definite disease and is often unac- companied by nausea. These headaches, as a rule, are not of serious import, and are usually classed under the term functional. They occur irregularly, and may be in any part of the head. They are often so severe that the child has to lie down. The intervals between the attacks are variable, and the length of the attacks varies from two to three hours to a day. Of these functional headaches the most frequent form in chil- dren is that due to anaemia. It is always, however, wiser to look upon this form of headache as a symptom of some undetermined disease. Although in many cases headaches are caused by an improper regula- tion of the diet, yet there is evidently some other cause which we do not recognize in their production, as with exactly the same diet tor many months a child will show no symptoms whatever of headache. In like manner, although we know that headaches in children may depend upon constipation, yet this class of cases occurs whetner constipation is preseni 940 PEDIATRICS. or not. The source of the headache cannot be determined by the part of the head affected. Migraine also may exist in children, and is characterized by severe pain in the head, sometimes unilateral, sometimes bilateral, accompanied by nausea, dizziness, and generally vomiting. The attacks occur at irregular intervals, and usually last the greater part of a day. They may be brought on by apparently slight causes, such as over-fatigue, eye-strain, or very mild indiscretions of diet, in those predisposed to them. These head- aches are markedly hereditary. Although all these forms of headache are ordinarily very intractable to cure, especially when no bad hygienic surroundings exist which might account for them, and when the child does not lead a sedentary life, yet, as a rule, the attacks have a tendency to lessen and disappear as the child grows older. One of the most common causes in children is pain caused by strain of the eyes. In all cases of headache in children the cause of which is not evident, a careful examination of the eyes should be made, even though there be no symptoms which point to the eyes themselves. Treatment. — The treatment of headache should be directed to that of the disease which is causing the disturbance when it can be detected, as in anaemia or hyperemia from various causes, gastric disturbances, the prodromal stages of the acute infectious diseases, malaria, uraemia, and other toxic causes ; when, however, no cause can be found, a darkened room and sufficient bromide of soda to allay pain and produce sleep are indicated. VERTIGO. Vertigo at times occurs in children. It is a term applied to a condi- tion in which the individual or the objects around him appear to be roll- ing about. It is called subjective vertigo when the patient himself seems to be turning, and objective vertigo when it is the surrounding objects that appear to move. Vertigo has a variety of causes. It may be due to organic cerebral diseases, such as tumors of the brain, especially of the cerebellum, and to diseases of the ear and of the eye. It may also be due to circulatory disturbances, as in cardiac disease, and to the stomach, as from improper food, also from tobacco and tea. The following case illustrates this condition : A boy, thirteen years old, had had a purulent otitis for several years, but this had healed three years previously, leaving a condition of adhesions and cicatrices with con- siderable impairment of hearing, but with no trouble of the labyrinth nor any symp- toms pointing to it. He was always strong and well until he was seven years old. At ten years he began to have attacks of dizziness accompanied by seeing white spots. At times he had nausea. A sensation of spinning around or falling subsequently developed, was constant, and increased in severity. He had no other abnormal symptoms except weakness. He slept well, his appetite was fair, and his bowels were regular. He had DISEASES OF THE NERVOUS SYSTEM. 941 good hygienic surroundings, did not smoke, and had never lived in a malarial district. He was a close student and led a sedentary life. He had never had any headache. He drank much tea. He was directed to stop drinking tea and to ride on horseback. Within a few weeks after the active exercise had been begun and the tea had been omitted from his diet, the boy ceased to have attacks of vertigo. PAVOR NOCTURNUS. The night-terrors of children may occur from a variety of causes, and should not be considered as one disease, but as a symptom of a number of diseases. Any nervous disturbance, whether central or peripheral, may produce so profound an impression on the sensitive cortical cells of the brain that the child's sleep may be disturbed by a cortical irritation. The following case represents the special form of pavor nocturnus which may be considered central: A boy. six years of age. had always been a delicate, thin, pale child, not caring much for out-of-door exercise, but inclined to remain in the house and to be read to or to have exciting stories told to him. His appetite was poor. He was mentally bright and precocious. Otherwise he appeared to be well, and showed no signs of any organic disease. One evening he was allowed to sit up rather later than usual, and a number of terrifying stories were told to him. He went to sleep as usual, but in about an hour waked up screaming. He was found sitting up in bed looking terrified. His eyes were staring at some invisible object, evidently a picture in his brain and. not a reality ; he was pointing at this imaginary source of his terror, and kept repeating that it was a black dog. It was impossible to pacify him for about ten minutes, and he did not recognize his mother during the attack. He then became more quiet ; the wild look passed from his eyes ; he recognized his mother, and soon lay down and went quietly to sleep. The cause of this attack, which is typical of the central form of pavor noc- turnus, was evidently an undue excitement of the cells of the cortex in a bright, nervous child before going to sleep. The treatment of a case of this kind is to accustom the child to more exercise in the open air, to prevent his reading anything but the most ordinary and simple books, and to have no stories whatever related to him, especially at night. The following case represents the peripheral form of pavor nocturnus: A girl, three years old, had been always well and strong ; she had a good appetite ; was not nervous or excitable ; she was fond of playing out of doors, and was not fond of having stories told to her. She was constipated, and had a tendency to overload her stomach. She had eaten a very heavy supper, and on going to bed immediately fell asleep, but soon began to be restless, to throw herself about, to groan, and to grind her teeth. A little later she woke up screaming, and apparently had a certain amount of dyspnoea. She did not recognize her mother, but sat up in bed looking very much frightened and clutching at her throat. Her mother made her drink some warm water, which produced copious vomiting. She then became rational again, recognized her mother, and soon lay down and went to sleep. 'She had no recollection of the attack on the following day. The irritation in this case was of the terminal filaments of the pneumogastric nerve in the stomach, causing reflex symptoms of the nervous centres to such an extent that the child was terrified and felt as though she would stifle. The treatment in cases of this kind should be by moderating the diet and allow- ing the child to have only a light and digestible supper. The two classes of eases arc 942 PEDIATRICS. distinct and their treatment is entirely different. A mixture of both of these forms is frequently met with, between which it is not possible to make a clear distinction. TREMOR. Universal or partial tremor is rare in infancy and in early childhood in comparison with later life. It does, however, occur, and is usually sig- nificant of an organic cerebral lesion. I have noticed it also in cases of infantile atrophy, in which as recovery gradually took place the tremor disappeared. In this form it appears to be chiefly a symptom of weak- ness. It may be quite marked as a general symptom, but it is not espe- cially significant, either in respect to the diagnosis or to the prognosis. TETANY. With the knowledge which we have at present of this condition we must look upon tetany as a symptom of nervous irritation and not a defi- nite disease. The condition is represented by tonic intermittent paroxysmal muscular contractures varying in duration and intensity. Although the seat of these contractures may be in other parts, such as the neck, face, and thorax, yet the chief and characteristic parts are the hands and arms, legs and feet. The wrist is sharply flexed and turned outward ; the thumb in the position of extension is drawn across the palm of the hand beneath the fingers, which are flexed at the metacarpophalangeal joints, but other- wise are in the position of extension. The feet are rigidly extended and may be in the position of talipes equinus or of equino-varus. The pha- langes of the toes are flexed and extended in the same way as those of the fingers. Tetany as a term should be used only when these character- istic contractures are present, and should not be applied to other condi- tions of increased reflex excitability. Opisthotonos may occur. The knee- and hip-joints are usually not affected. Etiology. — Tetany is a symptom of a number of different conditions, and is not pathognomonic of any one disease. It is at present believed that certain toxins may be developed which affect the central or periph- eral nervous system. This is especially liable to occur in gastro-enteric diseases, in rhachitis, in various acute diseases, such as pneumonia, and especially where the hygienic surroundings are bad. Pathology. — There is no definite morbid condition with which tetany is associated. The condition is functional rather than organic, and, accord- ing to Osier, certain forms depend on the loss of the function of the thy- roid gland. Symptoms. — The peculiar spasmodic conditions described above vary in their duration, and are usually paroxysmal. They may last only a few minutes or for hours or even clays. Pain is at times present, especially when the attempt is made to overcome the spasm. The temperature and pulse, according to the exciting disease, are increased. The electrical ex- citability, mechanical excitability, cutaneous reflexes, and knee-jerks are increased. DISEASES OF THE NERVOUS SYSTEM. 943 Trousseau's symptom (compression of the large nerve-trunks or blood- vessels of the parts affected bringing on the paroxysms) is generally present, and in some eases Chorstek's symptom (active contraction of the muscles supplied by the facial nerve produced by a slight tap on the course of the nerve) can be obtained. Laryngo-spasmus occurs in certain cases, espe- cially when rhachitis is present. When the muscles of the trunk are involved, dyspnoea, cyanosis, and even opisthotonos may occur. Diagnosis. — The peculiar bilateral spasms usually occurring in the course of such diseases as rhachitis or gastro-enteric disturbance, espe- cially when combined with Trousseau's and Chovstek's symptoms, serve to distinguish true tetany from other nervous manifestations of muscular irritability. From tetanus the diagnosis is made by the absence of trismus ; from meningitis by the absence of cerebral disturbance ; and from cerebral tumor by the bilateral spasm and absence of headache. Prognosis. — The symptom in itself is not a serious one, the danger depending upon the gravity of the special disease which is causing the tetany. Treatment. — The general nutrition of the child should receive careful attention. Hot baths, chloral, the bromides, and electricity are indicated, and the endeavor should be made to remove the especial cause, which is frequently to be found in the gastro-enteric tract. Thyroid extract should be tried when no primary cause for the tetany can be determined and other treatment is found to be inefficacious. DENTAL REFLEXES. The twitching which occurs in children at the time when a tooth is the apparent cause of a certain amount of discomfort and fever should be referred to here as a significant illustration of nervous phenomena from reflex causes. The cases are numerous, but scarcely of sufficient impor- tance to report. In certain instances, however, convulsions of a reflex nature occur at this time and cease when the tooth has assumed its place above the margin of the gum. I have also met with some interesting cases of local oedema arising during the period of dental irritation, and usually spoken of as angio-neurotic oedema. One of these cases was a male infant, fifteen months old, who some months pre- viously, while cutting one of the second molars, had an attack of oedema of the hands, which was not accompanied by irritation or any other symptom, and which passed off after a few hours. This same boy when the canine teeth were about to come through the gums was again attacked by oedema of the face. This local oedema, as in the previous instance, disappeared quickly. At times I have seen a local oedema attacking one eyelid, so that the eye could not be closed. Although we cannot say that irritation from the teeth is necessarily the cause of these conditions, yet they so often arise during the dental 944 PEDIATRICS. period, and not during other periods of childhood, or before the fourth or fifth month, that we can at least say that in individuals of an excessively nervous temperament the irritation which evidently arises in certain cases when the teeth are developing may be sufficient to cause a nervous explo- sion, which in this sense may be spoken of as of dental origin. NYSTAGMUS. By nystagmus is meant a peculiar rhythmical oscillation of the eye- balls, usually from side to side, but in some cases up and down. It may sometimes be dependent on organic disease of the brain, and again may arise from local diseases of the eye, so that a careful examination of the central nervous system and an expert examination of the eyes should always be made. In many cases, however, this condition appears to be purely reflex from various peripheral stimuli, and is not a very uncommon symptom in young children. I have notes of two cases, brothers, who during the dental period showed this oscillation of the eyeballs with no other symptoms. Complete recovery resulted when dentition was com- plete. The cause, however, of the reflex irritation must always be looked for, and it must not be taken for granted that the chief etiological factor is dentition, for in many cases disturbance of the gastro-enteric tract is present. GYROSPASM AND SPASMUS NUTANS. Gyrospasm (rotary movements of the head) and spasmus nutans (nodding) are peculiar movements of the head in young children which are apparently of reflex origin, and are at times associated with nystag- mus and strabismus. The chief causes are rhachitis, gastro-enteric irrita- tion, and dentition. The prognosis is usually good except when idiocy is present. The best treatment is with the bromides. REFLEX SYMPTOMS OF THE EAR. The reflex connection between the roots of the teeth and the mem- brana tympani by means of the otic ganglion produces the well-known reflex earache which occurs during the dental period. This has been described on page 634. REFLEX SYMPTOMS OF THE LARYNX. In certain cases reflex symptoms occur in the larynx. They are usually noted during infancy rather than in childhood. The affection has been called laryngospasmus, and although it is more usual for it to occur in rhachitic children than in others, it is not necessarily confined to rhachitis. It is not in my experience a very common disease, but when met with it is very characteristic. Symptoms. — The infant is suddenly attacked by a spasmodic contrac- tion of the larynx. This condition may be precipitated by various causes, such as fright and excitement. I have also seen it produced by various DISEASES OF THE NERVOUS SYSTEM. 945 peripheral irritations, such as those of the nose. At times the attack is so severe that the infant becomes unconscious and cyanotic. The attack lasts for only a few minutes, and on recovery the infant seems as well as ever. There does not seem to be an inflammatory condition connected with this disease, and apparently it is purely of a reflex nature. In some cases a crowing laryngeal sound will frequently precede and often succeed the more severe stage of the attack. Prognosis. — The prognosis in cases of laryngospasmus is, as a rule, favorable, although very weak infants may die in an attack. Treatment. — As the infants are usually delicate and of a highly ner- vous organization, the treatment should be directed to improvement of their general health and to protection from nervous excitement until they have attained an age when their nervous system is less irritable and is in more stable equilibrium. During an attack the treatment is to endeavor to produce relaxation of the spasm by peripheral irritation elsewhere. This is usually done by showering the child on the chest and face with cold water and lightly slapping the back. Among a number of cases of this kind which have come under my notice was this one : A boy, one year old, had always shown a nervous temperament and had had a number of convulsions when he was cutting his first teeth. With the exception of a light attack of epidemic influenza, he had been well and strong. Following the attack of epidemic influenza, in which the nasal symptoms were prominent, he was left with a very irritable naso-pharynx. He then began to have attacks characterized as follows : Whenever the nurse, while giving him a bath, attempted to cleanse his nose, no matter how gently, he would immediately gasp, with a catching sound in his breath- , ing, become rigid, draw himself back sometimes almost to the position of opisthotonos, become unconscious and cyanotic, and then after a few seconds the spasm would pass away and he would seem perfectly well again. These attacks continued for some months without apparently harming him, and they then grew less frequent and passed away entirely. As additional examples of reflex phenomena of the larynx having their origin in the ear may be mentioned the hoarseness which sometimes accompanies the impaction of cerumen in the ears, and which disappears almost immediately after the removal of .the mass. Blake reports a case in which a persistent laryngeal cough of several months' duration was immediately relieved by the removal of a bead from the external auditory canal. These cases, as well as those in which there is a reflex cough, can be explained by means of the following diagram, which shows the reflex connection between the ear and the larynx. The irritation of the sensitive fibres of the auriculo-pneumogastrkus distributed in the meatus and in the membrana tympani is reflected along the motor fibres of the superior laryngeal nerve, exciting in the larynx the act of coughing by causing contraction of the crico-thyroid muscle. When the original irritant, either in the meatus or in the mem- GO 946 PEDIATRICS. brana tympani, by its continued presence involves the vaso-motor fibres associated with the auricular nerve, they conduct their impression to the ganglion of the pneumogastric, and thence it is deflected through a sympa- thetic fasciculus proceeding from it to the first cervical ganglion. This Fig. 190. & -0 XE Reflex connection between the ear and the larynx. A. auditory canal, membrana tympani, and middle ear ; B, second ganglion of vagus ; C, first cervical ganglion of sympathetic ; D, auriculo- pueumo-gastric nerve ; E, sympathetic fasciculus connecting B and C ; F, nervi molles, vasomotor connection with external carotid ; G, external carotid ; H, laryngeal artery ; S, superior laryngeal nerve ; L, larynx. again through the nervi molles carries the impression to the external carotid artery, and by its branches to the mucous membrane of the larynx, and as a result of reflected vaso-dilator impressions we may have congestion of the vessels supplying the mucous membrane of the larynx, and perhaps effusion from these vessels. The detailed description of the anatomical conditions underlying these reflex phenomena will be found on page 634. PAROXYSMAL GASPING. A condition known as paroxysmal gasping occasionally occurs in young children. The child, previously quiet, suddenly becomes cyanotic, rolls up its eyes, stops breathing, gasps, and looks as though it were about to die. The seizure is apparently a reflex irritation of the diaphragm, and could be classed under hysteria. These cases respond quite readily to good care, well-regulated food, and relief from the duties of school. In some cases there are no serious symptoms, but mere gasping of light grade. REFLEX SYMPTOMS OF THE LUNG. In young infants pulmonary attacks closely simulating the symptoms of asthma occur from gastric irritation of the terminal filaments of the pneumogastric nerve. They are evidently reflex in their character, and are promptly relieved by treatment of the stomach. They are spoken of under the term asthma dyspepticum. In cases of this kind it is usually found that the peripheral irritation either arises from the too high per- centages of the solid constituents of the milk which is given to the infant. DISEASES OF THE NERVOUS SYSTEM. 947 or is caused by the total amount of milk given being too great for the infant's gastric capacity. Symptoms. — The first symptoms noticed in these cases are the pallor of the infant's face, and a slight cyanosis around the mouth. The respi- rations then become quickened, and the infant is evidently in great dis- tress. It becomes cyanotic, breathes very rapidly, and often looks as though it were about to die. On examining the chest the lung is found to be resonant, and there is nothing abnormal on auscultation except roughened respiration and a few sonorous rales. Treatment. — An emetic will quickly relieve this condition, which disap- pears as soon as the stomach is emptied. The attacks are sudden and often recur. Alter the attack has passed off, the abnormal sounds heard in the lung are found to have disappeared completely, and the infant seems per- fectly well again. Another class of reflex pulmonary symptoms Avhich has at times come under my notice consists of cases in which, from some peripheral irritation elsewhere, marked pulmonary symptoms simulating pneumonia arise. The first case was a little girl six years old. The first attack occurred at a time when she was having an exacerbation of an attack of subacute purulent otitis media. She had a heightened temperature, 40° C. (104° F.), and rapid respirations (60 in a minute). The alae nasi were moving slightly, and she showed a certain amount of or- thopnea. Her face was flushed, and she had a short, dry cough. She had a discharge of pus from both ears. On looking at this child one would naturally have said that she had pneumonia. Evidence of this was. given by the temperature, the respirations, the alae nasi, the cough, and the orthopnea. The lungs, heart, and throat were found on examination to be normal. The pulmonary symptoms were evidently reflex in their nature, as it is believed that in these cases the reflex symptoms are usually produced by the occlusion of the Eustachian tubes. On inflating the Eustachian tubes with the air-douche her breathing became nor- mal in rate, 24 to 28 in a minute, the alae nasi ceased to move, the cough disappeared, and the child could lie down with comfort. REFLEX COUGH. The nervous connection between the ear and the larynx gives rise at times when there is disease of the former, such as an otitis media, to a persistent cough, which is evidently reflex, and which is relieved only by treatment of the ear. A little girl, four years old, had an attack of measles which was complicated by an otitis media. She recovered entirely from the measles, and seemed perfectly well, except that the perforation of the membrana tympani had not entirely healed. Some- what later the cough began. Nothing was found to account for this symptom in the throat, lung, or larynx, except a slightly reddened appearance of the latter from cough- ing. The cough was intractable to all local treatment until the far, which had been in the process of healing, again showed signs of increased inflammation. Whenever the ear was discharging, the cough ceased entirely. When the oar was treated and the discharge grew less, the cough began again, and there was an evident reflex connection between the larynx and the ear. 948 PEDIATRICS. These reflex phenomena continued for some months, the child always coughing when the ear got better and ceasing to cough when the ear got worse. Finally, on the child's being taken to Switzerland and having an entire change of air, its general health was much improved, and the reflex cough passed off. There was no recurrence of this condition in the following ten years. When there is an irritation in the nasopharynx a reflex cough often occurs, and is best treated by local applications to the pharynx and naso- pharynx. It is important for the physician to recognize this class of coughs, as he might otherwise be very unsuccessful in treating these cases. Many children are treated with drugs for a cough which is usually ascribed to bronchitis, where no physical signs of irritation can be found in the lung, larynx, or throat, and where the irritation is in the nose or the naso- pharynx. In place of the many drugs usually given in these cases, a simple spray in the nose is indicated. REFLEX SYMPTOMS OF THE HEART. Cases of extreme palpitation in children are occasionally met with when nothing organic can be detected, and when no cause, such as tea- drinking, is discoverable. The children are of a highly neurotic temper- ament, and are usually much influenced by exciting surroundings in their homes. A boy, ten years old, was subject to fits of great excitement brought on by the most trivial causes, such as preparing to go to school or to take a journey. For some hours before the proper time for starting came he was apt to grow more and more agi- tated. He would then often be seized with violent palpitation lasting for several hours and forcing him to lie perfectly still on his back. At these times his skin was cool and pale, and his pulse weak and irregular. Nothing abnormal was detected on an exam- ination of the heart or any other organ. The attacks lasted until he was twelve years old, and have never occurred since. REFLEX SYMPTOMS OF THE STOMACH. There are a number of reflex conditions connected with the stomach arising from different causes but represented by the same symptom, vomiting. Instances of this condition are those cases of vomiting which arise from irritation of the larynx and pharynx and which are cured by local applications made to these parts. REFLEX SYMPTOMS OF THE BLADDER. Reflex spasm of the bladder occurs very frequently in young children, and this condition has been described under enuresis, page 871. REFLEX SYMPTOMS OF THE VAGINA. There is almost always a direct cause to be found for the reflex nervous symptoms which arise from vaginal irritation. One of the most common causes is the oxyuris vermicularis, which at times gives rise to extreme and severe symptoms when it has migrated from the rectum. In DISEASES OF THE NERVOUS SYSTEM. 949 addition to the local irritation, which causes the child great uneasiness, so that it cannot sit still and is continually moving its legs about, its tem- perament may be much affected. A child with this trouble is apt to be very fretful, to have violent outbursts of temper, to lose its appetite, and to grow thin. A little girl, five years old, had the most extreme vaginal irritation. When I saw her she had been affected for several months and was in a very weak condition. At times the irritation seemed to be more than she could bear, so that she would lose all control of herself, would throw herself on the floor, and would have violent spasmodic contractions of the legs. Her sleep was much interfered with, and her whole appear- ance was that of a child suffering from some serious disease. An examination showed that the oxyuris vermicularis was the cause of the vaginal irritation, and after a few days' treatment directed to the expulsion of the parasite the child ceased to have any irritation and subsequently recovered entirely. REFLEX SYMPTOMS OF THE RECTUM. In certain cases reflex symptoms of a most exaggerated type are localized in the rectum. The following cases are illustrative ; A girl, four years old, had always been remarkably strong and robust, and had never had any especial local trouble with the bladder or the rectum. She was, how- ever, of an excessively nervous temperament, and was surrounded by exciting in- fluences in her home. She began to have spasmodic contractions of the sphincter ani. When she attempted to have a movement of the bowels it frightened her, and she would clutch at any piece of furniture which happened to be near her and try not to have the movement. She would scream and cry out as if she were in much pain. An examination under ether showed nothing abnormal in the rectum or sphincter, such as from pressure or from lesions, and the condition was apparently simply that of spasm. She was treated by the daily dilatation of the sphincter ani with bougies, the size being increased gradually. This was followed by marked improvement, and the rectal spasm passed away. Although the rectal spasm did not return in this case, yet in its place the child began to have incontinence of urine. Another child, eight years old, for a whole year was affected by intense irritation in the region of the anus, which prevented her from sitting down for any length of time and kept her in a continual state of irritability. Nothing could be detected during this period which caused these symptoms. No trace of intestinal parasites could be found, and nothing abnormal, either at the anal orifice or in connection with the bowels, was seen, the skin around the anus being in a perfectly normal condition. The child was treated with bromide of potassium for several weeks, and recovered en- tirely. CEREBRAL ABSCESS. Cerebral abscess is a localized purulent encephalitis. It is probably always secondary to suppurative disease elsewhere. It may arise from a suppurative condition of the scalp, but its most common source is some purulent disease of the ear or its surroundings. It is also found as a sequel to traumatism of various kinds resulting in suppuration and in general pyaemia, and it may follow direct traumatic injury to the brain. Cerebral abscess is usually single, except when it is produced by pyaemia. 950 PEDIATRICS. The abscess may occur in any part of the brain. Cerebellar abscess is not uncommon. Symptoms. — A cerebral abscess may exist for a considerable time without producing any symptoms which can be recognized during life. In cases in which suppurative disease of the ear exists, a cerebral abscess may be suspected when, in addition to the temperature, which would naturally be raised from this process, the child's general condition be- comes worse without any apparent cause, and Avhen indefinite symptoms, such as mental dulness and irritability, arise. The temperature and marked leucocytosis may also suggest the presence of imprisoned pus, and the probability of cerebral disease, in cases where the pus cannot be found elsewhere. Cerebral abscess may, however, exist for a consider- able period without rise of temperature, and even with a subnormal temperature. It is apt to be slow in its progress and to cause general constitutional rather than local symptoms. Local symptoms produced by the presence of cerebral abscess are rare. When present, however, they are represented by headache, vertigo, mental dulness, vomiting, and con- vulsions, and are followed later by coma. When the abscess bursts into the ventricles, symptoms of sudden collapse appear, and death rapidly follows. Tremor and convulsions may occur in cases of cerebral abscess, but neither of them should be considered as in any way symptomatic of this condition. Prognosis. — The prognosis is very unfavorable unless the disease can be reached surgically. Treatment. — The treatment should be operative if the abscess can be localized. CEREBRAL, PARALYSIS (Infantile Cerebral Palsies). In using the term cerebral paralysis it must be understood that it is not intended to describe every disease of intra-cranial origin from which a paralysis may result. We may have a resulting paralysis from many intra-cranial lesions, such as hydrocephalus, cerebral abscess, cerebral tumors, and other causes. These conditions are not included in the class of cases designated as cerebral paralysis or infantile cerebral palsies, which are motor disturbances arising from certain cerebral lesions, occurring in intra-uterine life, during labor or after birth in the first three or four years. There is much concerning the definite pathology of this class of cases which is still undetermined, so that they will be more clearly understood if discussed as a group and their prominent features compared with each other. This is all the more necessary as the clinical manifestations of all of them are practically the same, and are represented by a spastic paralysis involving one or more extremities in the form of a hemiplegia, a diplegia, or a paraplegia. Monoplegias are rare in comparison with the other forms. Any one of these forms may be accompanied by contrac- DISEASES OF THE NERVOUS SYSTEM. 951 tures, choreiform movements, mental impairment, epilepsy, and a number of like nervous symptoms usually spoken of as post-paralytic. In 22b cases analyzed by Peterson and Sachs, right hemiplegia oc- curred in SI cases, left hemiplegia in 75, diplegia in 39, and paraplegia in 30. Etiology. — The cause of cerebral paralysis occurring in intra-uterine life has not been definitely determined, and our knowledge concerning this class of cases is very vague. It has, however, been found that instances not infrequently arise in which there is an hereditary history of epilepsy, insanity, or marked neuroses. Traumatism, severe illnesses, and fright in the mother are accepted as other possible causes. According to Sachs, syphilis does not play the important part in the etiology of intra- uterine palsies which has been given to it by some authors. The cerebral paralysis, which is the result of conditions occurring during labor (birth-palsies), may arise from asphyxia in tedious and pro- longed deliveries, which, according to Sachs, are more disastrous than the accidents which at times occur when the forceps are used. Certain etiological factors are well recognized as causes of the palsies which occur after birth in the early years of life. These are traumatic injury to the skull, fright, the acute infectious diseases, such as measles, scarlet fever, typhoid fever, variola, pneumonia, and cerebro-spinal menin- gitis. It has also followed acute tonsillitis, severe cases of gastro-enteric disease, pertussis, and, in certain instances, violent convulsions, though in most cases of the latter condition the convulsions are probably caused by, rather than causative of, the lesions producing the paralysis. In some cases the disease arises in apparently healthy children and without assignable cause. Pathology. — In the intra-uterine cases the lesions, according to Sachs, are represented by large cerebral defects (porencephaly), and also by a condition designated " agenesis corticalis" in which there is a defective development of the cellular elements of the cortical and particularly of the pyramidal cells, which is not restricted to any one part of the brain, but involves all parts of the hemispheres about equally. This condition is met with in the family form of idiocy. In the cases which occur during labor, birth-palsies, the primary lesion is usually a meningeal hemorrhage (rarely intra-cerebral), and, as shown by McNutt, more or less diffuse over both hemispheres. In the cases which occur after birth, extra-uterine palsies, as well as in the intra-uterine and birth-palsies, a distinction must be made between the primary lesions and the terminal conditions. In a series of 78 autopsies in infantile hemiplegia analyzed by Peter- son and Sachs, there were found as primary lesions, hemorrhage 23, embolism 7, thrombosis 5, and tubercle 1 ; while as terminal lesions there were atrophy, sclerosis, and cysts 40, and porencephalia 2. Por- encephalies denotes a pathological loss of substance, forming cavities or 952 PEDIATRICS. cysts running from the cortex of the brain towards the centre, affecting the motor region and being either unilateral or bilateral. Sclerosis con- sists of a shrinking and hardening of the cerebral tissues, usually more or less strictly localized. Although the primary lesions of all forms of the infantile cerebral palsies may be caused by embolism or thrombosis, yet these etiological factors are rare in comparison with hemorrhage, which is the most com- mon cause of the primary acute symptoms. This hemorrhage is more apt to be meningeal than cerebral and is usually in the subarachnoid space, thus differing from cerebral hemorrhage in the adult, which occurs more frequently in the region of the internal capsule. Thrombosis may be a cause where changes have taken place in the cerebral arteries clue to hereditary syphilis, and embolism may be the cause in such predisposing affections as valvular cardiac disease. The pathology, therefore, of the condition as a whole is a lesion of the motor tract followed by atrophy and retarded development of the part affected, and a descending degeneration of the pyramidal tracts and lateral columns of the cord. It is also possible that the primary cause of the disease may be a defective development of the nervous centres. Symptoms. — If the lesion has been of intra-uterine origin, we may get only the later manifestations, just as we do in congenital syphilis. The paralysis in this class of cases is usually cliplegic or paraplegic, and mental enfeeblement, amounting often to idiocy, is common. When the paraly- sis is due to defective cortical development the muscles may be flaccid instead of the characteristic spastic condition of the other forms of cere- bral paralysis. If the lesion has occurred at the time of delivery, the primary symptoms are often masked, and the resulting symptoms of the more advanced pathological condition are noticed later. The diagnostic early symptoms are paralysis, convulsions, rigidity, and stupor ; asphyxia and irregular respirations are common symptoms. The symptoms vary with the extent and locality of the lesion. There may be bulging of the fontanelle, changes in the pupils, and oscillation of the eyeballs. When the disease develops in extra-uterine life it is usually acute in its character and is marked by more or less fever, convulsions, and stupor. These early symptoms are merely those of a general nervous explosion following an irritation of the nervous motor centres. They may be' the first manifestations of a disease of any kind, or they may occur in the course of one of the diseases of which I have spoken under etiology. If they happen to occur at night and are of short duration, they may be entirely overlooked, and the later symptoms of a cerebral lesion may be the first ones to manifest themselves. The child may die from the severity of these initial lesions before the later symptoms of paralysis have developed by which we can diagnosticate the disease. Screaming, vomiting, and delirium may at times usher in the attack. In DISEASES OF THE NERVOUS SYSTEM. 953 the midst of or closely following these primary symptoms come the pro- nounced indications of a central nervous lesion, represented by hemi- plegia (paralysis of an arm and a leg on the same side), paraplegia (paralysis of both legs), or diplegia (paralysis of corresponding parts on the two sides of the body), cases of hemiplegia being the most common. In rare cases we find only one extremity affected (monoplegia). Hemi- plegia is by far the most common form. In addition to the paralysis of the limbs, facial paralysis may occur either in hemiplegia or in diplegia, and, as a rule, spares the upper part of the face, so that the eyes can be closed and the brows raised, thus showing that it is not a peripheral facial paralysis. This form of facial paralysis often disappears early. Strabismus is common. On examining the paralyzed limb we find a resistance to motion, the deep reflexes are exaggerated, and in most cases there is a feeling of rigidity on the paralyzed side. A few cases of flaccid paralysis have been reported. Sensation, as a rule, is not affected. When the child has come out of its stupor and the convulsions have ceased, it may be found to be aphasic, but aphasia is not so common as in the cerebral lesions of adults. The intelligence is usually impaired, but this depends upon the extent and location of the lesion and the period when it occurred. The intra-uterine and early infantile cases show the greatest mental disturbance. These children are apt to be very irritable, and, when the lesion is cortical, epileptiform convulsions are quite common. The mind may, however, remain perfectly clear in both the early and late stages of the disease, in spite of a marked hemiplegia. The electrical reaction of the muscles is normal. In the more advanced stages of cerebral paraly- sis additional symptoms begin to appear. The child learns to walk late, or, if it has already Avalked, the gait becomes peculiar. Rigidity fol- lowed by contracture of the flexor and adductor- muscles occurs. In about seventy-five per cent, of the cases of diplegia and paraplegia it comes early and develops oftener than in the adult cases. The rigidity is increased by manipulation or use of the limb, and disappears during sleep. Post-hemiplegic movements follow in a certain number of cases ; in others the spastic condition is so pronounced that the patellar tendon reflex and the ankle-clonus cannot be obtained. When walking is at- tempted, the patient is apt to stand on the toes, the knees knock together, and the spastic rigidity of the muscles produces what is called the spastic gait, represented in its exaggerated form by the cross-legged progression, which is largely caused by the rigidity of the adductors of the thigh. Pes equmus and pes equino-varus are the most common deformities of the foot. When the arm is affected with contractures, the fingers are pressed into the palm of the hand, the hand is flexed, and the arm is flexed at the elbow and held close to the side. The affected limbs are apt to show some disturbance of their circula- tion, and some coldness. There are more or less atrophy and shorten- 954 PEDIATRICS. ing of the bone, but to a less degree than in cases of poliomyelitis anterior. In a certain number of cases involuntary incoordinate move- ments are excited in the paralyzed limbs on voluntary effort (hemiataxia), and are usually designated as post-hemiplegic chorea. There may also be continuous movements (athetosis) of either a partial or a general variety. The sphincters are not affected, whether the case is one of hemiplegia or of paraplegia. Epileptiform convulsions may appear quite early in cases of cerebral paralysis, but may also be delayed for a number of years, so that the possibility of these children becoming epileptic must always be considered. Diagnosis. — The diagnosis in a marked case of the disease is not diffi- cult, but the determination of the exact lesion is often impossible after the period of onset has passed and we are left with a resulting paralysis. If facial paralysis is present, we can, as a rule, say that the lesion is in the brain ; but this rule does not always hold good, as there have been very rare cases in which this paralysis was present when the lesion was in the cord. The symptoms on which we chiefly rely in making our diagnosis of cerebral paralysis are (1) the distribution of the paralysis, hemiplegic, usually, or paraplegic ; (2) rigidity of the muscles ; (3) increased tendon reflex ; (4) comparatively slight wasting ; (5) normal electrical reaction ; and (6) mental impairment. Choreic or athetoid unilateral movements associated with a slight increase of tendon reflex point towards a previous cerebral paralysis. From Poliomyelitis Anterior. — The principal disease from which cere- bral paralysis is to be distinguished is poliomyelitis anterior. In contra- distinction to the chief diagnostic symptoms of cerebral paralysis just stated we find in poliomyelitis anterior (1) that the distribution of the paralysis is usually monoplegic ; (2) that there is an absence of tendon reflex ; (3) that there is an absence of rigidity in the early stages ; (4) that there is rapid and marked wasting of the affected limbs ; (5) that the reaction of degeneration is present ; and (6) that there is no mental im- pairment. From Idiocy. — In certain cases also a difficulty may arise in correctly understanding the relationship between cerebral paralysis and idiocy. The cerebral lesion is in many cases probably the same, but, according to its extent and location, we may have either (1) a cerebral paralysis alone ; (2) a cerebral paralysis accompanied by mental impairment or idiocy ; or (3) idiocy without cerebral paralysis. There is a certain class of low- grade idiots in which some impairment of motion exists, apparently due to a mental inability to co-ordinate the muscles of the limbs properly. This may sometimes be accompanied by a diminution of sensation, which seems to be due to a want of perception in the higher nervous centres rather than to any actual lesion of the sensory tract. When the idiot's attention can be kept centred on the limb, the actual sensation does not DISEASES OF THE NERVOUS SYSTEM. 955 seem to be much impaired. The differential diagnosis of this condition in idiots from cerebral paralysis is easily made, for it exists only in those cases of idiots in whom the mental development is much impaired, and it is not, as a rule, accompanied by true paralysis, as there is no weakness, but simply incoordination ; in these cases also the tendon reflexes are, as a rule, not increased. From Caries of the Spine. — Cerebral paralysis can be diagnosticated from the paralysis which occurs in connection with caries of the spine, princi- pally by the presence of cerebral symptoms in one case and the promi- nence of the spinal vertebrae and the rigidity of the spine in the other. From Syringomyelia. — Rare cases of syringomyelia may be mistaken for cerebral paralysis. The points of differential diagnosis in these cases are that in syringomyelia, although the weakness of the limbs may be so extensive as closely to simulate paralysis, yet the diminution of thermic sensation easily distinguishes it from the normal sensation which is present in cerebral paralysis in cases where the test for sensation can be em- ployed. Syringomyelia, however, is so rare in children that the diagnosis need not be dwelt upon. Progxosis. — In the intra-uterine forms of cerebral paralysis a large number of infants die at varying periods during the early months of life, so that for some weeks, at least, a prognosis as to life cannot be given. Quite a large number, besides developing epilepsy, also show the condi- tion of idiocy. A severe lesion may be inferred if convulsions occur in the early weeks and if apathy continues in the intervals between the convulsions. If after a few weeks or months the convulsions are markedly diminished, and if the infant begins to use its legs and to take notice of things, a more favor- able prognosis can be given. So long as contractures do not develop a fair use of the extremities may be acquired. Sachs states that in the intra-uterine cases diplegia and paraplegia are more apt to be associated with cerebral deficiency and epilepsy than is hemiplegia. In the acute extra-uterine cases the prognosis for life in cerebral paraly- sis is soon determined in the early days of the attack, and depends on the location and extent of the cerebral lesion, but the uncertainty in some cases may last for a number of weeks. On account of the usual menin- geal form of the hemorrhage it is less likely to prove fatal in infants than in adults. Entire recovery is rare. In hemiplegia the paralysis will prob- ably improve. The spastic rigidity usually goes on to decided contracture. In some cases no mental change is apparent, in others the mental devel- opment is merely retarded, and the child learns to talk some years later than is normal. In a large number of cases, however, the mind is much enfeebled. The occurrence of epilepsy as a result of cerebral paralysis is so common that it should be especially mentioned in this connection, as it makes the prognosis much more serious both as to the degree to which the mental impairment may attain and as to the life o( the patient. 956 PEDIATRICS. According to Gaudard, Osier, Wallenberg, and Sachs, the development of convulsions after an infantile apoplectic attack makes it probable that chronic epilepsy will result, and the prognosis becomes much more grave. Statistics show that epilepsy follows the hemiplegic cases rather more fre- quently than it does the diplegic and paraplegic, and that it occurs in about half the cases of hemiplegia. If after a few weeks there is improvement, the prognosis is good ; if, on the contrary, there is no improvement for months, it is bad. In some cases, however, after improving for even a year, convulsions may appear and epilepsy develop. Except in very rare cases, the children can eventually be taught to walk. In many instances, although during infancy there is complete help- lessness, later the condition is much improved, and sometimes considera- ble activity results. Treatment. — In the intra-uterine cases, as it is the later manifestations of the disease which are met with, the treatment should be the same as is indicated in the late treatment of the birth-palsies and of the extra- uterine cases. In acute cases the infant should be kept perfectly quiet, and, if unconscious and unable to nurse, the mother's milk or a carefully modified milk should be given by means of a dropper. If convulsions appear, small doses of the bromides, 0.18 to 0.48 gramme (3 to 8 grains), or chloral, 0.06 to 0.3 gramme (1 to 5 grains), and inhalations of ether are indicated, and in protracted convulsions minute closes of morphia, 0.0006 gramme (0.01 grain). Although the application of ice to the back of the neck is recom- mended when a cerebral hemorrhage is suspected, yet in young infants this procedure should be used with great caution, as cold is so apt to reduce their vitality. The following was a case of cerebral paralysis with left spastic hemi- plegia : The boy was six years old. The delivery was terminated with forceps, but the labor was not a severe one, and he was healthy at birth. He developed normally for two years, and walked when he was eighteen months old. He had convulsions in his third year, and these convulsions occurred again when he was four years old. They were followed by paralysis. He could not use his left hand well, and the grasp of the left hand was less strong than that of the right. The triceps reflex was exaggerated on both sides. The left foot could with difficulty be flexed dorsally. The right knee- jerk was normal, the left increased. He had flat-foot, and walked with his left foot inwardly rotated. He was otherwise well and strong. The following case represents hemiplegia of traumatic origin, probably hemorrhage : A girl, four years and nine months old, was brought to the hospital with a history of having fallen from the roof of a three-story building upon a brick sidewalk. She was un- conscious. She vomited slightly, and she was found to have an ecchmyosis on the left side of her head. Her pupils were equal and reacted to light. Her respirations were rapid ; DISEASES OF THE NERVOUS SYSTEM. 957 the extremities were cold. She moved all her limbs vigorously. Some clotted blood was found in and about the nostrils. The temperature was 36.3° C. (97.4° F.) ; the pulse was 90, and the respirations were 26. She ground her teeth and cried out in the night. The muscles of the left arm and leg moved actively. During the next four days she remained unconscious. Involuntary micturition, inequality of the pupils, the right pupil not reacting to light, irregular pulse, and slight opisthotonos developed as new symptoms. On the seventh day she appeared brighter, and followed objects with her eyes. Her pulse was irregular, from 80 to 90. Two days later she made voluntary movements, such as to push objects away from her, and gave evidence that she understood what was said to her. From that time she slowly improved. Fig. 191. Fig. 192. Cerebral paralysis. Spastic paraplegia. Cross- legged progression. Male, 5% years old. Cerebral paralysis. Diplegia. The left extremities affected more than the right. Female, 5 years old. On the twenty-ninth day from the time when the accident occurred she could walk, though with difficulty, as the right leg was very unsteady. One week later she was discharged from the hospital. She could then use the right arm fairly well, but still walked with some difficulty "on account of the weakness of the right leg. Her articulation was labored, and her pupils were still unequal. 958 PEDIATRICS. The following case (Fig. 191) represents a boy, five and a half years old, with spastic paraplegia resulting from a cerebral paralysis and showing cross-legged progression ■ The cerebral lesion occurred when he was an infant. Nothing abnormal was noticed about him until he was fifteen months old, when it was observed that he could not walk. He had more or less mental impairment, nystagmus, stiffness of the ad- ductor and flexor muscles, and paralysis of the extensors of the lower extremities. The knee-jerks were much increased, and there was slight ankle-clonus. He walked in the characteristic manner called cross-legged progression. The following case (Fig. 192) represents a girl, five years old, affected with diplegia resulting from a cerebral paralysis : She had a good family history. The labor was easy, and was not instrumental. She developed well and was healthy until she was ten months old, when it was noticed that she did not move her arms as she ought to, that she did not use her left arm at all, and that the left leg was not used as well as the right. This condition persisted. She had strabismus. She could not hold her head up straight. She could not sit up alone or stand. Her head was small and narrow, and had a long antero-posterior diameter. The reflexes were increased. . The power of her left arm was much im- paired, and there was some contraction of the fingers and elbow of a spastic character. She did not move her left leg well. Sensation was dulled alike in both legs. Her face had an idiotic expression, she was poorly developed mentally, and she could not talk. She showed the form of spastic cerebral paralysis which is called diplegia, the left extremities being more affected than the right. The face was not involved in this case. The prognosis of a case like this is unfavorable so far as recovery is concerned, on account of the great mental impairment. Operative treatment is, however, indicated, as at times improvement results in even decidedly idiotic cases. MYELITIS. The term myelitis denotes an inflammation of the spinal cord, whether of the gray or of the white matter. Acute myelitis has been used to designate an acute diffuse inflammation of both the gray and the white matter of the cord of non-traumatic origin, and is an affection almost unknown in children. The term meningo-myelitis is used to denote an inflammation of the meninges and of the spinal cord. Acute myelitis, meningo-myelitis. and hemorrhage into the cord are extremely rare in early life. INFANTILE SPINAL PARALYSIS (Poliomyelitis Anterior Acuta). Infantile spinal paralysis is the most frequent and therefore the most important disease which affects the spinal cord, with a resulting paralysis, in infancy and early childhood. It occurs most commonly in the first three years of life. It is rare in the first six months of life. It may occur in later childhood, and very rarely in adults. It is met with more commonly than cerebral paralysis. It is represented clinically by a motor paralysis rapidly leading to atrophy of the muscles affected. DISEASES OF THE NERVOUS SYSTEM. 959 Etiology. — The disease may be primary, in which case it is without any known cause : or it may be apparently secondary to other diseases, such as the acute exanthemata and erysipelas. Traumatism appears occa- sionally to give rise to the condition. Most of the cases occur during the summer months, and at night rather than during the day. It attacks healthy children as well as unhealthy. It is not hereditary. It may occur in epidemics, and is therefore supposed to be infectious in its origin, but no specific organism has been discovered. Pathology. — The pathology of poliomyelitis is still not definitely deter- mined. It is at present believed that the gray matter and its ganglion-cells may be involved throughout the entire length of the cord, the process being an interstitial inflammation with secondary changes of a degenera- tive character in the ganglion-cells. The cervical and lumbar enlarge- ments are most frequently affected. Goldsheiders investigations show that irritation is present in the walls of the blood-vessels, Avhich leads to their dilatation and to a proliferation of their endothelial elements ; the morbid process then extends to the neuroglia and produces a proliferation of its cells. He believes that the changes in the ganglion-cells and in the nerve-fibres are secondary and due to disease of the blood-vessels. Secondary changes also take place in the columns of Clarke, which disappear, and the anterior nerve-roots become smaller than those on the opposite side. This condition may be confined to the anterior cornua, but in some cases it may involve the spinal meninges. So few post-mortem examina- tions of the early lesions connected with this disease have been made that we are dependent for our knowledge of it mostly on cases which have been examined a number of months or years after the production of the initial lesion. These later pathological conditions are, however, quite characteristic. The circumference of the limb grows small in comparison with that of the opposite one, being the result of an active muscular wasting and of retarded growth. The bones of the affected limbs are often shorter than those of the other side, sometimes even to the extent of several inches. In certain cases, however, the lengths of the bones seem to be but little affected, although the atrophy of the muscles may be very marked. The anterior cornua of the region affected, which is usually in either the cervical or the lumbar enlargement, are found to be greatly atrophied and many of the large motor cells to have been destroyed. The affected half of the cord may be considerably smaller than the other, and the anterior lateral column may show slight sclerotic changes, chiefly in the pyramidal tract. Accompanying this condition the corresponding anterior nerve-roots are found to be atrophied, and the muscles connected with the region of the cord which is affected atrophy and gradually un- dergo a fatty and sclerotic change. The fibres are much diminished in size, many have disappeared altogether, and the normal fibres are at times replaced by adipose tissue. 960 PEDIATRICS. Symptoms. — The onset of the disease in the great majority of cases is acute. Its course is chronic. In the acute form the onset may be pre- ceded for some days by fever and restlessness, but it is apt to appear sud- denly with convulsions which, as a rule, are of a milder type than those which occur in cerebral paralysis, are general, and at times absent. The subacute variety of poliomyelitis anterior does not differ from the acute cases in any way in its symptoms, prognosis, diagnosis, and treatment. Following the acute onset there are at times unconsciousness, lasting sometimes for a number of days, vomiting, general nervous disturbance of the bladder and intestines, and a variety of symptoms of nervous irritability which may represent the prodromata of a number of diseases. The vomiting, when it occurs, accompanies the initial fever, resembles, according to Sachs, the cerebral type, and is not connected with gastric disturbance. Coma may be present, but is rarer than convulsions, and is not usually profound. The temperature is seldom very high, 38.3° to 38.7° C. (101° to 102° F.) ; it may, however, in certain cases be higher. At times there are no prodromata, but the paralysis is noticed in the morn- ing after a night's rest, although on the evening before the child was seemingly perfectly well. The severity and length of the prodromal symptoms are no indications of the gravity of the lesion or of the prog- nosis as to recovery. Pain in the paralyzed limb is not an uncommon symptom, but occurs only very early in the disease. The temperature of the limb is lowered, there is vascular sluggishness, and the limb has a bluish, flaccid, undeveloped look. The disease is primarily a motor dis- turbance, sensation remaining intact. Cerebral symptoms, if present, pass off rapidly with the appearance of the paralysis. The paralysis is usually apt to affect more than one limb in the beginning, but, as a rule, soon becomes monoplegic. The leg is more frequently affected than the arm. Paraplegia in the beginning is not uncommon, and all forms of paralysis may occur. There may also be diplegia, crossed paralysis, and paralysis of the muscles of the back and abdomen. Hemiplegia, so com- mon and almost characteristic of cerebral paralysis, may be present, but is rare in poliomyelitis anterior. The muscles most frequently affected are the extensors, adductors, and supinators. The distribution of the paralysis is usually in groups of muscles. The respiratory muscles may be affected, although rarely. Facial paralysis is so rare that it can almost be said never to occur in uncomplicated poliomyelitis. When the prodromal symptoms have passed off, as they usually do very quickly, the functions of the body are carried on as usual, and the general growth and mental activity are unimpaired. The tendon reflexes disappear in the affected limbs when all the muscles are severely affected. When the paralysis has reached its height, which is usually in a few hours or days, it remains stationary for perhaps from three to six weeks, and then gradual improvement begins, and goes on in certain groups of the paralyzed muscles for six or eight months, leaving other groups paralyzed. These groups again at times DISEASES OF THE NERVOUS SYSTEM. 961 recover entirely or remain disorganized, and thus lead later to contractures and deformities. When contractures occur they appear later than do those of cerebral origin. When paralysis affects wholly or chiefly the gastrocnemii and posterior tibial muscles, the other groups act predominantly, causing dorsal flexion of the foot, so that the child walks on its heel. This condition is termed talipes calcaneus. When, on the other hand, the tibialis anticus and ante- rior muscles of the leg are most affected, the deformity of talipes equinus occurs ; and if the peroneal muscles remain unaffected, there is valgus, while if they are affected with the anterior group, talipes equino-varus occurs. Dislocation of the hip may occur in rare cases of complete pa- ralysis of the leg. Severe cases may show complete flaccidity, and not infrequently the ligaments about the joints are so weakened that the joints become too movable, and the condition called flail-joint results. This con- dition may be present at the hip, knee, or ankle, and sometimes at the shoulder or wrist. Marked atrophy appears in a few weeks. Muscular atrophy, rapid and extreme, is the rule in poliomyelitis anterior, and begins a few weeks after the appearance of the paralysis. Shortening of the bones from arrest of growth may also appear. The surface tempera- ture of the affected limb is lowered, the limb feels cold, relaxed, and life- less, and the circulation is generally sluggish. Spasmodic movements, except the primary convulsions, are absent. In rare cases improvement begins immediately after the attack, and goes on to complete recovery (temporary spinal paralysis). In the epidemic form the fever is apt to be high, the distribution of the paralyses extensive, and in a series of ten cases examined by Brackett the sphincters Avere at times involved, and in the severe cases prolonged hyperesthesia occurred. Diagnosis. — In the stage of onset, and until paralysis has appeared, the diagnosis must be held in abeyance. The salient points by which a diag- nosis can usually be made are (1) sudden paralysis; (2) loss of tendon reflex ; (3) rapid atrophy ; (4) cold, flaccid limbs ; (5) absence of impair- ment- of sensation ; (6) presence of the reaction of degeneration and a diminished reaction to the faradic current. It is always difficult to diagnosticate poliomyelitis in the initial stage of the disease. At that time pain and sensitiveness of the affected limb may be present, and may lead us to suspect that the disease is rheumatism. The convulsions and unconsciousness which may appear at this stage are so often present in other diseases that they are not of much aid in making the diagnosis of poliomyelitis anterior. The most reliable test at our command for making the diagnosis of poliomyelitis anterior is the electrical reaction. The normal muscles react to both the faradic and the galvanic current. In applying the galvanic current a quick muscular contraction is noticed both on the opening and on the closing of the negative (cathodal) and of the positive (anodal) pole, 61 962 PEDIATRICS. but is greater when the cathodal pole is closed. When the galvanic cur- rent is applied to the muscles affected by poliomyelitis anterior, the con- tractions continue, but are slower and less sharp, and the reverse of what takes place in normal muscles occurs. Thus, the anodal closure causes a contraction equal to or greater than that caused by the cathodal closure (reaction of degeneration). As the muscles recover there is first a return to the normal galvanic reaction and later to their normal faradic excita- bility. The diagnosis in young children, however, by means of the gal- vanic current is practically useless except in the hands of an expert. The faradic excitability begins to diminish within a few days after the onset of the paralysis, and disappears entirely from those muscles which are severely affected. From Cerebral Paralysis. — Poliomyelitis anterior is most apt to be mis- taken for cerebral paralysis, and can be best differentiated from that dis- ease by means of the symptoms which have been described. TABLE 76. Cerebral Paralysis. Poliomyelitis Anterior. Motor disturbance Paralysis. Most common form Paralysis. Most common form hemiplegia. monoplegia. Spastic rigidity. Elaccid. Spastic gait. Groups of muscles in a limb All the muscles of a limb af- affected, usually the exten- * fected. sors. Contractures Of all the muscles, especially the flexors and adductors. Of the flexors in the calf. Spasmodic movements . . . Athetosis. Absent. Post-paralytic chorea. Convulsions may occur at the Epileptiform convulsions. onset of the disease. Sensation Unaffected. Unaffected. Nutrition Arrest of growth. Tendency to extreme atrophy coining on early in the para- lyzed limb. Electrical reaction Normal. Reaction of degeneration. Tendon reflex Exaggerated on the paralyzed side. Absent, Speech Liable to be impaired. Unimpaired. Intelligence Often impaired. Normal. From Multiple Neuritis. — The principal points by which multiple neu- ritis is to be distinguished from poliomyelitis anterior are (a) the sym- metrical affection of the limbs in the former and tenderness over the nerve-trunks ; (6) the atrophy in multiple neuritis is not so severe as in cases of poliomyelitis anterior ; (c) the course of the disease is different, cases of multiple neuritis almost invariably recovering, while severe cases of poliomyelitis do not recover. From Progressive Central and Progressive Neural Muscular Atrophies. — The diagnosis of these conditions will be found on pages 991 and 992. From Pseudo-Hypertrophic Muscular Dystrophies. — Pseudo-hypertrophic muscular paralysis in its early stage is not likely to be mistaken for polio- DISEASES OF THE NERVOUS SYSTEM. 963 myelitis, but in the later stages of this disease, in which atrophy may occur, it may be necessary to make a differential diagnosis. This will be described on page 994. From Rhachitis. — In certain cases of rhachitis the power of using the legs is so much affected that the mistake is quite commonly made of sup- posing that these children are affected by poliomyelitis anterior. The condition in rhachitic children is one of weakness and not of paralysis, and can be distinguished by the normal electrical reaction of the muscles and the lack of pronounced atrophy. From the Pseudo-Paralysis of Scorbutus. — The pseudo-paralysis which is commonly seen in cases of scorbutus is often mistaken for some organic disease of the central nervous system, with its resulting paralysis. The differential diagnosis from poliomyelitis anterior, however, is not diffi- cult to make, for the involvement of other joints in addition to those of the legs, the presence of pain and tenderness to such a degree that the child cries whenever the limbs are touched, and the normal temperature of the skin clearly distinguish this condition from poliomyelitis, in which disease normal sensation, freedom from pain, and a cold feeling of the limb affected are found. Prognosis. — So far as a fatal issue is concerned, the prognosis is very favorable. If death occurs, it usually takes place at the end of one or two weeks, and is the result of interference with respiration, which may be caused when the paralysis is extensive. When in the initial stage of the attack cerebral symptoms are prominent and continue for some time, the prognosis is grave. The prognosis is not so good in the epidemic form, which is much more severe in its manifestations. A second attack of the disease is very rare, and when it occurs it usually comes a few days after the original attack, and manifests itself by an increase of the existing paralysis. The paralysis, as a rule, will not increase when it has been stationary for twenty-four hours. The tendency of poliomyelitis is for a time to improve. Some of the limbs affected recover in the first few days, but if the paralysis persists longer perfect recovery is rare. When there is no improvement after six or eight months the probability is that entire recovery will never take place, al- though under proper treatment slight improvement may go on for years. We must remember that, even when untreated, a case of poliomyelitis is very apt to improve for one or two months quite rapidly, then slowly for two or three months, and after a stationary period, contractions, looseness of the joints, and malpositions may begin to be evident and may increase indefinitely. When proper treatment is carried out, the prognosis is much more favorable, and the period of possible improvement can be extended for some years. According to Bradford and Lovett, there is certainly no leg, however wasted and contracted, that is not amenable to some improvement by operative or mechanical treatment. 964- PEDIATRICS. Treatment. — The treatment of poliomyelitis by means of drugs has produced such unsatisfactory results that it may be said to be useless. At the onset of the attack the bowels should be freely moved, and con- vulsions, if present, should be treated symptomatically. as described on page 914. Although we know of no rational means of treating the primary lesion of poliomyelitis anterior, we know that the results of this lesion, as shown by paralysis of the muscles, are such that the paralysis should be treated at once. The indication is to combat the rapid atrophy which is part of the disease, and to prevent its increase and its later results from proceeding to a degree which would interfere with subsequent repair. To accomplish this, the affected limb should be supported in a normal position and carefully guarded against the stretching of joints, ligaments, and muscles. In addition to this, after an interval of two weeks, gentle massage and the faradic current applied five or ten minutes at a time at least four or five times a week are indicated to keep the affected muscles in the best possible condition and to combat the atrophy which to a greater or less degree occurs. The regular application of heat is also found to be useful where the limb is cold. The muscles are much less likely to contract and deformities to result in properly supported limbs. The later manifestations of club-foot and other deformities should be dealt with by the orthopaedic surgeon. Tenotomy and the transplanta- tion of tendons are of benefit in many severe cases. The following case and Fig. 193 represent poliomyelitis in a girl nine years old : She was perfectly well up to the time of an attack, which came on suddenly and without known cause. She was said to have fallen while she was playing, hut no injury of the leg could be detected, although she was carefully examined under ether. The exact date of the attack was not known, but it was not recent. Her general health was reported to have been very good, and she seemed to be bright mentally. She was well developed, and had a good color. Nothing abnormal had been detecled on physical examination of the lungs, thorax, abdomen, or other organs. The pulse was regular and of good strength. The left leg showed considerable atrophy, being 4.37 cm. (If inches) smaller than the right in the calf and 2.5 cm. (1 inch) in the thigh. The leg was somewhat cyanotic, and was cold to the touch. There was marked weakness of the muscles below the knee, especially the exte-nsors of the foot and of the toes. When she was lying in bed the movements of the thigh were performed with some strength. On walking she rotated the leg outward, so that the foot was at right angles with the line of motion, and she dragged the toes. The joints were freely movable. Nothing abnormal had been detected in connection with the spine, which presented the condition of a movable lateral curvature, due to the shortening of the affected leg. As the primary lesion probably occurred some years previously, the prog- nosis was bad as to complete recovery or much improvement. Fig. 194 represents a girl, two and one-half years old, Avho had an attack of poliomyelitis anterior of the abdominal muscles. DISEASES OF THE NERVOUS SYSTEM. 965 She had a sister who was said to have had an attack of poliomyelitis anterior when she was ten months old. No other history had been obtained about this case, except that she was well and strong until this attack, which occurred six weeks previous to the time when the picture was taken. The onset of the disease was sudden, and was Fig. 194. Poliomyeliti Poliomyelitis anterior. Abdominal muscles, left side. Female, 2% years old. accompanied by high fever, followed in three days by complete paralysis of the muscles of the upper and lower extremities of the body and of the head. The arms and head soon recovered. She was unable to sit up alone, and the abdominal muscles were paralyzed to such an extent on the left side that they were flaccid, bulged out, and did not react normally. The left leg was perfectly flaccid. The knee-jerks were absent. The surface temperature was diminished, and there was atrophy of both legs. Under treatment with electricity and massage, complete recovery took place in this case. Fig. 195 represents the condition of flail leg following an attack of poliomyelitis anterior. A boy, six and one-half years old, was apparently healthy at birth, and had never had any illness. When he was one year old he was noticed to have some motor dis- 966 PEDIATRICS. turbance of the left leg. On examination of the leg when he was two and a half years old the surface temperature was found to be diminished, the knee-jerk was ab- sent, and there was an atrophy of 5 cm. (2 inches) of the thigh and 6.5 cm. (2£ inches) of the calf. There was also 3.7 cm. (1J inches) shortening in the leg. The child walked with a marked limp of the left leg, and there was the condition of flail- joint in his left knee and ankle. This was a typical case of the appearances presented in the advanced stages of a severe case of poliomyelitis anterior. Fig. 196. Pig. 195- Poliomyelitis anterior. Flail leg, left side. Male, 6% years old. Poliomyelitis anterior. Talipes equinus on right side. Male, 11% years old. The following case represents diplegia caused by poliomyelitis : The child, a girl of five years, was well and strong until about her third year, when she had an attack of whooping-cough. During this attack she also had some other illness, which was characterized by fever and pain in the back. The loss of power of her legs dated from this time, and is said to have been gradual. She was fairly well developed, and the paralysis had affected both legs and thighs as well as the psoas and iliac muscles. There was marked atrophy, and the reflexes were absent. The limbs were held apart and were flaccid. If the case had been one of cerebral paralysis there would have been in place of this flaccid condition a contraction of the adductors of the thigh, which would have been apt to hold the limbs closely together. DISEASES OF THE NERVOUS SYSTEM. 967 Fig. 196 represents a boy, eleven and a half years old, with talipes equinns following acute poliomyelitis anterior. The anterior portion of the foot was flexed at a sharp angle at the medio-tarsal joint. The foot could be easily bent to a right angle, but not beyond. Tense bands of plantar fascia could be felt when the foot was straightened out, but it could be brought into position by the use of considerable force. The length of the legs was equal. There was 1 cm. (about f inch) atrophy in the right calf and 0.6 cm. (\ inch) of the right thigh. This condition of talipes equinus resulted from a contraction of the flexor muscles following an attack of infantile paralysis. PARALYSIS CAUSED BY CARIES OF THE SPINE. In cases of paralysis caused by caries of the spine the lesion is essen- tially a compression of the cord : this is usually slow in its progress, and is not apparently a true inflammation even in the beginning. The condi- tion resulting from compression occurring in the course of caries of the spine may be found in any part of the cord. It is most frequently met with in disease of the dorsal region, though it may occur in the cervical and lumbar regions. In caries of the spine the compression of the cord is not often the result of pressure from the vertebrae, but usually is caused either by an abscess in the vicinity of the diseased vertebrae, or more commonly by a thickening of the meninges. Etiology. — When the lesions of the cord are of any considerable extent, ascending and descending secondary degenerations follow after a time. If the process ceases, it leaves a certain amount of sclerosis of the cord at the seat of the disease. This may be very slight, or the cord may be considerably reduced in size and yet may transmit normal ner- vous impulses. Symptoms. — The onset of the disease is sometimes quite sudden, but more frequently it is gradual. The symptoms vary according to the part of the cord which is affected. When the lesion is in the dorsal or the lumbar region the onset is represented by numbness and weakness in the legs. This is quickly fol- lowed by a paralysis which may become complete in a short time. If the lesion is below the level of the sixth dorsal vertebra, the legs alone are affected ; if on a level with this point, the abdominal muscles are involved. Sensation up to nearly the level of the lesion may be diminished, or even lost entirely. In regions above the lumbar enlarge- ment the reflex reactions are exaggerated and ankle-clonus soon appears. When the disease affects the cervical enlargement, or any portion of the cord above, all the extremities are apt to be paralyzed. In severe cases there will be retention of urine, with subsequent incontinence. The bowels are usually constipated, but incontinence of faxes is some- times present. In lesions of the lumbar enlargement the knee-jerks will be lost. 968 PEDIATRICS. Trophic changes in the limbs are not marked, but the muscles are some- what wasted, and rigidity may develop. Bed-sores are apt to form. The reaction of degeneration is not present. The characteristic feature of lesions in the dorsal region caused by caries of the spine is a paraplegia. Diagnosis. — The disease is to be differentiated from poliomyelitis ante- rior, in which monoplegia is more common than paraplegia, and in which the reflexes are lost and the reaction of degeneration is present. In addition to this means of making a differential diagnosis, the absence of initial fever and prodromata, of disturbances of sensibility, of paralysis of the sphincters, and of a tendency to bed-sores in poliomyelitis anterior is of great aid in differentiating it from the results of caries of the spine, where rigidity of the limbs, increased reflexes, and contractures are promi- nent symptoms. The differential diagnosis from cerebral paralysis is more difficult, as the condition of the limbs is similar in both. The diagnosis is made by the absence of all cerebral symptoms, and by the presence of such special symptoms as rigidity and prominence of the vertebras in caries of the spine. Prognosis. — The prognosis is in general favorable. A certain number of cases remain uncured, but nearly all recover under treatment, although the condition may persist for months. Treatment. — The treatment of these cases is, as a rule, to be directed to the caries, and consists essentially in perfect rest on a rectangular bed- frame. Massage and electricity are sometimes of assistance when applied to the paralyzed limbs. Forcible correction of the deformity has the effect in many cases of improving the paralysis. When no improvement occurs after several months, laminectomy may be considered. OBSTETRICAL PARALYSIS. By obstetrical paralysis, or paralysis of the new-born, is meant that form of peripheral paralysis which occurs during the delivery, and which, as a rule, affects the face or one of the extremities. In this sense it is to be separated from injuries to the brain and spinal cord which are produced during the delivery. — in fact, from any paralysis of central origin which may occur in intra-uterine life, either before or at the time of delivery. Etiology and Pathology. — The cause of this form of peripheral paraly- sis is most often traction made upon the head of the child during delivery, thus producing a direct injury to the nerves, resulting either in pressure or stretching of the nerves, and in some cases in a rupture of the two upper roots of the brachial plexus. Although this form of paralysis has been known in a number of cases to result from pressure by the forceps during the delivery, yet it has also been met with after an apparently normal delivery, where the pressure did not seem to be especially severe or prolonged. DISEASES OF THE NERVOUS SYSTEM. 969 When the nerves of the face are affected, the resulting lesion is supposed to be from an injury of the facial nerve ; and when the arm is affected, the lesion is supposed to be an injury of the brachial plexus or of the nerves in the lower part of the neck. As a rule, the lesion is of one arm. Symptoms. — A paralysis of this form usually becomes apparent imme- diately after birth, but may be delayed for several weeks. When the face is affected, it is due, as a rule, to an injury of the seventh nerve, thus pro- ducing a peripheral facial paralysis. The peripheral form of facial paraly- sis is distinguished from the central in that in the former all three branches of the seventh nerve are apt to be affected, while in the latter form only the lower two branches are involved. In the peripheral form, therefore, the eye on the affected side cannot be closed entirely, causing the condition known as lagophthalmia, and there is inability to wrinkle the muscles of the forehead on the affected side. In facial paralysis of central origin the muscles of the forehead are not affected, and the ability to close the eye is but little decreased. Where the paralysis affects an arm it hangs lifeless by the side, with the palm turned backward and the fingers often flexed. The fingers and forearm may be moved, but the movement of the upper arm to any extent is lost. Diagnosis. — This form of paralysis is to be diagnosticated from cere- bral paralysis by the absence of increased reflex irritability and by the distribution of the paralysis. In the cerebral form all the muscles are affected ; in the peripheral form, only individual muscles, according to the extent and location of the lesion. It is doubtful whether paralyses of spinal origin occur in the early days of life. Cases of paralysis of the arm in the new-born should also be diag- nosticated from surgical injuries represented by fractures, dislocations, and separation of the epiphyses. Prognosis. — The prognosis, so far as the face is concerned, is very good, as the paralysis in these instances may last but a short time. We must, however, be somewhat guarded in the opinion which we give con- cerning these cases, as in some instances the paralysis does not disappear and the muscles of the face are left irreparably injured. In regard to the paralysis of the arm, in severe cases the prognosis is generally unfavorable, especially if marked improvement does not soon occur, and ordinarily when improvement takes place it is very slow. Most of these cases never recover completely, and even partial recovery should not be expected for a number of years. Shortening of the arm is marked in the later history of the severer cases. Treatment. — Electricity and massage should be begun after two or three weeks and may have to be continued for a long period. Continu- ously applied for a number of years they are a very important part of the treatment of these cases, and counteract the atrophy of the muscles from disuse, Avhich must necessarily take place to a greater or less extent. 970 PEDIATRICS. The following case is illustrative of the effects of obstetrical paralysis : A boy, two years old, was healthy at birth, but the labor was instrumental. When he was three days old it was found that his left arm was swollen. He was first seen at the hospital when he was seven weeks old. At that time he was able to move his fingers and wrist, but held his arm with the elbow straight to the side and the hand pronated. At the age of two years he was able to make slight movements of flexion of the elbow and slight contractions of the deltoid. Under the use of elec- tricity he showed gradual improvement. He could grasp objects fairly well with his left hand, could flex the elbow completely, and could raise his hand and forearm as far as the nipple. He could raise his right arm with ease to his head, but could not raise the left hand farther than the lower part of the chest. NEURALGIA. Neuralgia is a functional affection of the sensory fibres of the periph- eral nerves, represented by pain. Neuralgia is rare in infancy and early childhood. It may occur in very different localities, and may be repre- sented by intercostal neuralgia or the various milder forms of flitting pains in different parts of the body. Sciatica is a form of neuralgia which may occur in children, ana is characterized by neuralgic pain and tenderness in the course of the sciatic nerve, especially at its point of exit from the pelvis. In most cases of neuralgia temporary relief from the pain can be obtained by the use of phenacetine. It can be given in doses of 0.06 to 0.3 gramme (1 to 5 grains), according to the age of the child. Its effects should be guarded by giving brandy and water. EPIPHYSEAL HYPEREMIA (Growing Pains). During the period of middle childhood children at times complain of pains in their limbs, especially the legs. In some cases these pains are probably closely associated with muscular rheumatism, since they may also occur in the joints. These indefinite pains are usually spoken of as " growing pains ," but should be distinguished from rheumatism by their slight and evanescent character and by their lasting perhaps only for a few minutes or hours. They are supposed to be induced by fatigue and to be in some way con- nected with hyperemia of the epiphyses in the process of their develop- ment. HYDROCEPHALUS. By hydrocephalus is meant an accumulation of serous fluid in the cranium. This may occur either in the subarachnoid space [external hydrocephalus) or in the ventricles {internal hydrocephalus). When the accumulation of fluid represents the only pathological condition present the term primary hydrocephalus is used, while where it follows in the course of other diseases it is termed secondary. Hydro- cephalus may also be acute or chronic, congenital or acquired. Acute Hydrocephalus. — Etiology. — Acute hydrocephalus may be DISEASES OF THE NERVOUS SYSTEM. 971 either external or internal, and is usually a combination of both. It is generally sudden in its onset, and while in some cases it may be idio- pathic (meningitis serosa), in most cases it is secondary to a number of conditions, such as cardiac disease, pertussis, rhachitis, neoplasms, tumors in the posterior fossa, acute inflammatory processes in the brain and its meninges, and acute febrile diseases, such as typhoid and pneumonia. Symptoms. — The amount of fluid in these acute cases is, as a rule, not large, 90 to 120 c.c. (3 or 4 ounces), and the symptoms are those which arise in meningitis when there is increased intracranial pressure, such as unequal pupils with sluggish reaction, optic neuritis, rarely con- vulsions, and cerebral paralyses, which are seldom severe or lasting. In mild cases recovery may take place in a few weeks, but in the more severe forms the increased intracranial pressure may prove fatal. Both the congenital and the acquired varieties of external hydrocepha- lus are so rare that they need not be more than mentioned as possibly occurring in certain congenital malformations, in atrophy of the brain (hydrocephalus in vacuo), and following cerebral hemorrhage. The general shape and circumference of the head in infancy and childhood vary normally in the individual to a considerable degree. On the other hand, when these variations in size pass a certain limit or are combined with certain nervous phenomena, they have a distinct patho- logical significance. Chronic Internal Hydrocephalus. — The chronic internal variety of hydrocephalus consists of a transudation into the cerebral ventricles. It may be congenital (intra-uterine) or acquired (extra-uterine). It may follow an operation for spina bifida or be produced mechanically by internal pressure from any cause. It may also represent the termination of an acute inflammatory process. The chronic form of acquired internal hydrocephalus resembles so closely congenital internal hydrocephalus that we can consider them together, and, so far as the name of the disease is concerned, the term hydrocephalus should be restricted to (1) congenital internal hydrocepha- lus and (2) chronic acquired internal hydrocephalus. In other words, there exists pathologically a certain class of effusions into the ventricles for which no cause is apparent. When these effusions reach a certain amount the resulting symptoms are quite typical of what is called hydro- cephalus, and clinically the term has therefore been confined to cases of this class. Pathology. — The anatomical appearance of the brain itself, as a rule. corresponds with and may be accepted as the result of pressure by an intra-ventricular fluid. Fig. 197, page 972, represents the brain of a child who died of congenital internal hydrocephalus, and well exemplifies the pathology of the disease. The convolutions are flattened and the walls of the ventricles are much thinned by the intra-ventricular pressure, while the ventricles 972 PEDIATRICS. themselves are much dilated. In some parts the cortex is less than 1 cm. (f inch) in thickness. The amount of fluid in these cases varies from a few cubic centimetres to three or four litres. The fluid has a specific gravity of about 1004. The earlier the hydrocephalic condition begins, the larger will the cranium become. We therefore find the very large heads, as a rule, to be of the congenital variety. The head is at times of such a size as to cause difficulty in the delivery, or the fluid may collect very rapidly after birth, and the head soon assumes the characteristic appearance of hydrocephalus. Figs. 198 and 199 represent the hydrocephalic skull at three years in comparison with a normal skull of the same age. The face in these cases of hydrocephalus remains about the same size as it would be normally, but usually looks much smaller from the disproportionate size of the head, which rests upon it like a globe. Symptoms. — The symptoms of congenital internal hydrocephalus are essentially those caused by pressure. We naturally, therefore, find the fontanelles bulging and fluctuating, and the bones thin and forced out of position. The temporal and parietal bones diverge as they extend up- ward, while in the normal skull they ascend almost perpendicularly. Fig. 197. Hydrocephalic "brain. Warren Museum. Harvard University. This is shown in Figs. 198 and 199. If the disease has existed for some time, the upper wall of the orbit becomes flat and the eyeballs protrude. The intra-cerebral pressure often produces a strong collateral circulation in the scalp and in the forehead, where the vessels appear like tortuous blue cords. Functional disturbances are numerous, and vary in almost DISEASES OF THE NERVOUS SYSTEM. 973 every case. As a rule, the children are idiotic, but at times, even in marked hydrocephalus, we find the mental condition normal, even when paralysis is present. As the various cerebral centres become affected by pressure, symptoms arise corresponding to the parts of the brain which are involved. Among these symptoms are nystagmus and, less frequently, strabismus. The pupils at first are usually moderately dilated. Later they become fixed, and sensibility to light is lost. The hearing lasts for a long time. The ability to walk is interfered with. Partial or general convulsions, paral- ysis (usually paraplegic), and contractures may occur. Pain in the head is often complained of, but, as a rule, is not so severe as in meningitis. There is difficulty in keeping the head erect, owing to its weight. The digestion is often good, and the appetite usually extreme. The res- piration is normal from adaptation. The pulse is usually not retarded. The temperature, as a rule, is normal. The adipose tissue is often abnormally increased. Diagnosis. — As congenital internal hydrocephalus is almost invariably attended by enlargement of the head and separation of the sutures, the diagnosis is not especially difficult, and is determined by comparing the measurements of the head with those of a normal head of the same age. It must be remembered, however, that hydrocephalus may exist with a small head, and that the general shape and circumference of the head in infancy vary in the individual to a considerable degree. When, however, these variations in size pass a certain limit or are combined with certain nervous phenomena they have a distinct pathological significance. In addition to the enlargement of the head, the symptoms of direct intra- cephalic pressure make the diagnosis very simple. Prognosis. — These congenital cases, as a rule, die before childhood has been reached, but they have been known to live to middle age. Death usually occurs from some intercurrent affection. Complete re- covery is very rare. Treatment. — The treatment of congenital internal hydrocephalus has been varied, but without marked success. When the effusion is not large and is not increasing, moderate pressure with a rubber bandage seems to have a favorable result. When the disease is apparently not in an active state and is characterized by a very slight increase of fluid, aspiration through the anterior fontanelle of a small quantity of fluid at a time has been of temporary benefit. The point of aspiration should be 2 to 3 cm. (| inch to 1J inches) from the median line, so as to avoid puncturing the longitudinal sinus. In this way the condition of the patient is often rendered more satisfactory. An operation for chronic hydrocephalus presents no technical difficul- ties. Of course only certain cases are suitable for operation. Moderate effusions should be let alone, also those cases in which a rudimentary development of the brain is suspected. Cases where an operation is 974 PEDIATRICS. especially indicated are both physically and mentally comparatively well developed up to the time when the enlargement of the cranium began. Such children should show the symptoms of direct intra-cranial pressure. They gradually become weak-minded or idiotic. They do not learn to talk, or they quickly forget what they have learned. They may also become totally blind. The power of walking is interfered with. Con- tractions and partial and general spasms are of ordinary occurrence. Unless the pressure is speedily removed, atrophy of the brain results, and if they live they remain idiots for life. It may, however, be said that no brilliant results as yet have followed the operative treatment of hydro- cephalus. Fig. 200 represents a case of congenital hydrocephalus in an infant seven months old. Fig. 200. Fig. 201. Congenital internal hydrocephalus. Male, 7 months old. It had always been nursed. When it was two days old it had convulsions. Three weeks later it had bronchitis, and accompanying this disease a return of the convul- sions, which occurred as often as six or seven times in the day. They were localized in the left arm and left leg. These convulsions lasted for three weeks, gradually growing less severe. There was at this time a certain amount of intes- tinal disturbance, which, however, disappeared later. There was also a history of a purulent discharge from the ears before the infant was admitted to the hospital. It cried out sharply at night. The measurements of the head were 56.5 cm. (22f inches) in circumference, and 36.7 cm. (14J inches) from ear to ear over the vertex. The anterior fontanelle was bulging. The eyes were markedly divergent and protruded from their orbits. Fig. 201 represents a child, five years Congenital internal hydrocephalus. old, With chronic hydrocephalus. Female, 5 years old. She was nursed by her mother for over a year, and cut her first tooth. when she was six months old. She was always well and strong, but high-tempered. She had never had any other disease. When she was "five months old she fell from her crib and struck her head, but it did not seem to hurt her especially. Her head was always noticed to be of a peculiar shape. When she was eight months old she fell out of a DISEASES OF THE NERVOUS SYSTEM. 975 chair and was stunned, but was not otherwise hurt. She had convulsions from time to time, but her mind had always been bright. She was unable to hold up her head until she was three years old, and had always complained of more or less frontal head- ache. Her appetite had always been excessive, and her taste for food somewhat pecu- liar. She gradually grew stronger and was beginning to attempt to walk when last seen. She slept well and her bowels were regular. Her head measured 57 cm. (22^ inches). The following case represents chronic acquired internal hydrocephalus in a boy four years and eight months old. The child's parents were healthy ; his mother had other healthy children and had had no miscarriages. The child had always been well, measles being the only disease which he had ever had. At the age of six months, while in the process of cutting a tooth, he had three convulsions, from which he recovered entirely. His appetite had always been capricious, but his digestion was good. His bowels had always been reg- ular. He had lately come from a malarial region, where he had lived in a rather damp dwelling for a year. On May 6 he vomited twelve or thirteen times. The vomiting then stopped, but returned later from time to time. He complained of pain in his stomach, had no fever, and sometimes appeared to feel chilly. His bowels were constipated, and in the be- ginning of the attack his pulse was slow. He had been subject to night-terrors for some time previous to this sickness. The vomiting had lessened by May 27, and the report of my examination on that date is as follows : Pulse 60, rhythmical ; respirations regular ; temperature normal ; has had ear- ache lately ; no discharge from the ear since he was an infant ; the examination of the ear was negative ; yesterday morning he had a general clonic convulsion lasting for some time ; his tongue is slightly coated ; he lies in an apathetic state ; though perfectly conscious ; he is losing in weight and strength, and has lost his appetite ; urine normal. Nothing abnormal is found on examination of the thorax or abdomen. The examination of the eyes, on June 15, showed that there was much swelling of the optic nerve, increased prominence of the retinal vessels, hemorrhages, and neuritis. The child seemed much brighter, and played about. His intelligence was perfectly good ; he had had no more convulsions and no paralysis, and seemed perfectly well, except that his pupils were dilated and he was totally blind. This child came to see me eight years later, when he was twelve years old. He had been and was at that time perfectly well. He was a bright, well-developed, healthy boy. His pupils reacted, but he had never recovered his sight. He weighed 19.8 kilogrammes (90 pounds). His bowels were regular ; his appetite was good ; his knee- jerks were not increased ; his head measured 49 cm. (19£ inches). THROMBOSIS OF THE CEREBRAL SINUSES. Etiology. — Thrombosis of the cerebral sinuses is more frequent in in- fancy and early childhood than in adult life. It is caused by the forma- tion of an ante-mortem clot in one of the sinuses of the brain. As a primary condition it is exceedingly rare. It is usually secondary to some condition which has produced an extreme reduction of the child's vitality. such as profound anaemia, exhausting diarrhoea, or a collection of pus in any part of the body, but especially about the scalp, as in erysipelas. A purulent otorrhcea is perhaps the most common etiological factor. *It is not necessary here to do more than refer to the traumatic cases of this disease, in which the ear and the scalp are involved, as in fracture, or in 976 PEDIATRICS. which the thrombosis is caused by compression, as from a cerebral tumor. The pathology of the secondary cases includes the lesions of the different processes which have caused the thrombosis. The thrombosis may take place in any of the cerebral sinuses, and at times may occur in the course of a meningitis. When the thrombus is formed, the venous branches be- hind the obstruction become distended mechanically, and thus give rise to capillary hemorrhages and softening of the floor of the ventricles. When the thrombosis has taken place in the neighborhood of some inflammatory focus, such as a purulent otitis media, pyaemia may result. Symptoms. — The symptoms which existed in cases in which this condi- tion has been found on post-mortem examination are not such as to suf- fice for making a differential diagnosis during life between this and other intra-cranial conditions, such as occur in profound anaemia. When, how- ever, convulsions occur in an atrophic child, especially if there has been chronic trouble in the ear, we can suspect the presence of this condition after carefully differentiating all other causes. Cases of thrombosis of the lateral sinus may be suspected when there are symptoms of a severe purulent affection following a suppurative otitis, with involvement of the mastoid cells, and when there is tenderness over the external jugular vein. Prognosis. — The prognosis is usually fatal, except when the throm- bosis occurs in the lateral sinus and can be relieved by operation, Pitt reports the recovery of a boy ten years old who had chronic otorrhcea, followed by acute symptoms of fever and aural tenderness. Following these symptoms, a Aveek later, he had a rigor, and optic neuritis was developed on the right side. Exploration of the lateral sinus disclosed a clot, which was removed, and the boy recovered. The following case of cerebral thrombosis came under my observation at the infant hospital : An infant, nine weeks old. was apparently strong and well up to January 16, when it began to lose in weight. By January 23 it had lost over 200 grammes (6§ ounces) with- out showing any other symptom of disease. By January 27 it had lost 480 grammes (16 ounces). Two days later it was attacked with convulsions and died. The autopsy showed nothing abnormal except a capillary hemorrhage into the ventricles caused by a thrombosis of the straight cerebral sinus. The pathological diagnosis in this case was that of a sinus-thrombosis of undeter- mined origin, a condition which is exceedingly rare, and instances of which, established by autopsy, have seldom been reported. ATHETOSIS. Athetosis is a symptom, and not a disease, and is represented by con- tinuous incoordinate arhythmical movements of the extremities, the face, and the body. This condition may be acquired or congenital. The acquired form may follow cases of hemiplegia or diplegia, in which event it affects the paralyzed limbs. Certain cases of acquired athetosis occur without any accompanying paralysis. In congenital athetosis, and in the DISEASES OF THE NERVOUS SYSTEM. 977 acquired form without paralysis, the symptoms usually begin in the first year. Pathology. — The pathological condition which exists in cases of athe- tosis is supposed to be a chronic cerebral irritation in the neighborhood of the basal ganglia and in the internal capsule. The condition as we see it clinically, therefore, is wholly a symptom of some organic lesion of the brain. Diagnosis. — The diagnosis of acquired athetosis is made by the charac- ter of the movements. These are continuous, and are distinguished from those of chorea by being vermicular and less spasmodic. The diagnosis in cases of congenital athetosis is not difficult, as in no other disease does an infant present at birth these peculiar movements and this grotesque form of flexion and extension of the fingers and toes. The disease called congenital chorea, in which involuntary arhythmical movements exist, is distinguished from athetosis by the character of the movements, which in the former resemble those of ordinary chorea. Eig. 202. Congenital athetosis. Female, 2 years old. Prognosis. — The prognosis of athetosis in regard to recovery is un- favorable. So far as the general health is concerned, the individual may develop fairly well and may live for years. Treatment. — There is no known treatment which has proved to be of benefit in children. As they grow older the training of the affected limbs may be undertaken, but, as a rule, the results are unsatisfactory. Massage and electricity have proved to be of no value. Fig. 202 represents congenital athetosis in a girl two years old. She never had had any acute disease. She was horn after a normal labor, and had received no subsequent injury. She had never talked nor shown much interest in her surroundings, nor had she been able to sit up or hold up her head without support. The bowels had always been regular and the appetite good. She was well developed and well nourished. The disease was characterized by the continual incoordinate arhythmical move- G2 978 PEDIATRICS. ments of the head, trunk, and extremities; these movements were often quite rapid. There were constant flexion and extension of the hands and lingers, the fingers at times being bent backward and assuming most grotesque positions. This phenomenon was also seen in the toes. The expression of the face was not that of ordinary intelligence. The reflexes, on account of the resistance of the child to examination, could not be determined. She was usually irritable, but occasionally smiled slightly, and took some slight notice of those who were near her. INTRA-CRANIAL TUMORS. Etiology. — In infancy and early childhood tumors of many varieties may occur in the brain and its meninges. The most common form of intra-cranial tumor is tubercular. The next in frequency are glioma, sarcoma, and glio-sarcoma. The other varieties, such as carcinoma, lipoma, myxoma, and teratoma are very rare ; syphilitic gumma, which is so frequent in adults, is exceedingly rare in infancy and early child- hood. The parasitic cysts in the brain which occur quite frequently in individuals in other parts of the world, especially in Germany, are seldom met with in this country. These tumors may be either of intra- or extra-uterine origin. Of these the tubercular is the most common. Pathology. — The tubercular tumors of the brain or its meninges are, as a rule, secondary to a tubercular growth in some other part of the body, or to tubercular disease of some part of the skull, such as the orbit or ear. These tubercular tumors may be single or multiple, the latter being the more common variety. They may be found in any part of the brain or its meninges, and occur with especial frequency in the cerebellum. They may vary in size from a small collection of miliary tubercles to much larger masses. When one or more cheesy masses of a tubercular nature are found in different parts of the brain, the condition is called solitary tubercle. The gliomata grow most frequently in the white substance of the brain, but sometimes develop in the gray matter. According to Starr, they grow less rapidly than sarcomata, and never involve the membranes. They are usually primary, but may develop secondary to glioma of the retina (Starr). The sarcomata are both of the round-celled and of the spindle-celled variety. Although not quite so frequently found as the gliomata, they are more frequent than the glio- sarcomata or myxomata. They are usually round in shape, develop both in the nervous tissue and in the cerebral membranes, and in both the white and gray matter of the cerebrum and cerebellum. The other varieties of tumor of the brain are so rare that they need not be con- sidered here. Intra-cranial aneurisms are rare in childhood and are never very large. They are found in the larger arteries of the base of the brain and in the Sylvian arteries. Symptoms. — The general symptoms vary very much in accordance with the size and vascularity of the tumor, and according as it is growing or has DISEASES OF THE NERVOUS SYSTEM. 979 become stationary. In the former case the symptoms are often apt to be more severe than later, when, the tumor having become stationary, the brain-tissue adapts itself to the new conditions produced by the morbid growth. Intra-cranial tumors in infants and in young children are often latent, present no symptoms, and are sometimes discovered only after death. A certain number of cases, on the other hand, present only general symptoms, such as headache, cerebral vomiting, attacks of vertigo, convulsions, and optic neuritis, which cause us to suspect intra-cranial disease, but give an indefinite idea of its location. Again, these tumors may produce local symptoms in addition to the general ones. These local symptoms are represented by paralyses of different kinds, anomalies of sensation, affections of the special senses, and staggering. These later symptoms arise according to the site of the tumor and the parts of the brain which are affected by it, and by means of them we can more or less approximately judge of its situation, size, and rapidity of growth. Paralyses of the extremities are caused by an affection of the motor cortex, the internal capsule, or any portion of the motor tract on the opposite side of the brain, above the crossing of the pyramids. Stagger- ing or ataxia is suggestive of cerebellar disease, while the involvement of the intra-cranial nerves suggests a tumor of the base of the brain or pressure on these nerves at some point, and more rarely an affection of their nuclei. The tendon reflexes are apt to be exaggerated, but in some cases are normal, and in others are said to be absent. The symptoms of cerebellar ataxia which at times occur when the tumor is situated in the cerebellum consist of a staggering gait resembling that of an intoxicated person, the steps being irregular in length and the body swinging from side to side. The child in these cases has a subjective sense of falling or turning back, and grasps for support or sinks into a chair or to the floor. This form of ataxia is to be distinguished from that which is found in spinal disease, where it is due to an inability to co-ordinate properly the muscles of the lower extremities. This latter form of ataxia is much more regular than the former, each step being insecure and unsteady, but with- out the violent and sudden reeling, after two or three steady steps, which occurs in the cerebellar form. In young infants a tumor may cause a pro- tuberance of some part of the skull by pushing one of the bones outward. Diagnosis. — The diagnosis of tumors of the brain must in the great majority of cases be made by elimination. The variety of tumor can be determined most readily by considering the history of the case, as to whether it is tubercular, syphilitic, or otherwise. The diagnosis of a tumor can often be made by the slow and gradual development of the disease. When severe headache and vomiting exist, followed by paraly- sis, either monoplegic or hemiplegic, especially if this paralysis develops slowly, we should suspect the presence of some form of intra-cranial growth. This suspicion is much strengthened by the presence of optic neuritis or optic atrophy. The presence of localized convulsions in such 980 PEDIATRICS. cases tends to confirm the diagnosis, while if marked ataxia exists we are justified in suspecting cerebellar disease. A normal or only slightly ele- vated temperature Avith these symptoms also points to the diagnosis of a cerebral tumor. Prognosis. — The prognosis of tumors in early life is very unfavorable, no matter what the variety of the tumor may be. Although the patient may for a long time remain wholly unaffected by the morbid growth, he eventually, except in rare cases, succumbs to the disease. Treatment. — Surgical interference in children, as in adults, proves, on the whole, to be the most valuable means at our command for lengthening life in cases of cerebral tumors, but the results have not been what was hoped for when cranial surgery came first into prominence. There is no other treatment which is of any especial benefit in either retarding the growth or curing this class of cases. Where the exceedingly rare form of syphilitic gumma exists, iodide of potassium may be of much value, and is indicated as in adults. The following case was one of solitary tubercles of the brain : An infant, thirteen months old, had never had any especial disease, and entered the hospital weak and emaciated. Its mind was clear. Its pulse was weak but regular, and neither slow nor rapid for its age. Its temperature was at times somewhat raised, varying from 37.2° to 38.4° C. (99° to 101° F.). There were no convulsions, and no paralysis or contractures, but merely progressive loss in weight, and finally death. An examination of the brain showed miliary tubercle of the pia mater at the base of the brain without acute inflammation, which accounted for the lack of acute cerebral symptoms. Of especial interest, however, in the case were some patches of solitary tubercles, 1.2 cm. (J inch) in diameter, in the left temporal and occipital lobes and in the right frontal lobe of the cerebrum, and also in the lower left cerebellum. There were also caseous tubercles of the post-bronchial lymph-nodes, tubercles of the lungs with a slight amount of broncho-pneumonia, miliary tubercles of the pleura, liver, and spleen, and caseous tubercles of the mesenteric lymph-nodes. CEREBRAL SYPHILIS. Intra-cranial syphilis may be either congenital or acquired. Accord- ing to Bullard, the intra-cranial lesions are essentially the same in both forms. Pathology. — Intra-cranial syphilis may be divided pathologically into three forms : (1) diffuse inflammation of the meninges or their neighbor- ing tissues, (2) localized growths or tumors (gummata). and (3) syphilitic endarteritis. In the latter case (endarteritis) there may be local dilatation or local occlusion of the blood-vessels. These conditions are apt to occur simultaneously. When the dilatation reaches an advanced stage a thinning of the arterial walls results, which may lead to rupture of the blood-vessels or to hemorrhage. More common than the hemorrhage, however, is the occlusion of the blood-vessels, which cuts off the blood- supply and acts in the same way as in other cases of thrombosis of the arteries, causing more or less softening and disintegration of the cerebral DISEASES OF THE .NERVOUS SYSTEM. 981 tissues supplied by them. The arteries of the base of the brain are the ones that are most frequently affected, and there are secondary lesions of the parts of the brain supplied by them. Symptoms. — The symptoms dependent on these lesions vary in accord- ance with the pathological condition. In syphilitic meningitis the principal symptoms are severe headache in various parts of the head, more or less constant, lasting for many days or even weeks, and frequently accompanied after a time by paralysis of some of the intra-cranial nerves, especially of the third or of the seventh. As in other cases of meningitis, the optic nerves may also be affected, and the child shows the general symptoms of a severe intra-cranial affec- tion, such as vomiting, dulness, headache, and localized paralyses. The localized tumors or gummata present essentially the same symp- toms as other forms of tumors of the brain. The symptoms produced by syphilitic endarteritis vary according to the areas of the brain affected, but the most common ones are the various forms of paralysis of the extremities and sensory disturbances. Diagnosis. — In regard to the diagnosis of cerebral syphilis in children, the symptoms differ greatly in different cases. The most characteristic group of symptoms, and one which is exceedingly suggestive of intra- cranial syphilis, includes attacks of organic paralysis, central in origin, occurring at intervals of clays or months without known cause, and with- out marked symptoms of either tumor or tuberculosis The diagnosis of syphilitic meningitis may be made from the occur- rence of severe headaches, followed by paralysis of one or more of the motor cranial nerves, and occurring without marked rise of temperature. Gummata present no especial symptoms from other intra-cranial tumors. The presence of syphilitic lesions elsewhere is our principal ground for making the diagnosis. Syphilitic endarteritis may be suspected when an acute affection in the neighborhood of the pons or medulla not produced by traumatism occurs in a syphilitic subject, or when acute symptoms suggestive of hemorrhage or embolism occur, and when no other probable cause can be shown, such as cardiac or renal disease. Prognosis and Treatment. — The results of antisyphilitic treatment in these cases are sometimes striking. The treatment should be pushed to the limit of tolerance. MENINGITIS. Although inflammation of the meninges may occur secondarily to disease of the brain itself, and may affect either the dura mater or the pia mater, yet clinically by far the most common condition met with in early life is a leptomeningitis forming itself the most important part of the morbid process. Pachymeningitis is in early life so rare, except from traumatism or as a lesion of some specific disease such as syphilis, that it need simply be mentioned as of possible occurrence. 982 PEDIATRICS. The term meningitis may represent a number of diseases, and the symptoms in all are very similar and depend largely on the intensity of the inflammation and on the parts of the brain affected. The disease may be caused by various specific organisms, such as the tubercle bacillus, the diplococcus intracellularis, the pneumococcus, the ty- phoid bacillus, the influenza bacillus, and others, or it may be secondary to other diseases or lesions of traumatic origin. These secondary forms are grouped under the head of simple acute meningitis. Tubercular meningitis has been described on page 406 and cerebro-spinal meningitis on page 432. Simple Acute Meningitis. — Etiology. — An acute meningitis may arise in the course of a number of infectious diseases, such as erysipelas or ulcerative endocarditis ; also after insolation and injuries to the head. It may attack robust as well as debilitated children, and may occur at all ages. It is rare in the first year of life. It is most common in the middle period of childhood. It is especially liable to arise from an ex- tension of the inflammation from disease of the ear, and this in young subjects may take place through the unclosed petrosquamosal suture. According to Sachs, the cases of idiopathic meningitis which have been reported, which are not due to the specific organisms already described, are probably due to some slight traumatism which has passed unnoticed. Pathology. — The pathology of simple acute meningitis is practically, in infants and young children, an inflammation, of the pia mater, but there is also usually a mild grade of inflammation of the dura and of the gray matter of the brain. It may be acute or chronic. It is, as a rule, non- purulent in character. The arachnoid may appear somewhat opaque and the cerebral substance cedematous. There is an increase in the cerebro- spinal fluid and the ventricles may be so distended as to correspond to an acute hydrocephalus. The pia of the convexity is most frequently affected, while that of the base may be entirely free, with possibly a slightly increased exudation of lymph in the interpeduncular space. There is usually an extravasation of white blood-corpuscles near the blood-vessels, which are found on microscopic examination to be slightly engorged. When the meningitis has lasted for a time, the pia, because of the agglutination which has taken place, cannot be removed without injuring the gray matter. In any case of acute meningitis the inflam- mation is apt to extend downward and to involve the pia mater of the cord. In the chronic form the pia mater at the base of the brain alone may be inflamed (basilar meningitis), or the lesions may be found distributed in small or large areas over the convexity. In these cases the pia mater is thick and opaque, and there is a production of pus, fibrin, and serum, with a formation of new connective tissue. The relative quantity of these in- flammatory products varies, and sometimes results in firm and extensive adhesions between the dura and the pia mater. Other conditions which DISEASES OF THE NERVOUS SYSTEM. 983 represent the results of chronic inflammation may also be present, but need hardly be referred to here, further than to say that the ventricles of the brain may in this chronic form contain an increased amount of serum and may be dilated. The ependyma also may be thickened and rough- ened. Symptoms. — Where acute simple meningitis is secondary to injuries or to other diseases, the characteristic symptoms may, of course, be compli- cated and even obscured by those of the primary cause. The symptoms, however, are very similar to all the other forms of meningitis which have been described under specific infectious diseases except that they corre- spond to an inflammatory condition of the convexity rather than to that of the base. The course is often short, sometimes not more than seven or eight days. The disease may, however, prove fatal in forty-eight hours ; on the other hand, it may last a number of Aveeks. When the convexity is chiefly affected, the onset is characterized by intense head- ache, vertigo, vomiting (usually of a cerebral type), and a high tempera- ture. 40° to 41.1° C. (104° to 106° F.). The respirations are rapid, 30 to 50, and comparatively regular. The pulse in the early stages is rapid, 150 to 170, but is usually regular; later it becomes irregular and slow. Convulsions occur early in the attack. Irritability, listlessness, apathy, and drowsiness subsequently develop. The pupils are contracted at first, but later become dilated ; delirium appears ; rigidity of the neck is present, and in some cases a marked spastic condition of the lower extremities. The deep reflexes are usually increased ; the abdomen is retracted, and the bowels are constipated. All these symptoms develop rapidly in a few days, and then are in- tensified as the disease progresses. Blindness (from optic and ocular paralyses) in the form of strabismus and ptosis may appear. A tache cerebrale is apt to be found, but is not diagnostic. A monoplegic or hemiplegic paralysis having all the symptoms of a cerebral paralysis may develop. In favorable cases the symptoms lessen in severity, and the rigidity, blindness, and paralysis gradually disappear as the child comes out of its coma. In fatal cases the symptoms grow still more severe ; the rigidity and retraction of the neck increase ; opisthotonos may occur, and the respiration assumes a markedly Cheyne-Stokes type until it ceases at death. Photophobia, contracted pupils, and delirium are present. Diagnosis. — Great caution should be used in differentiating a simple acute meningitis from the cerebral symptoms accompanying so many acute infectious diseases, for the symptoms are often very similar. Other dis- eases should therefore first be excluded. The form of meningitis which is to be especially differentiated from simple meningitis is the tubercular, in which the symptoms correspond more to lesions of the base of the brain as described on page 415. Prognosis. — The prognosis is very unfavorable. It is possible, how- 984 PEDIATRICS. ever, for the child to recover completely. Perhaps only a changed men- tal condition will remain, boys appearing effeminate or more easily excited than would be considered normal. Some of the more acute forms affect also the brain, and we find their results in idiocy and contractures. Treatment. — The treatment of simple acute meningitis varies with that of the disease or condition to which it is secondary. The child should be kept in a cool, dark room and protected from noise. In the treatment of meningitis, whether primary or secondary, the indications are to re- duce the temperature of the body and to support the general strength until the disease has run its course. The former is accomplished best by sponging the entire body every three or four hours with water at a tem- perature of from 15.55° to 22.22° C. (60° to 70° F.), and by the appli- cation of cold to the head preferably by Leiter's coil. The strength should be supported by the administration of milk, and, when necessary, of stimulants. The bowels should be freely moved with some purgative such as calo- mel. Bromide of soda in doses varying from 0.3 gramme (5 grains) to 0.6 gramme (10 grains) should be given according to the age of the child, and every four to six hours according to the severity of the symptoms. In cases of recovery the greatest care should be taken to keep the child free from excitement for many months, and to insure an absolutely restful life with freedom from physical fatigue. Massage and electricity should be used where there are paralysis and contractions. ACUTE ENCEPHALITIS. Although this disease is frequently associated with leptomeningitis, and may occur by simple extension in meningitis due to traumatism or to acute or chronic intoxication, it may also occur, according to Sachs, independently of meningeal lesions, and usually before puberty. Symptoms. — For a few days headache, dizziness, irritability or depres- sion are noticed. The drowsiness increases to coma, but the loss of consciousness need not be complete, and remissions may be distinct in the first week of the disease. The pupillary reflexes are normal or slug- gish ; the deep and superficial reflexes are not altered. Rigidity of the neck and opisthotonos, monoplegia, or hemiplegia develop early, and aphasia may or may not be present. Ocular and cranial paralyses occur and simulate basilar meningitis, excepting that the loss of consciousness is not complete. The respiration may become irregular and the pulse slow, rapid, or irregular. The symptoms vary according to the lesions, whether they are of the convexity or base. The disease may last two or three weeks and then prove fatal, or there may be prolonged remissions and complete recovery. Strumpell, Furbringer, and others have endeavored to establish a form of acute hemorrhagic encephalitis developing commonly after some acute infectious disease, especially influenza, and the pathology is supposed to DISEASES OF THE NERVOUS SYSTEM. 985 consist in small and strictly circumscribed inflammatory areas which may be developed in symmetrical parts of the brain. Prognosis. — The prognosis is bad according to the intensity of the symptoms and the degree of septicaemia present. Treatment. — The treatment should be such as has been described for simple acute meningitis. BULBAR PARALYSES. Diseases of the pons and medulla are very rare, but may occur in children with the same symptoms as in adults. They need not be more than mentioned. Polio-encephalitis, superior and inferior, and the acute and pseudo-bulbar paralyses occur so rarely in early life that they hardly have a place in the nervous diseases of childhood. MULTIPLE NEURITIS. Neuritis is an inflammation of the peripheral nerves. It is accom- panied by pain and tenderness in the affected regions, and in the more severe cases by paralysis and atrophy. Neuritis of a single nerve-trunk or of its branches may be caused by traumatism, cold, or pressure, or may occur in the course of various diseases. In certain constitutional condi- tions a number of nerves in different parts of the body are affected with neuritis, constituting the disease called multiple neuritis. Etiology. — Multiple neuritis usually occurs in the course of or subse- quent to one of the infectious diseases. Of these diseases diphtheria is the most common, but it is said to follow scarlet fever and measles. A mild form sometimes occurs after typhoid fever. At times multiple neuritis is produced by drugs, such as lead, arsenic, or alcohol. It is not a common disease among children. The epidemic form of the disease, known by the terms kakke and beri-beri, is quite rare in this country. Pathology. — The pathological condition in multiple neuritis is an in- terstitial or parenchymatous inflammation of the nerves. A few nerves may be affected, or the distribution may be general. The nerves of the special senses, however, are rarely affected, and the nerves of the head and face are not usually involved. Symptoms. — The onset of the disease may be acute or subacute, but in most cases the onset is gradual. It may at the beginning present severe symptoms, such as extreme pain, tenderness over the nerve-trunks, and fever with an accompanying paralysis. M5n the other hand, the pain in the beginning may be very slight, and the first symptoms noticed may be a gradually increasing weakness of the limbs, while the tenderness may be found only when especially sought for. There may' be hyperesthesia, anaesthesia, numbness, and loss of muscular pow T er. Both the sensory and motor nerves are affected and the condition is symmetrical. Alter the acute symptoms have passed away the faradic irritability is diminished : the action of the nerves to the galvanic current is diminished, and the reaction 986 PEDIATRICS. of degeneration is present. When the extensors of the leg are affected there is foot-drop, and when those of the forearm are affected there is wrist-drop. All the muscles, although rarely, may be affected and the child may become perfectly helpless. The course of the disease is apt to be a long one of several months, and in the later stages atrophy occurs, while the early hyperesthesia may give place to a more or less marked anaesthesia, and numbness and various other paresthesia may occur. In mild cases, where only pain and tenderness exist, the knee-jerks are not diminished, and may be even slightly increased, but in the more typical cases of the disease they are absent. Contractures and spasmodic condi- tions are absent, the paralysis being flaccid. The bladder and rectum are not affected. The temperature is apt to be somewhat raised, and is decidedly so at the onset when the disease is acute. The sensory symp- toms are most marked in the beginning of the attack and improve and subside more rapidly than the motor. Diagnosis. — The diagnosis is made by the same nerve areas being affected by sensory and motor symptoms and by the persistent sensitive- ness of these areas. In certain cases poliomyelitis may simulate mul- tiple neuritis, the former being distinguished by the vague pains instead of the pain definitely following the nerve-tracts, by the limited distribu- tion of its paralyses, and by its lack of symmetry. The electrical reac- tions are much the same in both diseases. The disease might in some cases be mistaken for a form of acute ascending paralysis, known as Landry's paralysis. The latter condition is, however, exceedingly rare in children. Landry's paralysis begins in the legs, involving successively the muscles of the abdomen, thorax, upper extremities, pharynx, larynx, and eyes. The rapid and progressive character of the paralysis and the absence of sensory symptoms are the main points of difference between the two conditions. If Landry's paralysis is made to include cases with sensory symptoms, as is some- times done, the differential diagnosis from multiple neuritis may at times be impossible. Prognosis. — The prognosis of multiple neuritis is favorable even when the disease begins with an acute onset accompanied by delirium and high fever, and, although the paralysis may last for many months, the cases usually recover. Exceptionally, however, the paralysis may be permanent, and death may take place from paralysis of the heart or of the muscles of deglutition and respiration. When the reaction of degenera- tion is present the prognosis for complete recovery is not so good and the case is apt to be prolonged. Treatment. — The treatment is at first by absolute rest in bed, and later with electricity, massage, and strychnine. The primary cause of the disease having been determined, such cause should, if possible, be removed. For instance, if the child lives in a malarial district it should be removed. DISEASES OF THE NERVOUS SYSTEM. 987 The treatment of those cases which follow the acute infectious dis- eases is symptomatic and hygienic. For the pain the application of heat is the most efficacious remedy. In the acute cases electricity should be begun after three or four weeks ; faradism should be used if a reaction is obtained with a moderate current, otherwise galvanism. Iodide of potassium is indicated in those cases which are caused by lead or arsenic. In the subacute cases electricity and massage should be employed from the very beginning. It is safer to wait until the pain and marked tenderness have disap- peared before beginning the administration of strychnine. The following case, a girl, eleven years old, represents multiple neuritis produced by doses of 1 gramme (15 minims) of Fowler's solution given three times a day for some weeks during an attack of chorea. The first symptoms which were noticed while she was taking the arsenic were that she vomited several times, but this was not supposed to have been caused by the arsenic, and the drug was therefore continued. It was next noticed that the child was unable to walk. Her limbs appeared to be very weak, and there was absence of knee-jerks and ankle-clonus. The sensation of the limbs was normal. A few days later she was found to have tender points over various parts of the legs. The legs then became atrophied. About a month later tender points developed in the arms, and she soon lost the power of using her arms, to such a degree that she had to be fed. At this time, although the arsenic had been omitted for several days, a large quantity of it was found in the urine. One month later it was found that she could almost support herself without assist- ance. A little later she walked with crutches, and a month later she could walk with- out assistance, but with difficulty. The knee-jerks were still absent. She continued to improve, and finally after a number of months recovered entirely. INSULAR OR DISSEMINATED SCLEROSIS. Insular or disseminated sclerosis is a chronic degenerative disease of the brain and cord, characterized by multiple distribution of areas of sclerosis. Etiology. — The disease appears most frequently as a result of the spe- cific infectious fevers. Heredity is of some importance in the etiology, chiefly inasmuch as it predisposes to a neurotic disposition. The disease is most common in the second and third decades, but many cases in early life, even in infancy, have been reported. Pathology. — The sclerotic patches may occur in the brain or cord or in both, and are very irregular in their distribution. The white matter of the brain, the pons, the medulla, and the lateral columns in the dorsal and lumbar regions are most commonly involved. The sclerosed patches consist of proliferated neuroglia, the growth of which destroys the me- dulla of the nerves with but little destruction of the axis-cylinder. Symptoms. — The disease is generally slow in its development, and is characterized by tremors on attempting voluntary motions [intention tremors) ; by scanning speech, the words being pronounced slowly or with 988 PEDIATRICS. accentuation of the syllables and distinct tremulousness of the voice ; by nystagmus, a rapid oscillatory movement of the eyes, especially when they are moved laterally ; and by spastic paralysis, the gait being clumsy and staggering. The muscles are rigid and the deep reflexes increased. Ocular disturbances are common and are similar to those observed in hysteria. Inequality of the pupils and atrophy of the optic nerve may occur. In the majority of cases there is no disturbance of sensation. As the disease progresses the speech becomes unintelligible, the mem- ory fails, and the muscular weakness and paralysis is more and more marked until the patient is bedridden. Some cases are of more rapid de- velopment than others. Some may present bulbar symptoms in which not only the power of speech but of deglutition and respiration is affected. Diagnosis. — A marked degree of muscular atrophy, paralysis of the bladder and rectum, and changes in electrical reaction are not present in multiple sclerosis, and their absence is of much aid in the differential diagnosis. Multiple sclerosis may be distinguished from transverse myelitis by the extreme rarity of the latter condition in early life, by its acute onset, the involvement of the bladder, and the sensory symptoms. The diagnosis from hereditary ataxia is given on page 989. The nys- tagmus, scanning speech, and intention tremor will serve to distinguish the disease from hysteria, Avhich it may at times resemble. Chorea may be eliminated in the diagnosis by the absence of tremor, by the presence of the characteristic incoordinate movements, and by the absence of nystag- mus and true ataxia. Prognosis. — The disease is incurable, and may last for years. Remis- sion of the symptoms and even improvement may occur, but the general course of the disease is progressive. Treatment. — Rest in bed, hydrotherapeutics, massage, and general hygiene are desirable in that they alleviate the condition, rendering life more bearable, but no treatment can be said to be in any way curative. HEREDITARY ATAXIA (Friedreich's Disease). Hereditary ataxia is a very rare disease, dependent on a slowly pro- gressive sclerosis of the cord at different levels, which involves especially the posterior and lateral columns. It usually occurs in several members of a family, and develops in late childhood. Symptoms. — The characteristic symptoms are ataxia of the legs and arms, gradual loss of muscular power, with atrophy of the muscles, loss of the knee-jerks, disturbance of speech, and, in the late stages, nystagmus, muscular contractures, from muscular paralyses, and complete helpless- ness, with mental impairment. A cerebellar form of the disease has been described, characterized by an increased knee-jerk, loss of ocular accommodation, light reflexes, and absence of deformities. DISEASES OF THE NERVOUS SYSTEM. 939 Diagnosis. — The disease is differentiated from tabes dorsalis by the absence of the crises and Argyll-Robertson pupil of tabes, by the heredi- tary character of the affection, and the extreme rarity of tabes in early life. It is differentiated from multiple sclerosis by the absence of increased reflexes, intention tremors, spastic gait, and ocular palsies. Prognosis axd Treatment. — The prognosis and treatment of hereditary ataxia is always unfavorable, and no treatment is of benefit except for the relief of symptoms. LOCOMOTOR ATAXIA. Locomotor ataxia, or tabes dorsalis, is almost unknown in childhood. The very rare cases resembling it probably represent entirely different lesions from those which are found in cases of the disease occurring in adults. SYRINGOMYELIA. Syringomyelia is exceedingly rare in early life. It is regarded as a gliosis, a development of embryonal neuroglia tissue about the central canal of the spinal cord, in which hemorrhage and degeneration takes place with the formation of cavities. In this disease we usually find a diminution of sensation to heat and cold, according to the site of the lesion, which is commonly a point in the upper dorsal or the lower cervical region. There is apt to be a weak- ness of one or both arms, accompanied by marked wasting. There is also usually some weakness in the legs. The reflexes are increased, and a spastic condition is likely to result. These symptoms are usually ac- companied by marked lateral scoliosis. Syringomyelia is an incurable disease, and the treatment is therefore usually limited to correcting, if possible, the lateral curvature which fre- quently accompanies it. HEREDITARY SPASTIC PARALYSIS. The term hereditary spastic paralysis has been applied by Sachs to an hereditary disease characterized by spastic rigidity, chiefly of the lower extremities. He recognizes two types of the disease. One is of spinal type, a spastic paraplegia with contractures and increased reflexes, due to interference with the pyramidal tract in the lateral column of the cord. Another type, the cerebral type, develops at about four or five months of age. It is characterized by increasing mental dulness, defective vision, ending in blindness, nystagmus, and gradual physical deterioration. Con- vulsions are never present. The symptoms may continue for one or two years, but end fatally. The treatment is symptomatic. PROGRESSIVE CENTRAL MUSCULAR ATROPHY. Progressive muscular atrophy of central origin, also described as the Aran-Duchenne type, develops in the great majority of cases in adult life after the twenty-fifth year. A few cases, however, have been reported 990 PEDIATRICS. iii young children, notably two by Hoffman, one of which occurred in a. girl four years of age. and another in her brother, in whom the symptoms began at about the same age. Various forms are recognized in adults and are known as amyotrophies, by which is meant a progressive wasting due to lesions in the spinal cord, as distinguished from the term myopathies or dystrophies^ in which the pri- mary disease is in the muscles themselves. Midway between these two types of muscular atrophies, both in the pathological lesions and clinical symptoms, is another, which will be described later as progressive neural muscular atrophy. Etiology. — The direct cause of the progressive muscular atrophy of central origin is not known. Hereditary and family influences are, in adults, of much less importance in relation to this spinal type of progres- sive muscular atrophy than they are in the muscular atrophies of neural origin and of the dystrophies. The association of the disease, however, in the children of one family has been noted, and is a characteristic of the infantile form. Trauma, exposure to wet, cold, fright, and nervous shock are mentioned as etiological factors. Pathology. — The pathological lesions consist primarily in a slow de- generation of the upper and lower neurons of the motor path, resulting in progressive atrophy of certain groups of muscles. The chief histologi- cal changes consist of an atrophy of the ganglion-cells of the anterior horns and an increase in the neuroglia. The lateral pyramidal tracts show degenerative changes, which, in some cases, have been traced to the motor cortex, and even to the cortical motor cells themselves. The direct cerebellar and ventro-lateral tracts are not involved. The muscles and the inter-muscular branches of the motor nerves show degenerative changes. Symptoms. — Indefinite pains suggesting those of chronic rheumatism may be the earliest symptoms. These are folloAved by a gradual loss of power and atrophy of the muscles. The muscles of the thumb, both in the thenar and hypothenar groups, and then the interossei and lumbri- cales are first affected, leaAung depressions between the metacarpal bones. The wasting process then attacks the flexor and extensor muscles of the forearm, contractions set in, and the characteristic " claw-hand* ' develops. The deltoid is the first of the shoulder muscles to atrophy, and then follow in the typical cases the remaining muscles of the upper extremity, the muscles of the trunk, and finally those of the lower extremity. The trapezius and face muscles are among the first to be attacked. This order of progression is not always maintained. In rare cases the legs may begin to atrophy soon after the affection of the hand. Muscular con- tractures from the action of antagonistic muscles, fibrillary twitching in the unaffected muscles, numbness and coldness in the regions of atrophy, and diminution and even loss of muscular reaction to faradic and galvanic currents are generally present in advanced cases. The reaction of degen- DISEASES OF THE NERVOUS SYSTEM. 991 eration may be present in the very rapidly progressive lesions. The ex- citability of the nerve-trunks outlasts that of the muscles. The muscular weakness is proportionate and generally dependent upon the degree of atrophy. Sensation of heat, touch, and pain is not impaired. In another type of cases, described by Charcot as amyotrophic lateral sclerosis, a spastic paralysis precedes the wasting, but so far as I know this condition does not occur in children. In very rare cases in children the degenerative processes may affect the nuclei of the motor cranial nerves, both the upper and lower divisions of the motor tract being involved (Sachs). The symptoms in these cases bear a close resemblance to the progressive bulbar paralyses of adults, but are so rare that they need merely be referred to. Diagnosis. — The diagnosis is made on the slow, progressive wasting of muscles in the order described, on the gradual loss of power in the affected groups, on the fibrillary muscular contractions, on the diminution in the electrical reactions, on the absence of marked impairment of sensa- tion, and, in the great majority of cases, on the absence of hereditary or family influences. The rarity of the disease in early life is also of some value in the diagnosis. Prognosis. — The disease is progressive and may last for many years. It is invariably fatal, although there may be periods in which there is an apparent arrest of the process, but which is only temporary. Treatment. — The treatment is at best palliative and for the most part ineffective. Massage, electricity, anti-specific treatment if there is any evidence of a syphilitic taint, arsenic, and hypodermic injections of strych- nine, as recommended by Powers, may be tried. PROGRESSIVE NEURAL MUSCULAR ATROPHY. Progressive neural muscular atrophy is also known as the peroneal or leg type of progressive muscular atrophy. Etiology. — The disease is an hereditary or family affection, beginning in very early life in the cases reported by Sachs, and as late as twenty years in the case described by Charcot and Marie. Dubreuilh has reported a fatal and very typical case in a child in a family in which the mother and eleven children were similarly affected. Pathology. — The pathological conditions found in Dubreuilh' s case showed chronic degenerative changes in the peripheral nerves, without lesions in the gray substance of the spinal cord, with the exception of a very slight increase in the glia of the column of Goll. The motor nerves of the hands and feet were especially involved. The muscles showed atrophy of the fibres ; some were degenerated and some were hypertro- phiecl. The transverse striations were diminished and the nuclei in- creased. According to Sachs, these muscular changes more closely resem- ble those which occur in the primary dystrophies than those which are dependent on changes in the spinal ganglia, and the slight lesions in the 992 • PEDIATRICS. cord are probably secondary to those in the peripheral nerves. As this class of cases is intermediate between those of central origin and the primary dystrophies, he considers the neural origin of the disease a theory to be accepted with reserve until verified by other cases. Symptoms. — The peroneal muscles and the muscles of the feet are the first to be affected, atrophy sets in, contractions of antagonistic muscles follow, and end in the production of club-foot, either pes equinus or pes equino-varus. Eventually the entire leg may atrophy. The upper ex- tremities and body are rarely affected until late in the disease, and the atrophy is not so marked as in the cases of central origin. In very rare instances the disease may begin in the hands. Fibrillary contractions and tAvitchings are present. The electrical reactions of both muscles and nerves are much diminished. The reflexes of the lower extremities are either lost or diminished. The sensations may be either normal or slightly altered ; the sense of pain is sometimes increased. Muscular weakness propor- tionate to the atrophy and deformity is present, and gives rise to a wad- dling gait, and especially to difficulty in going up-stairs. Diagnosis. — The diagnosis of progressive neural muscular atrophy is to be made from several similar conditions. From Progressive Muscular Atrophy of Central Origin.-r— This may be necessary in those cases in which atrophy of the lower extremities follows soon after the affection of the hands. The rarity of this condition in early life, the absence, as a rule, of hereditary influences, and the normal sen- sation are the only points in the differential diagnosis. Typical cases of either disease are readily distinguished by the onset and manner of pro- gression, but in atypical cases the differential diagnosis may not be pos- sible. From Poliomyelitis. — In poliomyelitis the sudden onset, retrogressive character of the atrophy, the absence of hereditary influences, and the absence rather than diminution of knee-jerks serve to distinguish the dis- ease from the slowly progressive hereditary paralysis which has just been described. The diagnosis from the subacute and chronic forms of polio- myelitis is often difficult until the progressive character of the disease becomes apparent. From Hereditary Ataxia. — The absence of ataxia, the abnormal electri- cal reactions, and the persistence of the reflexes in certain cases of pro- gressive neural muscular atrophy render the diagnosis from hereditary ataxia clear in most cases. From Chronic Multiple Neuritis. — In the muscular atrophy dependent upon neuritis, the greater prominence of pain and tenderness, the absence of hereditary or family influences, and the extreme rarity of the develop- ment of double club-foot generally enables us to distinguish neuritis from progressive neural muscular atrophy. Dejerine and Soltas have described a family disease of rare occurrence beginning early in life and resembling in many respects a progressive DISEASES OF THE NERVOUS SYSTEM. 993 neural muscular atrophy. It is characterized by the symptoms of tabes dorsalis combined with progressive muscular atrophy involving the face and lips and by an interstitial hypertrophic neuritis extending into the dorsal columns of the cord. The condition is sometimes called progressive interstitial hypertrophic neurit)* of infants. Prognosis. — The duration of the disease is very chronic, but there may be periods of arrest in its development. Treatment. — The disease is incurable. Much can be done by ortho- paedic surgery for the relief of deformities produced by the contractions. Massage and electricity are the main indications for treatment. PROGRESSIVE MUSCULAR DYSTROPHIES. Classification. — The group of diseases known as primary muscular dys- trophies, or primary myopathies, are represented by several forms, which differ from progressive muscular atrophy of central origin (Aran-Duchenne type) in that the lesions are primary in the muscles and are not dependent upon degenerative changes in the spinal cord. For the sake of convenience Erb has divided the muscular dystrophies into two large groups, which are still further subdivided into types de- pendent partly on pathological and partly upon clinical differences. This classification may be expressed as follows : I. Progressive Muscular Dystrophy of Infancy. A. Hypertrophic Form, in which the muscles are increased in size, and eventually become atrophic. a. With real hypertrophy of the muscle fibres. b. With false hypertrophy, the muscular fibres having un- dergone lipomatosis. B. Atrophic Form, in which there is no stage of hypertrophy. a. The Landouzy-Dejerine type, in which there is primary involvement of the face. b. An atrophic form without involvement of the facial muscles. II. Progressive Muscular Atrophy of Youth and Adult Life. This is also known as Erb 1 s juvenile form. All these forms have certain points in common. There is a distinct hereditary influence or family association. The electrical reactions are diminished in all, but none show a typical reaction of degeneration. The reflexes diminish proportionately to the degree of muscular atrophy. As Sachs has pointed out, the chief distinction therefore between these clinical types are in reference to the distribution of the atrophy or hy- pertrophy. Etiology of the Muscular Dystrophies. — Heredity or association of cases in one family are the only etiological factors of any importance, so far as is known. This peculiarity serves as the most important point in the diagnosis of the dystrophies from progressive central muscular atro- G3 994 PEDIATRICS. phy, almost all cases of which, except Erb's infantile form, are free from hereditary influences. The disease is usually transmitted through the mother, who may not herself be affected, may run through as many as five generations, and generally attacks the males. The disease, as a rule, begins before puberty, rarely after the twentieth year. Pathology. — The chief histological changes in the muscular dystrophies consist in hypertrophy and atrophy of the muscular fibres, with pro- liferation of the nuclei, vacuolization and segmentation of the fibres. The hypertrophy of the muscle fibres appears to be an early process in all forms of muscular dystrophies, and is associated with lipomatosis and changes in the connective tissue. Atrophy of the muscle fibres is a later stage of the disease. No sharp distinction histologically can be drawn between the muscular lesions of the spinal amyotrophies and the muscular dystrophies, as hypertrophy of the muscle fibres may rarely occur in the spinal amyotrophies (Sachs). The dystrophies are, however, not asso- ciated with lesions of the central nervous system. Symptoms. — Pseudo-Hypertrophic Forms. — The earliest symptoms noticed are weakness of the muscles, a shuffling, clumsy gait, and awkwardness in the ordinary motions, especially in rising from the floor or climbing stairs. These symptoms generally precede any noticeable enlargement of the muscles. Gradually, however, the muscles of the calves increase in size and are hard and firm. The thighs are rarely hypertrophiecl. Atrophy of the thighs and of the deep muscles of the back, shoulder, and scapulae sets in. Late in the disease the atrophic process becomes general, affecting even the hypertrophiecl calves. The muscles of the face are not involved until in the very last stages. Children who are affected with this form of dystrophy learn to walk late, and assist themselves by leaning on the furniture or other objects in their path. When the child is placed on the floor on its back it has difficulty in getting up. It has to turn over on its face first, and then to aid the weakened muscles of the legs and trunk by means of the hands and arms, climbing up, as it were, upon itself by placing the hands upon the knees and then farther and farther up the thighs. Fibrillary con- tractions do not occur. The knee-jerks in some cases disappear as the disease advances. Sensation, as a rule, is normal. There is seldom any disturbance of the bladder or rectum. In the later stages of the disease contractions of the muscles occur, and in this way permanent distortions of the joints may result. The most Common deformities are talipes equinus and flexion of the knees and hips. Lateral curvature occurs, or a permanent flexion of the spine from weakness of the erector spinse muscles may result so that the child sits bowed forward, or when kneeling on the hands and feet there is a saddle-shaped depression of the back. The electrical reactions show only quantitative changes. The reaction of degeneration is never present. DISEASES OF THE NERVOUS SYSTEM. 995 Atrophic Form. — This form is known as the Landouzy-Dejerine type. The muscles of the face and shoulder are primarily affected ; there is no hypertrophy except in very rare instances. The muscles of the fore- arm, hands, legs, and back remain unaffected. Westphal has described a case in which the face muscles were involved in an otherwise typical case of pseudo-hypertrophy. Other forms occur without involvement of the facial muscles. The Landouzy-Dejerine type, therefore, is not abso- lutely distinctive. I have reported a case of this affection in the first edition of this work. Fig. 203. Fig. 204. Pseudohypertrophic muscular paralysis, showing enlarged calves. Ldo-hypertrophic muscular paralysis, sho position assumed in rising from the floor. Erb's Juvenile Form. — The shoulder muscles are primarly affected. The disease begins in late childhood or early youth, and is characterized by progressive atrophy of the muscles of the shoulder, upper arm, pelvis, thigh, and back, the forearm and legs remaining normal. True or pseudo-hypertrophy may be associated with the atrophy in certain groups of muscles, notably in the deltoids, supra-spinati and infra-spinati muscles. 996 PEDIATRICS. Diagnosis. — The differential diagnosis of the different forms of pro- gressive muscular dystrophies present many difficulties, and depend pri- marily upon the distribution of the lesions, as in all other respects they may be practically the same. The group differs from the spinal or central form, however, in the hereditary character of the affection, in the primary appearance and the distribution of the lesions, in the absence of fibrillary contractions, in the absence of marked electrical changes, and in their greater frequency in early life. The chief point in the diagnosis from progressive neural muscular atrophy is in the peculiar distribution of the atrophy in the latter affection to the muscles of the feet and to the peroneal group. Prognosis. — All forms of the muscular dystrophies are slowly pro- gressive and are incurable. The pseudo-hypertrophic type may render the patient a helpless cripple in two or three years. The other forms may last for ten, twenty, or thirty years, but the patient is very suscep- tible to intercurrent diseases. Treatment. — The treatment is very limited and does not differ from that of progressive central muscular atrophy described on page 991. Fig. 203 illustrates the hypertrophy of the calves which occurs in the pseudo-hypertrophic form of progressive muscular atrophy. Fig. 204 represents a child with the same condition in the characteristic act of " climbing up on himself." DIVISION XVII. UNCLASSIFIED DISEASES. HAEMOPHILIA. In contradistinction to the hemorrhages of infectious origin which occur in the early weeks of life is that class of hemorrhages which can be classed under the term kcemophilia. Haemophilia simply means a morbid condition characterized by a ten- dency to bleed spontaneously or from any insignificant wound. Indi- viduals who are liable to bleed in this way are designated as having a hemorrhagic diathesis. The disease is not especially common in the early weeks of life, and usually occurs at a later period of development. It begins to be more frequent towards the end of the first year, and is apparently well established in the second year and later in childhood. It does not have a self-limited course, as is the case with the other form of hemorrhage. It is not infectious, and is not accompanied by fever. It may be for many years masked, and then may become manifest from some trivial cause, such as the extraction of a tooth. It is a dangerous disease, and death is very liable to occur from inability to control the hemorrhage. The condition is hereditary, being transmitted through the females to the males, but seldom occurring in the females, the proportion being one to eleven or thirteen (Osier). In addition to the hemorrhage which occurs in various parts in haemophilia Konig describes a condition of the joints which for a long- time was supposed to be of gouty origin. This affection of the joints, like other haemophilic hemorrhages, occurs most commonly in boys and young men. The onset of the attack is sudden, and often without any history of trauma. The effusion into the joint is found to be of pure blood, and the quantity may be large. This effusion may be entirely absorbed spontaneously, or may occur later in the same joint or else- where. Shaw reports a case in which the recurring effusion into and about the joints was regularly preceded by a definite prodromal discomfort in the joint. After repeated attacks, chronic joint changes may ensue. There is no tendency to suppuration. The effusion sometimes occurs about, rather than in the joint. The disease is liable to be mistaken for, and is to be differentiated from, tumor albus and tuberculosis. Careful 997 998 PEDIATRICS. attention to personal and family history is the only safeguard in making a diagnosis of this disease, although we should always bear in mind the possibility of its presence in case of the affection of a joint of sudden onset in a young male and without history of severe traumatism. Treatment. — There is no treatment which has been found successful in these cases beyond the active local employment of styptics and com- pression. PURPURA. Purpura is a term applied to certain conditions in which there are hemorrhages into the skin or mucous membranes. These hemorrhages may be of various sizes. When small, they are called petechia ; when larger, they are called ecchymoses. There is no proof that purpura is a disease of the blood. Its etiology is very obscure, and although this con- dition has been divided into various forms, such as purpura simplex and purpura hemorrhagica, it is doubtful whether these are not all microbic in their origin and simply represent different degrees of infection. In the more simple forms of purpura the hemorrhages are only in the skin, while in the more severe affection the mucous membranes of the mouth and gastro-enteric tract are usually involved. Not only does purpura occur in what may be called primary forms, but this purpuric condition may also be secondary to a number of dis- eases, especially those of an exhausting nature. Thus, I have seen it in the more severe and later stages of infantile atrophy, in which the hem- orrhages may cover almost the entire front of the body. It may also be a symptom in the more severe cases of measles, scarlet fever, varicella, variola, diphtheria, and in the course of a prolonged rheumatic attack. In an infant who died of infantile atrophy at the Infants' Hospital the skin of the extremities showed numerous ecchymoses of various sizes and of a dark red and pur- ple color. On the thorax on both sides above the nipples were two large ecchymoses, and there were smaller ecchymoses all over the rest of the trunk. On post-mortem examination nothing abnormal was found except a slight atelectasis of the lower lobes of both lungs, with pleuritic adhesions at the base of the right lung and slight granular degeneration of the heart, liver, and kidneys, with hyperplasia of the mesenteric lymph- nodes. Purpura Simplex. — In the simple forms of purpura the disease in children is often mild, and is accompanied by a loss of appetite, slight anaemia, a slight degree of fever, and the appearance of petechia? in va- rious parts of the skin. The prognosis is good, and the duration of these attacks is usually from one to two weeks. They are at times associated with pains located in various places. Purpura Rheumatica. — The form which has been called purpura rheumatica (peliosis rheumatica ; Sehonlein's disease) probably has no con- nection with rheumatism beyond the possibility of their both being mi- crobic, and merely simulates rheumatic arthritis from the fact that it affects UNCLASSIFIED DISEASES. 999 the joints. The diagnosis is made by the characteristic association of mul- tiple arthritis with purpura and urticaria. Henoch's Purpura. — Closely simulating and probably representing purpura rheumatica, except that the gastro-enteric symptoms are more prominent, is a form which has been called Henoch's purpura. It occurs especially in children between the ages of three and nine years. Its direct cause is not known, although it usually occurs among children who have had bad hygienic surroundings and have been ill cared for. Symptoms. — The symptoms are more or less malaise, and pains not especially localized, but chiefly occurring in the extremities and back, sometimes accompanied by slight oedema of the part affected. These early symptoms of pain occur in one or more joints, usually on the outer sides, and sometimes there are swelling and redness simulating articular rheumatism. In this stage there may be a sudden rise of temperature. Accompanying these symptoms there may be a few purpuric spots, but, as a rule, there is a period of several days between the appearance of the pains in the joints and the purpuric appearances on the skin. The pur- puric spots may coalesce, and thus form ecchymoses of various sizes and colors. They are very apt to begin on the lower leg and spread up to the thighs, genitals, and body. Somewhat later intestinal symptoms develop. While the purpura is spreading there is severe colic, and the pain is very intractable to treatment. The abdomen is retracted and tender. There is obstinate vomiting. The pulse is weak, and the face has an anxious expression. There is more or less diarrhoea, which usually occurs at the end of an attack of colic. The colic and vomiting some- times last for one or two days. There may be a little blood in the vomitus and in the movements. The vomiting then diminishes, the colic ceases, and later the diarrhoea stops, the pain in the joints passes away, the pur- puric spots gradually fade and disappear, and the child, although left in an exhausted condition, is otherwise well. There are very apt to be relapses, which may appear within a few days or not for several weeks. These are the symptoms of a typical case ; but there are many varia- tions. As a rule, the younger the child the more typical is the case. Sometimes the purpuric spots closely simulate urticaria. They may occur, although rarely, in the mouth. They sometimes simulate the lesions of erythema nodosum. The attacks of colic have a paroxysmal character. There may be swelling of the joints. The disease is rarely fatal unless it is complicated by some such dis- ease as nephritis or endocarditis. The treatment is purely symptomatic. Purpura Heemorrhag-ica. — The most severe form of purpura which occurs is that which is called purpura hemorrhagica (morbus maeuloms Werlhofii). The hemorrhages in this form are from the mucous mem- branes as well as into the skin. The disease begins with debility. A few days later purpuric spots appear on the skin, and subsequently lnema- 1000 PEDIATRICS. turia and haemoptysis occur, from which excessive anaemia may result. There is usually slight fever. When recovery takes place it is gradual, usually occupying two or three weeks. The prognosis is unfavorable in early life, as death may take place from the exhaustion following loss of blood or from hemorrhage into the brain. The diagnosis of purpura haemorrhagica is to be made from scorbutus by the general history of the case, and by the absence, if teeth are present, of stomatitis ulcerosa. Purpura Fulminans. — A very malignant purpura haemorrhagica may occur, sometimes proving fatal within twenty-four hours. This form of purpura is usually spoken of as purpura fulminans. It is most commonly met with in infants and in very young children, and is characterized by cutaneous hemorrhages which develop with great rapidity, death some- times taking place before there has been any hemorrhage from the mu- cous membranes. I have met with the reports of only seven or eight cases of this malignant form of purpura. The following case represents this severe form of purpura : An infant, seven months old. had always been perfectly well, and was being nursed by its mother, who was a healthy, strong woman, and had a number of other healthy children. The father was also a remarkably strong and well man. This infant, without noticeable previous symptoms, suddenly developed this severe form of purpura. Large ecchymoses appeared upon the buttocks and on the trunk, and the infant rapidly failed in strength, and died in twenty-four hours. There was no hemorrhage from the mucous membranes. STATUS LYMPHATICUS (Lymphatism). Status lymphaticus is a term which has been given to a condition which occurs chiefly in childhood, and is characterized by a hyperplastic condition of the lymph-tissues and lymphoid bone-marrow throughout the body. Etiology. — The cause of this condition is not known. It has been found in connection with rhachitis and hyperplasia of the heart and aorta. Unhygienic surroundings tend especially to the production of the disease, and heredity seems to be a factor in the etiology. Pathology. — The lymphatic tissues are generally hyperplastic, but the proliferation is especially marked in the pharyngeal, thoracic, and abdomi- nal groups of lymph-nodes. The enlargement of the spleen is moderate and its tissues are soft and hyperaemic. The thymus is large and may be ten centimetres in length. Hyperplasia of the bone-marrow, heart, aorta, and thyroid gland is present. Symptoms. — The symptoms of status lymphaticus are those which may occur in any case of lowered vitality, but distinct clinical features do not exist. Diagnosis. — The diagnosis is not easily made. It depends upon the UNCLASSIFIED DISEASES. 1001 recognition of the general lymphatic enlargement and the exclusion of other causes, such as tuberculosis and leukaemia. Prognosis. — The special tendency to sudden death which exists in this condition must be borne in mind. The vitality of the child is distinctly lowered, and it is especially susceptible to the toxic actions of the acute infectious diseases. At the same time there is a tendency to outgrow this condition as puberty approaches, so that with careful management the prognosis may become favorable. Treatment. — The treatment is essentially symptomatic, and consists chiefly in the regulation of the food and hygiene of the child. MUSCULAR. RHEUMATISM (Myalgia). Muscular rheumatism is an affection characterized by pain and stiff- ness in certain groups of muscles. It may be acute or chronic. Etiology. — The disease is usually seen in children between the ages of five and fifteen, and generally follows exposure to cold or dampness and to bad hygienic surroundings. It has been held by Leube, Peltessohn, and others to be due to infectious micro-organisms, but there is as yet no proof of this. Symptoms. — Pain on movement and tenderness and stiffness of certain muscles are the typical symptoms. Fever is rarely present. The pain is at times quite severe, slight movements of the muscles bringing on sharp exacerbations. Certain names have been given according to the group of muscles affected, such as cervicodynia, or acute torticollis, when the process is located in the muscles of the neck ; pleurodynia when in the intercostal muscles ; lumbago when in the lumbar muscles ; cephalodynia when in the muscles of the head ; scapulodynia and omodynia when in the mus- cles of the shoulder. The disease may be acute or chronic, the acute cases recovering in a few days. The chronic cases may persist for weeks, often leading to increase in the connective tissue, producing muscular stiffness and con- tractures. Diagnosis. — The diagnosis is to be made from pleurisy by the absence of physical signs and by the pain and muscular tenderness. It is distin- guished also from neuritis, in which the tenderness is along the course of the nerves and in which massage is not efficient. Treatment. — Drugs are of less use than hot air and massage. Heat may be applied by means of a hot flat-iron rubbed on the affected part protected by a piece of thick flannel. Massage is especially to be recom- mended. Electricity is of service in chronic cases. Phenacetine and the salicylates are the drugs which are indicated ; they should be used with caution if they seem to benefit the especial case, and should not be em- ployed as a routine treatment. The lithia Avaters should be given freely. The following case is illustrative of acute torticollis dependent upon acute muscular rheumatism : 1002 PEDIATRICS. The boy was five years old. Since he was three years old he had been subject to attacks of torticollis, apparently of rheumatic origin. He was brought into the hos- pital in one of these attacks. His temperature was somewhat raised, and he had a slight loss of appetite, but otherwise was perfectly well, and did nut suffer any pain except when his neck was touched. The head was drawn rigidly back. These paroxysmal attacks usually lasted two or three days, when they passed off as sud- denly as they came. The last attack which he had was one year before. Fig. 20-3. Acute rheumatic torticollis. Fifth day of attack. On the following day the stiffness and the pain in the neck passed off, and the head resumed its normal position. Various drugs had been given in these attacks, but none with any especial benefit except salicylate of sodium, which seemed to control the pain. I have also had under my care a little boy, about four years of age, who was attacked with fever, pain in the region of the spine, and spasm along the entire length of the spinal column. There was no pain or tenderness anywhere except over the verte- bral column, and these symptoms were not so marked in the cervical region as lower down. The child had no mental disturbance, but for a number of days was in a con- dition of continued opisthotonos from the hips upward, so that he had to be kept in a reclining chair with pillows under his arched back. The normal functions of the bladder and intestine were not interfered with. The pulse was rapid, the temperature was moderately raised, and the respirations were normal. The appetite was lessened. He remained in this condition for about a week, when the spasm of the back began to disappear. The muscles relaxed for a short time and then stiffened again. Finally complete relaxation took place, and the child recovered entirely. The attack was acute in its onset, and did not follow any injury. The treatment was with bromide of potas- sium, 0.3 gramme (5 grains) three or four times in the twenty-four hours. UNCLASSIFIED DISEASES. 1003 ARTHRITIS DEFORMANS. Arthritis deformans, while generally a disease of adult life, may occur in children, usually after the age of six, and may present the same char- acteristics as in later life. There is, however, in young children a special variety of the disease, which has been described by Still. This form generally occurs before the second dentition, and is more frequent in girls than in boys. There is a general enlargement of the joints associated with swelling of the spleen and lymph-nodes. The onset is sometimes acute, with fever and even chills. The joints gradually become stiffened and enlarged, clue to a proliferation of the soft tissues rather than of a bony enlargement. The limitation of motion and muscular wasting about the joints is often pronounced, but there is no bony grating. There may be profuse sweat- ing. The blood shows only a secondary anaemia. Prognosis. — The disease is incurable, and progresses slowly for many years. At times an arrest of the disease occurs. Treatment. — The treatment by drugs is useless, except so far as to control the symptoms. Arsenic and iron are useful for the anaemia. Food and fresh air, hydrotherapy, massage, and hot-air are the principal indi- cations for treatment. CHRONIC RHEUMATISM. Etiology. — Chronic rheumatism may occur in children as a result of acute rheumatic fever, but is more likely to come on insidiously in con- nection with unhealthy surroundings, poor food, and undue exposure to cold and dampness. Pathology. — The pathological lesions are represented by injection of the synovial membranes, thickening of the capsules and ligaments of the joints and of the neighboring tendon sheaths, and erosions of the car- tilages if the process has been of long duration. Symptoms. — Pain and stiffness in the joints with a susceptibility to exacerbations, during which swelling and tenderness without redness set in, are the chief symptoms. Ankylosis of the joints may occur event- ually. Debility and anaemia appear as secondary conditions. The dis- ease is usually persistent and slowly progressive, but does not directly shorten life. Treatment. — Avoidance of cold weather and dampness is desirable. General hygiene, good food, massage, and the treatment with hot air are of great benefit. Many cases will improve under treatment at various hot springs. DIABETES INSIPIDUS. Diabetes insipidus is a disease characterized by the passage of large quantities of urine of very low specific gravity, free from sugar and other abnormal elements, and often with a considerable increase in the total amount of solids. 1004 PEDIATRICS. Etiology. — The cause of the disease is not known. It is probably in the nature of a neurosis, causing a vasomotor disturbance of the renal vessels with continuous congestion of the kidney. In a series of eighty-five cases collected by Strauss, nine were under five years and twelve between five and ten years. In seventy cases reported by Roberts, twenty-two occurred before ten years. It may be congenital or begin in infancy, but is an exceedingly rare disease. In certain cases there is a strong heredi- tary tendency. It has been recorded in the members of four generations of one family (Weil). Pathology. — Enlargement and congestion of the kidneys, hypertrophy of the bladder, dilatation of the ureters and pelves of the kidney, and inconstant lesions of the nervous system have been noted. Symptoms. — The symptoms are directed especially to the urine, which is .passed in very large quantities ; in one case of Trousseau's, in an adult, amounting to twenty-eight quarts a day. There is a very low specific gravity, varying from 1001 to 1005 or 1007. Glucose is never present, but inosite (muscle-sugar) has at times been noted. Albumin and casts are of only rare occurrence. The total solids are normal or in many cases greatly increased. Intense thirst, a dry skin, disturbance in the surface circulation, and general nervous symptoms are present, but emaciation is not apt to occur as in diabetes mellitus. The appetite is good. Often the general health is not interfered with, and the disease may last for a period of years. Diagnosis. — The condition is to be distinguished from nervous or hys- terical polyuria, which is of temporary duration and is associated with other hysterical symptoms. It is differentiated from diabetes mellitus by the absence in the urine of glucose or grape-sugar. Chronic interstitial nephritis may be excluded from the diagnosis by the presence of albumin and casts and the low percentage of solids eliminated, together with the clinical symptom of chronic nephritis. Prognosis. — Occasionally spontaneous recovery may take place, but oftener the disease is likely to remain chronic and the child to die of some intercurrent affection. Treatment. — A nitrogenous diet with small amounts of carbohydrates and only a moderate restriction of fluids are indicated. Drugs do not control the disease, although many have been recommended, the most prominent of these being belladonna in increasing doses up to its physio- logical limits and opium, continued for many months. Arsenic and the bromides may also be tried, but their beneficial action is doubtful. DIABETES MELLITUS. Diabetes mellitus is a disease characterized by the excretion in the urine of glucose or grape-sugar in considerable quantities and for a long period. It is sometimes acute, but is generally chronic. It is to be dis- UNCLASSIFIED DISEASES. 1005 tinguished from the condition known as temporary glycosuria, in which sugar is present in the mine for a short time only, as after certain acute infectious diseases, injuries to the head, or from absorption of some toxic substance. There is still another variety of glycosuria which is spoken of as temporary alimentary glycosuria. In this form sugar appears in the urine after the ingestion of large quantities of saccharine foods, and. dis- appears at once upon reducing the sugar in the diet. Etiology. — Diabetes mellitus may occur in infancy or at any period of childhood. It is very common among the Jews, and is infrequent among the negroes. It occurs more frequently in girls than in boys. In Stern's analysis of one hundred and seventeen cases in children, six were under one year of age. In many cases an hereditary influence seems to be a factor in the etiology ; in others a severe nervous shock, such as may come from sud- den fright or great grief, may be an exciting cause. Trousseau states that the children of tubercular parents are particularly susceptible to diabetes. Injuries to the head, especially if the floor of the fourth ventricle is in- volved, may cause the appearance of sugar in the urine. Occasionally temporary glycosuria may arise from the administration of antitoxin, and it may appear shortly before death in cases of chronic diffuse and subacute glomerular nephritis. Pancreatic diabetes follows the removal of the pancreas in dogs, and lesions in the pancreas are found in about half of the cases of diabetes mellitus ; the appearance of sugar in the urine in these cases is supposed to be due to the absence of the glycolytic ferment in the pancreatic juice. Phloridzin and a few other substances may cause diabetes mellitus by destroying the power of the epithelium to keep back the sugar. Faulty metabolism and defective assimilation of the glucose probably underlie most cases of diabetes, but much is to be learned as to the real nature of the disease. Pathology. — Lesions in the medulla from tumors or scleroses have been found, and glycogen has been found in the spinal cord. There may be a secondary multiple neuritis. The blood may contain as much as 0.4 per cent, of sugar instead of the normal 0.15 per cent. The plasma is fatty and the polynuclear leucocytes contain glycogen. Tuberculosis of the lungs is not uncommon, and may follow an acute broncho- or pneumococcus lobar pneumonia. The liver is enlarged and fatty. Lesions of the pancreas, generally atrophy, are present in nearly fifty per cent, of the cases. The kidneys usually show evidence of diffuse nephritis with fatty degeneration. Symptoms. — The symptoms in the temporary form of diabetes may be slight, and the sugar is discovered only in the routine examination of the urine. There may be an increased flow of urine and a craving for sweet 1006 PEDIATRICS. articles of diet. The appetite is good. The thirst may be increased. Indigestion is not uncommon. In true diabetes the symptoms are much more severe. Great thirst, excessive appetite, and polyuria are the striking symptoms. There is pro- gressive and extreme emaciation, the skin is harsh and dry ; sweating is rare. Constipation is usually present. The Aoav of saliva is abundant. The genitals are at times irritated by the urine. Urine. — The quantity of urine is greatly increased, generally averaging between 3000 to 5000 c.c. (100 to 166 ounces), although it may be much more or be less than normal. The urine is pale, strongly acid, and of high specific gravity, the degree depending upon the amount of sugar present. The solids are relatively diminished but absolutely increased in amount. Glucose or sugar is always present, and varies from a mere trace to 8, 10, or 12 per cent., and the total quantity in twenty-four hours varies from 20 to 60 grammes (f to 2 ounces), often amounting to sev- eral hundred grammes. There is usually the slightest possible trace of albumin and a few casts, indicative of a mild, active hyperemia of the kidneys. Diabetic Coma. — Diabetes mellitus frequently ends in coma, this pre- sumably being brought about by some toxic substance in the blood. This complication is especially common in children. It is at times precipitated by sudden changes in diet, especially when the patient is put upon a rigid, nitrogenous diet, but it may also follow many other conditions, such as intercurrent acute diseases and operations. Acetone and diacetic acid are found in the urine in advanced cases of diabetes, and are always of serious prognosis, as they indicate a threat- ened state of coma, but they may be present for months before any symptoms of coma appear, and may even disappear as the patient im- proves under treatment. Acetone and diacetic acid are probably rarely, if ever, present in cases of temporary glycosuria. The advent of coma may be suspected by the appearance of mental apathy, nausea, vomiting, and epigastric pain. The breath has a peculiar odor of acetone. Convulsions rarely occur, Avhich is a point of con- siderable value in excluding a coma due to uraemia. Bremer's blood-test with methylene-blue or congo-red will also aid in determining the nature of the coma, as a positive reaction will almost always be obtained, even in the early stages of diabetes mellitus. Complications. — Boils, furuncles, eczema, and prurigo are common complications. Gangrene may occur. Pneumococcus lobar pneumonia, broncho-pneumonia, and especially tuberculosis of the lungs, are likely to occur and prove fatal. Peripheral neuritis Avith pain and paralysis may occur, sometimes Avith symptoms suggestive of tabes. The disease may be manifested by paralysis, either the arms or legs being affected, the form being diplegic. Absence of the knee-jerk is not uncommon, and is probably due to UNCLASSIFIED DISEASES. 1007 neuritis. Mental depression or extreme restlessness or nervousness often develops. Cataract, retinitis, sudden amaurosis, ocular paralysis, and atrophy of the optic nerves occasionally occur. Otitis media or a mastoiditis may appear suddenly. (Edema is a common symptom, and does not always depend on disease of the heart or kidney. Diagnosis. — It is important to distinguish between diabetes mellitus and temporary glycosuria. This is sometimes difficult. In the former, however, sugar is present in every specimen of urine passed, irrespective of the time of day. In temporary alimentary glycosuria the urine in the early morning, after ten or twelve hours of fasting, is generally free from sugar, or only traces are present, whereas after a meal considerable quantities of sugar are eliminated. A rigid diet, free from carbohydrates, will also help to make the distinction clear, as the quantity of sugar in true diabetes mellitus is reduced only with difficulty and often cannot be markedly influenced. From other forms of polyuria the diagnosis is made clear by the presence of sugar as determined by Fehling's test. Bremer's blood-test with congo-red is a valuable aid in differentiating true diabetes mellitus from phloridzin diabetes. Prognosis. — The disease runs a much more rapid course in children than in adults. In Stern's one hundred and seventeen cases the shortest duration was two days. In seven cases death took place within a month. He mentions one case of a child whose urine contained sugar at birth, and who recovered in eight months. In children the disease is almost universally fatal, but C. Sterns, in a series of seventy-seven cases in chil- dren, found that fourteen recovered, and in one hundred and eight cases, also children, reported by Wegeli, only sixty-four terminated fatally. The younger the child the more grave is the prognosis. Treatment. — The treatment of diabetes mellitus consists practically in the regulation of the diet, the endeavor being to limit the ingestion of carbohydrates. The diet should consist, so far as possible, of meat, fish, eggs, green vegetables, salads, and nuts. Too great a quantity of meat should be avoided, as excessive nitrogenous food as well as carbohydrates will increase the percentage of sugar in the urine- It is well to test the patient's capacity to assimilate sugar by quanti- tating the sugar passed in twenty-four hours when on ordinary diet, and then to institute a strict diet for several days, the sugar being estimated daily. The results will give us indications as to whether to push the re- stricted diet or to allow more freedom in the choice of foods. When coma is threatened, or when the reaction for diacetic acid with ferric chloride is positive, carbohydrates should be added to the diet for a time. If under a strict diet the sugar disappears, the diet can gradually and cautiously be increased, but at intervals of a few months diabetics should 1008 PEDIATRICS. return to their restricted diet for a few weeks as a matter of precaution and to increase their power of assimilation of the carbohydrates. The following articles represent as varied a diet list for diabetics as is compatible with conservative treatment : oxtail soup, bouillon, and clear soups made from meats ; lemonade, chocolate, and cocoa, with saccharin for sweetening ; soda-water and charged waters. Fresh fish of all sorts, with oysters in season, poultry, game, eggs, butter, buttermilk, and cream cheese, lettuce, tomatoes, spinach, chicory, sorrel, radishes, asparagus, watercress, cucumbers, celery, and endives are permissible. Of the fruits, lemons, oranges, currants, plums, cherries, pears, apples, melons, raspberries, and strawberries may be taken in moderation if a strict diet is not being adhered to. Nuts may be given if they do not dis- turb digestion. Among the articles especially to be avoided are thick soups, liver, all forms of bread, and all dishes prepared with flour or sugar. Vegetables growing under ground are to be avoided. Beers, wines, and alcoholic drinks should not be used. Most of the gluten breads and diabetic flours in the markets are adul- terated with flour, and cannot be relied upon. A mixture of practically sugar-free milk can be obtained at the various milk-laboratories, and will probably in the future prove to be of much use in the dietetic treatment of diabetes, especially in infancy. But little is to be expected in the treatment of diabetes from the use of drugs, except so far as to allay symptoms. Opium, usually given in the form of codeia, is quite generally used, but I have not myself seen striking results from its administration. NDEX Abdomen, anatomy and relations of the, 57 ; at term. 33 Abscess, cerebral, 949; of the liver, 836; of the lung, 707 ; peritonsillar. 654 ; psoas, 429 ; retropharyngeal. 656 Acardia. 721 Acarus seabiei, 355 Acetone in diabetes mellitus, 1006 Achondroplasia, 342 Achorion Schoenleinii. 360 Acidophilic, 875 Acquired disease, definition of, 19 Acute circumscribed oedema, 379 fatty degeneration of the new-born, 312 fermental diarrhoea, 805 infectious osteomyelitis, 51 miliary tuberculosis of the lungs, 393 nervous diarrhoea, 796 nervous vomiting, 774 torticollis, 1001 yellow atrophy of the liver, 835 Addison's disease, 908 Adenitis, simple acute, 897 ; simple chronic, 898 Adenoid growths, 645 Adolescence, albuminuria of, 848 Adrenal gland, diseases of the, 908 JEstivo-autumnal parasite, 483, 484 Age, determination of, in premature infants, 257 Agenesis corticalis, 931, 951 Albuminuria of adolescence, 848 physiological. 847 Albumin water, preparation of, 791 Alopecia areata, 361 ; in syphilis, 525 Amaurosis in scarlet fever, 573 Amnesia, temporary, 937 Amoebic ileo-colitis, 501, 820 Amyloid degeneration of the heart, 734 infiltration of the kidnev, 859 ; of the liver, 837 Amyotrophic lateral sclerosis, 991 Amyotrophies, 990 Anaemia, primary or pernicious, 890 ; pseudo- leukaemic, 888 ; secondary, 894 Anatomy of infants and children vide In- fant at term, and Normal development ; topographical, 88 Anencephalia, 290 Aneurism, 720; intra-cranial, 978 Angio-neurotic oedema, 379, 943 Animal parasites, 829 ; ascaris lumbricoides, 831 ; oxyuris vermicularis, 829 ; taenia saginata or mediocanellata, 832 ; taenia solium, 832 Antitoxin, dose of, 471 ; immunizing dose of, 469 ; technique of injection of, 473 ; in treatment of diphtheria, 471 Anuria, 847 Anus, imperforate, 307 ; in syphilis, 827 Anopheles, genus, in malaria, 481 ; quadri- maculatus, 482 Aorta, transpositions of, 721 Aortic insufficiency, 743 ; stenosis, 744 Aortic orifice, lesions of the, in congenital disease, 726 Aphasia, organic, 938 ; temporary, 937 Appendicitis, 815; catarrhal, 816; chronic, 818; diagnosis, 819; etiology, 815; ob- literative, 818; pathology, 815; prog- nosis, 819; simple, 816; symptoms, 816; treatment, 819 ; ulcerative, 816 ; with general suppurative peritonitis, 817 ; with peri-appendicular peritonitis, 817 ; with septicaemia, 818 Aran-Duchenne type of progressive muscu- lar atrophy, 989 Arrested psychical development, 938 Arteries, transposition of the large, 726 Arteritis umbilicalis, 301 Arthritis of infants, 511 ; deformans, 1003 Ascaris lumbricoides, 831 Ascending colon, relations of, 69 Ascites. ( Vide symptoms of the especial dis- eases. ) Asphyxia in the new-born, 312 Aspiration pneumonia, 691 Asthma, bronchial, 673 ; dyspepticum, 946 ; false, 674 Ataxia, hereditary, 988 ; locomotor, 989 Atelectasis, 705 ; acquired, 706 ; in broncho- pneumonia, 694 ; congenital, 705 Athetosis, 954, 976 Athrepsia, 348 Athyrea, 901, 905 Atomization, 655 Atropine, doses of, in children, 470 Attenuants of cow's milk, 179 Aura, in grand mal, 926 Babcock fat-tester, 124, 191 Bacillus, Brieger's, 177 ; of Eberth, 447 ; of Friedlander, 691 ; comma, of Koch, 505 ; Klebs-Locffler, 459 ; lactis aerogenes; 87. 177, 182; of Pfeiffer, 476; of tetanus, 496 ; tubercle, 381 Bacteriologv of cow's milk, 180 Balanitis, 870 Barley-jelly, preparation of, 239 -water, preparation of, 239 64 1009 1010 INDEX. Basophiles, 874, 878 Basophilic, 875 Bath, temperature of, 96 Bathing of infants, 96 ; in typhoid fever, 455 Bednar's aphthae, 622 Beri-heri, 985 Bile at term, 38 ; in infancy and childhood, 83 Bile-ducts, congenital obliteration of the. 308 Biliary calculi, 837 Birth-palsies, 951 Bladder at term, 36 ; in childhood, 58 ; dis- eases of the, 865 ; reflex symptoms of the, 948 ; tuberculosis of the, 431 Blood, at term, 38 ; amount at birth, 876 ; average number of corpuscles at different ages, 878 ; color, 876 ; development of the, 56 ; diseases of the, 874 ; haemo- globin, 876, 880 ; in abnormal condi- tions, 879 ; in chlorosis, 893 ; in infancy, 874 ; in leukaemia, 884 ; in normal con- ditions, 875 ; in pernicious anaemia, 890 in pseudo-leukaemia, 888 ; in secondary anaemia, 895 ; nomenclature of the, 874 percentages of various leucocytes in the 879 ; reaction, 876 ; red corpuscles, 877. 880; specific gravity, 876, 880. ( Vide also, symptoms and diagnosis of the espe- cial disease. ) Blood-corpuscles, description of different va- rieties of, 874 ; red, 877, 880. ( Vide, also, Blood. ) Blood-vessels, diseases of the, 720 Bone, lesions of the, in cretinism, 901 ; in rhachitis, 329 ; in syphilis, 523, 528, 536 Bone-marrow, 81 ; at term, 37 Boracic acid, strength of, in local applica- tions, 869 Bow-legs, 111 Brain, at term, 29 ; development of the, 47 ; in cerebro-spinal meningitis, 434 ; syph- ilis of the, 978, 980 ; tuberculosis of the, 406, 978 Branchial fistula, 296, 767 Brandy, dose of, 456 Breast-pump, 119 Breck's feeder for premature infants, 273 Bremer's blood-test in diabetes mellitus. 1006 Brieger's bacillus, 87, 177 Bright's disease, acute, 853 ; chronic, 857 Broadbent's sign, 765 Bromides, doses of, in epilepsy, 929 Bronchi, diseases of the, 665 Bronchial asthma, 673 Bronchiolitis exudativa of Curschmann, 673 Bronchitis, acute, 666 ; capillary, 697 ; chronic, 671 ; fibrinous, 672 ; unusual forms of, 669 Bronchocele, 899 Broncho-pneumonia, acute, 691 ; acute tu- bercular, 394 ; aspiration, 691 ; chronic, 704 ; definition of, 675 ; diagnosis, 700 ; etiology, 691 ; pathology, 692 ; physical signs in, 699 ; primary forms in, 691 ; prognosis, 700; secondary forms in, 691 ; symptoms, 696 ; terminations and com- plications in, 699 ; treatment, 701 Brooder for premature infants, 267 Brown atrophy of the heart, 734 Bruit de diable. 893 Buhl's disease in the new-born, 312 Bulbar paralysis, 985 Bursa pharyngea at term, 28 Cachexia strumipriva, 901 Caecum and ascending colon, relations of, 69 Calcareous degeneration of the heart, 734 Calculi, biliary, 837 Calomel, dose of, 796 Canal of Nuck, encysted hydrocele of, 306 Cancrum oris, 629 Capillary bronchitis, 697 Caput succedaneum, 286 Carcinoma of the brain, 978. ( Vide, also, Tumors. ) Cardiac disease, vide Heart ; dilatation, 732 ; hypertrophy, 731 Cascara sagrada, dose of, 805 Caseinogen, 178 ; definition of, 223 Castor oil, dose of, 796 Catalepsy, 935 Catarrhal fever, 476 Cephalhaematoma, 287 Cephalodynia, 1001 Cereals in laboratory feeding, 202 Cerebral abscess, 949 meningitis, table of, diagnosis of, 415 palsies, infantile, 950 paralysis, 950 sinus, thrombosis of the, 975 syphilis, 978, 980 Cerebro-spinal fluid in cerebro-spinal menin- gitis, 439 Cerebro-spinal system, tuberculosis of, 405 Cervicodynia, 1001 Chenopodium, dose of the oil of, 832 Cheyne-Stokes respiration in acute broncho- pneumonia, 698 Chicken broth and jelly, preparation of, 244 Chicken-pox, 605 Chilblains, 365 Chloral, dose of, 574 Chloranaemia, 895 Chlorate of potassium, dose of, at different ages, 624 Chlorosis, 892 Cholera asiatica, 505 infantum, 502 Chorea, 916 ; congenital. 977 ; electrica, 924 ; habit, 924 ; hereditary or Hunting- ton's, 924; post-hemiplegic. 954 Choreiform diseases, 924 Chondro dystrophia, 342 Chovstek's symptom, 943 Chronic fermental diarrhoea, 809 nervous diarrhoea, 798 Chyluria, 850 Cirrhosis of the liver, 838 Citrate of potash, dose of, 574 Cleft palate, 292 Clothing of infants, 98-102 Club-foot, 311 -hand, 311 Cocaine, doses of, 823 ; suppositories, 814 INDEX. 1011 Colitis in measles, 598 Colles's law in hereditary syphilis. 521 Colon, dilatation of the. 810 ; irrigation of, the. 823 Colostrum milk, 122 ; chemistry of. 122 ; corpuscles, 122 ; period. 122 : influence of, on the infant's weight, 76 Common carotid artery at term, 32 Compensation of the heart. ( Vide the espe- cial diseases of the heart. ) Concussion. 937 Condylomata in syphilis. 527 Congenital chorea. 977 disease, definition of, 19. ( Vide, also, Diseases of the new-horn. ) hydronephrosis. 865 ; stridor, 660 Congestion, chronic passive, of the kidney, 852 of the liver. 835 Conglomerate tubercles, definition of, 384 Constipation.. 798, 802 ; atonic, 803 ; spas- modic. 803 Convulsions, 911 ; clonic, 911 ; epileptic, 925 ; epileptiform, 925 ; general symptoms of, 912; of central origin. 912; of periph- eral origin, 913 ; proo-ru>sis in, 914 ; reflex, 911, 913: tonic. 911; treatment of, 914 Conus arteriosus, stenosis of the, 725 Cor biloculare, 721 ; triloculare, 721 Cord, encysted hydrocele of the, 306 ; in cerebro-spinal meningitis, 434 Corrigan pulse in aortic insufficiency, 743 Corrosive sublimate, strength of, in local applications, 869 Coryza, acute, 640 Cow. the, adaptability of, for infant feeding, 169; Ayrshire, 168; Bretonne, 169 Brown Swiss, 169; care of the, 170 Devon, 168 ; Durham, or shorthorn, 168 Holstein-Friesian, 169 ; source of milk- supply, 168 Cow-pox. ( Vide Vaccinia. ) Cow's milk. ( Vide Milk of cow 7 s. ) Cows, tuberculin test of, 172 .Craniotabes in hereditary syphilis, 524, 529 ; in rhachitis, 333 Cranium, 45 ; at term, 26. ( Vide, also, Face and cranium. ) Cream, average analysis of 16 per cent., 223 ; definition of, 223. Creolin, strength of, in local applications, 869 Cretinism, 901 ; endemic, 901 ; sporadic, 901 Cricoid cartilage, 42 ; distance of the, to sternum, 43 Croup, 662 ; false, 662 ; membranous, 662, 664 Culex, genus, in malaria, 482 Curschmann's bronchiolitis exudativa, 673; spirals, 673 Cyclic vomiting, 774 Cystitis, acute, 865 ; chronic, 865 D. Dactylitis syphilitica, 524, 529 Degeneration, acute fattv, of the new-born, 312 Deglutition pneumonia, 691 Dental periods, 50 reflexes, 943 Dentition, difficult, 634. ( Vide, also, Teeth. ) Depressed sternum, 297 Dermatitis, 363 ; calorica, 365 ; exfoliativa neonatorum, 362 ; medicamentosa, 365 ; traumatica, 364 ; venenata, 364 Descending colon in infants, 70 Development, arrested psychical, 938 : nor- mal, 39 Dextro-cardia, 721 Diabetes insipidus, 1003 ; mellitus, 1004 ; pancreatic, 1005 Diabetic coma, 1006 Diacetic acid in diabetes mellitus, 1006 Diameters of thorax at term, 30 Diaphragm at term, 31 ; relations of, 53 Diarrhoea, 793 ; acute fermental, 805 ; acute nervous, 796 ; chronic fermental, 809. ( Vide, also, symptoms of the especial disease. ) Diet in the regimen of lactation, 186. ( Vide, also, Feeding, and the treatment of the especial disease. ) Difficult dentition, 634 Digitalis, doses of, 470 Dilatation, cardiac, 732 Dilutions of cream, with solutions of sugar, 231 ; with water, 231 ; with whey, 233 ; with whole milk, 231 Diphtheria, 459; antitoxin in, 468, 470; atypical infections of throat in, 464 ; complications and sequela?, 466 ; diag- nosis, 466 ; efflorescence in, 467 ; etiology, 460; incubation, 462; intubation in, 474; laryngeal, 465 ; malignant forms of, 464 ; nasal, 465 ; operative treatment, 474 ; pathology, 461 ; prognosis, 467 ; prophy- laxis, 468 ; serum-therapy in, 470 ; symp- toms, 462 ; tracheotomy in, 474; treatment, 469 ; variations of type in, 464 Diplegia, 953 Diplococcus intracellularis meningitidis, 432 Disseminated sclerosis, 987 Diuretin, dose of, 747 Drugs in disturbed lactation, 138 Ductless glands, diseases of the, 899 Ductus arteriosus, persistence of the, 725 ; post-natal changes in the, 55 Ductus venosus, post-natal changes in the, 55 Duodenal indigestion, acute (vide Intestinal indigestion), 797; chronic, 798 Duodenum at term, 34 Dura mater, 47 Dysentery (vide, also, Ileo-colitis), 820; chronic, 824 ; endemic, 501 ; tropical, 501 Dyspepsia, acute, 778 ; chronic, 779 Dystrophies, 990 Dyspnoea. ( Vide symptoms of the especial disease. ) E. Ear, the, 47 ; at term, 29 ; diseases of, 644 ; in cerebro-spinal meningitis, 439 ; in diph- theria, 465 ; in measles, 582, 591 ; in pneu- monia, 682; in scarlet fever, 548, 570 ; in syphilis, 538 ; in variola, 599 ; reflex symp- toms of, 944 Ear-drops, prescription for, 637 Ears, protrusion of the, 293 Eberth's bacillus, 447 1012 INDEX. Eclampsia infantum, 911 Eczema, 369 ; regional, 369 ; universal, 370 Emphysema. 706 ; compensatory, 706 ; in broncho-pneumonia, 696 ; interstitial, 706 ; obstructive, 706 Empyema, 713 ; in measles, 593 ; in pneu- monia, 682 Emulsion in modified milk, 203 Encephalitis, acute, 984 Encephalocele, 290 Endocarditis, acute, 735 ; pathology, 736 ; septic or malignant, 735, 736, 738 ; simple or verrucous, 735, 736 ; treat- ment of, 739 ; ulcerative, 736 chronic, 740 ; aortic insufficiency, 743 ; aortic stenosis, 744 ; diagnosis, 745 ; etiology,' 740 ; general symptoms, 740 ; mitral insufficiency, 741 ; mitral stenosis, 741 ; pathology, 740 ; prog- nosis, 745 ; pulmonary insufficiency and stenosis, 745 ; treatment, 746 ; tricuspid insufficiency, 744 ; tricuspid stenosis, 744 Enemata, rectal, 830 Enteric fever, 447 Enuresis, 871 ; functional, 871 ; organic, 871 Eosinophiles, 875 ; percentage of, in the blood, 879 Eosinophilic, 875 Epidemic cerebro-spinal meningitis, 432 ; diagnosis, 440; etiology, 432; pathol- ogy, 433 ; prognosis, 440 ; symptoms, 436 ; treatment, 440 ; tvpes of the disease, 435 Epidemic pemphigus infantilis, 362 Epididymitis, 870 Epiglottis, 43 Epilepsy, 925; grand mal, 925, 926; Jack- sonian, 925 ; petit mal, 925, 926 Epileptic status, 927 Epileptiform convulsions, 925 Epiphyseal hyperemia, 970 Epiphysitis, acute, 511 Epispadias, 308 Epistaxis, 644 Epsom salt, doses of, 833 Erb's juvenile form of progressive muscular atrophy, 993 Erysipelas, 497 ; ambulans, 497 ; migrans, 497 ; of the new-born, 498 ; of sucklings, 498 Erythema, 366 ; intertrigo, 367 ; multiforme, 366 ; neonatorum, 324 ; nodosum, 367 ; simplex, 366 ; urticatum, 367 Erythrocytes, 877, 880 Eustachian tubes, 48 ; at term, 28 Eustachian valve, post-natal change of the, 55 Examination and treatment, general princi- ples of, auscultation, 250 ; history, 247 ; inspection, 248 ; lumbar puncture, 253 ; method of examining a child, 246 ; palpa- tion, 248 ; percussion, 249 ; prophylaxis, 256; respiration, 248; Rontgen " light, 253 ; temperature, 248 ; treatment in gen- eral, 255 Exanthemata, the, as a group, 542 ; differ- ential diagnosis of, 612 Exercise in the regimen of lactation, 137 Exophthalmic goitre, 905 Extremities, diseases of the, in the new- born, 310 ;. in rhachitis, 336 ; length of, in cretins, 902 Eye, at term, 29 ; in cerebro-spinal menin- gitis, 438 ; in measles, 592 ; in syphilis, 526, 538 Eace and cranium, at term. 26 ; develop- ment of, 45 Faecal dejections, influence of fat on the color of the, 216 Faeces, incontinence of, 802 False asthma, 674 croup, 662 Fat-free milk, definition of, 223 Fats in human milk, 124, 127, 128 Fatty degeneration, acute, in the new-born, 312 of the heart, 734 Fatty infiltration of the heart, . 734 ; of the liver, 836 Faucial tonsils at term, 28 Feeding, 160 ; after the twelfth month, 243 ; amounts of food in, 67, 68 ; amount at each, 188 ; apparatus, 186 ; by stomach- tube, 781 ; direct substitute, 160 ; directly from animals, 164 ; general principles of, 112 ; general rules for, during first year, 188 ; indirect substitute, 164 ; intervals of. 135, 188; intervals and number of, 136; maternal, vide Maternal feeding ; mixed, 156 ; nipples in, 188 ; of average infants born at term, 214 ; of premature infants. 273 ; Ssnitkin's rule, 189. ( Vide, also, Percentage feeding. ) Feet, 81 ; at term, 37 ; care of, in children, 102 Femoral hernia in the new-born, 305 Fibroid phthisis, 695 Filaria sanguinis hominis, 850 Fingers in the new-born, 310 Fissures, 813 Fistula?, 814 Flat-foot, 81 Flexner's bacillus, 820 Foetal circulation, 19 rhachitis, 342 Fontanelles, at term. 25 ; development of. 45 Food, artificial, for infants, 240; malted. 241 ; management of, in early days of life. 135 ; source of, in indirect substitute feed- ing, 166 Foramen ovale, open, 723 ; post-natal changes in the, 55 ; premature closure of the, 723 Forced feeding, 781 Forchheimer's exanthem in rubella, 594 Foreign bodies in the larynx, 661 ; in the oesophagus, 768 Formuhe, general, for calculation of all percentage combinations, 235 ; for calcula- tion of sugar percentage, 231 ; for cream and fat-free milk, 237 ; for cream and whey, 238 ; for cream and whole milk, 236 Fossa of Rosenmuller, 28 INDEX. 1013 FraenkePs pneumococcus, 675 Freckles. 376 Friedlander, bacillus of, 691 Friedreich's disease, 988 Frowlowsky's rule for gastric capacity, 59 Functions, development of. 82 Funnel chest in rhachitis. 384 Furunculosis, 358 Gangrene of the lung, 707 ; in pneumonia, Gastralgia. 777 Gastric catarrh, acute. 789 ; chronic, 792 Gastritis, acute. 789 ; catarrhalis acuta. 789 ; chronic catarrhal. 792 : corrosiva acuta, 789. 791 : pseudo-membranosa, 789, 791 G.astro-diaphane. 785 Gastro-enteric diseases. American Pediatric Society's classification of the, 769, 778 ; general bacteriology, 770 ; general diag- nosis. 771: general etiology. 770; general symptomatology, 771 : general treatment, 772; table of classification, 773 Gastro-enteric tract, tuberculosis of the, 399 Garage. 780 Genitals, diseases of the. $>V) German measles. ( Vide Rubella.) Giant urticaria, 379 Glioma. 978 Glossitis. 633 Glottis, cedema of, in measles. 593. ( Vide, also, the especial disease. ) Glycosuria, 851 ; alimentary. 851 ; dietetic, 851 : in scarlet fever, 573 ; temporary ali- mentary. 1005 Goitre. 899; exophthalmic, 905 Grand mal, 925. 926 Green sickness, 893 Growing pains, 970 Gum-lancing. 636 Gums at term. 27 Gyrospasm, 944 H. Habit chorea, 924 Haematoblaste, 874 Haematoma of the sterno-cleido-mastoid, 295 Hematuria, 849 ; in chlorosis, 893 ; in per- nicious anaemia, 890 ; in scorbutus, 344 ; in secondarv anaemia. 895 Haemoglobin,' 875, 876,' 880 Haemoglobinaemia, 875 Haemoglobin uria, 849, 875 ; paroxysmal, 849 infectious, in the new-born, 314 Haemolysis, 875 Haemopericardium, 754 Haemophilia, 997 Hands at term, 37 Hard palate, 29, 48 Harelip, 291 Harrison's groove in rhachitis. 334 Headaches. 939 Head- anencephalic, 290; at term, 25; de- velopment of the, 43 ; diseases of the, in the new-born, 286 ; in rhachitis, 333 ; macrocephalic, vide Hydrocephalus ; mi- crocephalic, 932 Hearing at term, 38 Heart, at term, 32; diseases of the, 719; in scarlet fever, 554 ; post-natal changes in the, 54 ; reflex symptoms of the, 948 acquired diseases of the, 730 ; amyloid degeneration, 734 ; brown atrophy, 734 ; calcareous degeneration, 734 ; dilatation, 732 ; endocarditis, 735 ; fatty degeneration, 734 ; fatty infiltra- tion, 735 ; hyaline transformation, 734; hvpertrophy, 731; mvocarditis, 733 congenital diseases of the, 720 ; defect of the ventricular septum, 724; dif- ferential diagnosis of the, 726 ; gen- eral diagnosis, 723 ; general symp- toms, 721 ; general treatment, 730 ; lesions of the aortic valve in, 726 ; lesions of the mitral valve in, 726 ; open foramen ovale in, 723 ; per- sistence of the ductus arteriosus in, 725; pulmonary atresia in, 725; pul- monary stenosis in, 724 ; transposi- tion of the large arteries in, 726 ; tri- cuspid insufficiency in, 726 ; tricuspid stenosis in, 726 ; stenosis of the conus arteriosus in, 725 functional diseases of the, 748 murmurs. ( Vide lesions of the especial valves. ) Heat-stroke, 935 Height, at term, 36, 73 ; in infancy and childhood, 73 Hemiplegia, 953 Hemitaxia, 954 Hemorrhage in early life, 317 ; in scorbutus, 344 ; in syphilis, 526 ; in typhoid fever, 448, 450. ( Vide, also, symptoms of the especial disease. ) Hemorrhagic diathesis, 997 Hemorrhagic disease of the new-born, 317 Hemorrhoids, 814 Henoch's purpura, 999 Hepatitis, interstitial, 838 ; atrophic and hypertrophic, 838 ; suppurative, 836 Hepatization, red and gray, 676 Hereditary ataxia, 988 chorea, 924 spastic paralysis, 989 syphilis. ( Vide Syphilis. ) Hernia, 813 ; congenital, funicular, and in- fantile, 304 ; inguinal, 304 Herpes zoster, 374 Hip, congenital dislocation of the, 311 ; tuberculosis of the, 429 Hives, 367 Home modification of milk, 217 ; apparatus for, 224 ; definition of terms in, 223 ; diffi- culties and dangers of, 217 ; final remarks on, 239 ; materials for, 223 ; method of obtaining cream and separated milk for, 225; prescriptions for, 226; table for cal- culation of, 229. ( Vide, also, Formulae.) Human milk. ( Vide Milk, human.) Huntington's chorea, 924 Hyaline transformation of the heart, 734 Hydatids of the liver, 8:57 Hydrocele, 305 ; congenital, infantile, and funicular, 805; in the new-born, S0o 1014 INDEX. Hydrocele, encysted, of the canal of Nuck, 306 ; of the cord, 306 Hydrocephalic cry, 408 Hydrocephalus, 970 ; acute, 970 ; chronic internal, 971 ; congenital, 291 ; external, 970 ; internal, 970 ; in vacuo, 971 Hydronephrosis, 865 Hydropericardium, 754 Hydrothorax, 717 Hyperemia, active, 851 ; epiphyseal. 970 ; passive, 852 Hyperpyrexia, treatment of, by hathing, 455 Hyperthyrea, 905 Hypertrophy, cardiac, 731 Hypnotic state, 935 Hypospadias, 308 Hypostatic pneumonia, 705 Hysteria, 932 Ichthyosis, 377 ; foetal, 377 ; neonatorum. 378 Icterus, 835 ; neonatorum, 323 Idiocy, 930 Ileo-colitis, 820; acute (simple catarrhal), 821; amoebic, 501, 820; chronic, 824; diagnosis, 822 ; general etiology, 820 ; non- ulcerative follicular, 821 ; pathology, 821 ; prognosis, 823 ; pseudo-membranous, 821, 822"; treatment, 823 ; tubercular, 399 ; typhoidal, 447 ; ulcerative, 821 822 ; variations in the type of, 820 Imbecility, 930 Impetigo contagiosa, 357 Incubator for premature infants, 266 Indigestion, acute gastric, 778 ; acute intes- tinal (duodenal). 797 ; chronic duodenal, 799 ; chronic gastric, 779 ; chronic intes- tinal, 802 ; chronic nervous intestinal, 798 ; chronic tubular, 798 Infant at term, the, 21 ; abdomen, 33 ; bile, 38 ; bladder, 36 ; blood, 38 ; bone-marrow, 37 ; brain, 29 ; bursa pharyngea, 28 ; com- mon carotid artery, 32 ; cranium and face, 26 ; diameters of thorax, 30 ; diaphragm 31 ; duodenum, 34 ; ear, 29 ; Eustachian tubes, 29 ; eye, 29 ; faucial tonsils, 28 feet, 37 ; foetal circulation, 19 ; fontanelles 25 ; general description of, 21 ; head, 25 hands, 37 ; hard palate, 29 ; hearing in 38 ; heart, 32 ; height, 36, 73 ; intestines 35 ; intestinal discharges, 39 ; 'jaws. 26 kidneys, 33 ; lachrymal glands, 38 ; larg< intestines, 36 ; larynx, 25 ; - liver, 33 lungs, 32 ; lymph-vessels of pharynx, 27 lymphatic system, 39 ; lymphoid tissues 28; mastoid antrum, 29; meconium, 39 mouth, 29 ; naso-pharynx, 27 ; neck, 24 ossification of sternum, 30 ; pancreas, 39 pelvis, 36 ; petro-squamosal suture, 30 pharyngeal tonsil, 28 ; pulse, 36 ; respira tion, 33, 36, 72 ; salivary glands, 38 ; se baceous glands, 38; sight, 37; skin, 21 small intestines, 36 ; smell, 38 ; soft palate 29 ; spine, 22 ; sternum, 30 ; stomach, 34 suprarenal capsule, 33 ; sweat-glands, 38 taste, 38; teeth , 29; temperature, 36, 70 thorax, 30 ; thymus gland, 32 ; tongue 29; touch, 38; uric acid infarction, 34 urine, 39, 85 ; uterus, 36 ; uvula, 29 veins, 32 ; vernix caseosa, 21 ; vitality, 37 ; voice, 37 ; weight, 36 Infantile atrophy, 348 cerebral palsies, 950 spinal paralysis. 958 Infantilism, 537 Infants, normally developed, 88 ; prema- ture, vide Premature infants ; when to take out of the house, 106 Infectious diseases, specific, 381 haemoglobimemia of the new-born, 314 hemoglobinuria. 314 Influenza, epidemic, 476 ; febrile type, 478 gastro-enteric type, 478 ; nervous type, 478 ; pseudo-, 476 Inguinal hernia in the new-born, 304 Insanity, 929 Insolation, 935 'Insular sclerosis, 987 Intention tremors, 987 Intestinal contents, 793 ; amount, 795 ; color, 793 ; composition, 794 ; con- sistency. 794 discharges at term, 39 ; in infancy, 87 ; Intestines, at term, 35 ; congenital oblitera- tion of, 310; development of, 68 developmental diseases of the, 795 ; malformations, 795; malpositions, 795 diseases of the, 767, 793 ; American Pediatric Society's classification of the, 769, 773 ; diarrhoea in, 793 ; gen- eral considerations of, 793 ; intestinal contents in, 793 ; prophylaxis in, 793 functional diseases of the, 795 ; acute indigestion, 797 ; acute nervous, 796 ; chronic duodenal indigestion, 799 ; chronic intestinal indigestion, 802 ; chronic nervous, 798 ; chronic tubu- lar, 798 ; constipation, 802 ; elimina- tive, 805 ; incontinence of fasces, 802 organic diseases of the, 805 ; acute fer- mental, 805; appendicitis, 815; chronic fermental, 809 ; dilatation of the colon, 810; dysentery, 820 (vide, also, Ileo-colitis) ; fissures, 813 ; fis- tula?, 814 ; hemorrhoids. 814 ; hernia, 813 ; intussusception, 811 ; mechani- cal, 809 ; new growths. 814 ; polypi, 814 ; proctitis, " 815 ; prolapse, 813 ; volvulus, 811 Intussusception, 811 Iodide of potash, dose of, in syphilis, 538 Iron, dose of, in chlorosis, 893 Irrigation of colon, 823 ; nasal, 473 Isthmus aorta?, absence of, 720 ; narrowing of, 720 Ivy poisoning, 364 Jacksonian epilepsy, 925 Jalap, compound powder of, dose of, 574 Jaws at term, 26 Joints in cerebro-spinal meningitis, 439 ; in scarlet fever, 575 ; tuberculosis of the, 427 K. Kakke, 985 Kaposi's disease, 376 Keratitis, interstitial, in syphilis, 538 Kernig's sign, 409 INDEX. 1015 Kidneys, at term. 33 ; in cerebrospinal meningitis, 435 ; in childhood. -57 ; enlargement of the, 866 : in measles, 592 ; in scarlet fever. 553, 572 ; dis- eases of the, 844 acquired diseases of the. vide, also, Ne- phritis : active hyperemia, 851 ; acute pyelitis and pyelonephritis, 862 ; albuminuria oi adolescence. 848 ; amyloid infiltration, 8-39 ; anuria, ^47 ; chronic passive congestion, 852 ; general etiology of. 844 ; general pa- thology of, 844 : general symptoma- tology of, 846 ; hsematuria, 849 ; hemoglobinuria, 849 ; malignant growths, 866 ; passive hyperemia, 852 : physiological albuminuria, 847 : tuberculosis. 431 congenital diseases of the. 844 Klebs-Loerrler bacillus, 459 Knee, congenital dislocation of the, 311 ; tuberculosis of the, 429 Knock-knee. Ill Koplik's gastro-diaphane, 785 spots in measles. 583 ; in rubella, 594 Kumyss, 241 Kyphosis in rhachitis, 336 Laboratorv modification of milk, practical limits of, 199 Lachrymal o-lands at term, 38 ; development of, 82 Lactalbumin, 178; definition of, 223 Lactation, disturbed, 138 ; analyses of hu- man milk in, 143 ; general principles for the management of, 140, 141 ; menstruation in, 139 prolonged, 156 regimen of, 136 Lacto-globulin. 178 Lagophthalmia, 969 La grippe, 476 Landouzy-Dejerine type of progressive mus- cular dystrophy, 993 Landry's paralysis, 986 Large intestines at term, 36 ; development of, 69 Laryngismus stridulus, 660 Laryngitis, 662 ; acute catarrhal, 662 ; chronic, 662 ; membranous, 465, 593, 664 Laryngospasmus, 660, 944 Larynx, 43 ; at term, 25 ; diseases of the, 660 ; foreign bodies in the, 661 ; new growths, 660 ; oedema of, 662 ; pseudo-membranous, 664; reflex symptoms of the, 944 Lavage, 780 Leg type of progressive muscular atrophy, 991 Lentigo, 376 Leptomeningitis, 981 Letter S curve, 710 Leucocytes, 874, 881 ; in children, 877 Leukocytosis, 875; in children, 881; in secondary anaemia, 895. ( Vide, also, symp- toms and* diagnosis of the especial disease. ) Leukaemia, 882 ; lymphatic, 883 ; splenic myelogenous, 882 Lichen planus, 377 Lingua geographica, 633 Lipoma of the brain, 978 Liver, abscess of the, 836 ; acute yellow atrophy of the, 835 ; anatomy, 834 ; at term, 33 ; amyloid, 837 ; in cerebro-spinal meningitis, 435 ; in childhood, 57 ; cir- rhosis, 838 ; congestion, 835 ; diseases of the, 834 ; fatty infiltration, 836 ; hydatids, 837 ; icterus, 835 ; new growths, 837 ; in syphilis, 522 ; tuberculosis of, 431 Lobular pneumonia, 691. ( Vide, also, Broncho-pneumonia. ) Locomotor ataxia, 989 Lordosis in rhachitis, 336 Lumbago, 1001 Lumbar puncture, 253 Lungs, the, abscess of, 707 ; acute miliary tuberculosis of, 393 ; at term, 32 ; chronic localized tuberculosis of, 395 ; chronic dif- fuse tuberculosis of, 395 ; development of, 56 ; diseases of, 665 ; gangrene of, 707 ; in cerebro-spinal meningitis, 434, 438 ; re- flex symptoms of, 946 ; syphilis of, 523 ; tuberculosis of, 393 Lupus, 432 Lymphangioma cavernosum, 634 Lymphatic leukaemia, 883 system at term, 39 ; development of, in early life, 83 Lymphatism, 1000 Lymph-nodes, diseases of the, 897 ; in cere- bro-spinal meningitis, 435 cervical, in measles, 592 ; in scarlet fever, 549, 569 ; in syphilis, 525 ; in tuberculosis, vide Tuberculosis of the lymph-nodes Lymphocytes, 878 ; large, small, mono- nuclear, and transitional, 874 Lymphoid tissue at term, 28 Lymph vessels of the pharynx at term, 27 M. Macrocytes, 874 Macroglossia, 634 Malaria, 481 ; 'chronic, 488; diagnosis, 488; etiology, 481 ; genus anopheles in, 481 ; genus culex in, 481 ; intermittent, 485 ; pathology, 485 ; paroxysms in, 486 ; prog- nosis in, 488 ; prophylaxis in, 489 ; remit- tent, 485 ; symptoms, 485 ; subacute forms, 488 ; treatment, 489 Male fern, oleoresin of, dose of, 832 Malformations of intestines, 795 Malignant endocarditis, 736, 738 ; septic type, 739 ; typhoidal type, 739 Malignant growths. ( Vide New growths and tumors. ) Malposition of the intestines, 795 Malted foods, 241 Mammary gland, 114 Marasmus, 348 Marmorek's antistreptococcus serum in scar- let fever, 562 Mastitis, 118 ; in the new-born, 296 Mastoid antrum at term, 29 Masturbation, 873 Maternal feeding, 116 ; contraindication to, 117 Maternal impressions, 285 Matzoon, 241 Maxillary bones, 48 1016 INDEX. Measles, 579 ; complications and sequelae of, 590 ; contagiura in, 580 ; desquamation, 584. 589 ; diagnosis, 58-4 ; efflorescence, 584, 588 ; etiology, 579 ; incubation, 582, 588 ; hemorrhagic or malignant form, 588 ; pathology, 581; prodromata, 582, 588; prognosis, 585 ; recurrent, 589 ; relapses, 589; symptoms, 582 ; treatment, 585 ; variations in type, 587 Meckel's diverticulum, 303 Meconium, 39 Megaloblasts, 874 Megalocytes, 874 Mekena neonatorum, 320 Melanoderma lenticularis progressiva, 376 Meningitis, 981 ; basilar, 982 ; cerebral, table of diagnosis, 415; epidemic cerebro- spinal, 432 ; in pneumonia, 684 ; serosa, 971 ; simple acute, 982 ; tubercular, 406 ; tubercular, infantile form, 410 Meningocele, 289 Meningo-myelitis, 958 -myelocele, 298 Menstruation in disturbed lactation, 139 Mental development in syphilis, 537 Mental impressions, development of, 82 Mercurials, use of, in syphilis, 531 Micro blasts, 874 Microcephalia, 932 Micrococcus lanceolatus, 676 Microcytes, 874 Microglossia, 634 Microsporon furfur, 360 Migraine, 940 Miliary tubercles, definition of, 384 Miliary tuberculosis, 387. ( Vide Tubercu- losis.) Milk, 120; care of, 172; formation of, 120; home modification of, 217 (vide, also, Home modification) ; nervous disturb- ances affecting the, 121 ; peptoniza- tion of, 202 human, 124 ; analyses in disturbed lac- tation, 143 ; average analyses of, 127 (vide, also, the analyses in the illus- trative cases of breast and substi- tute feedings, 143-155 and 210-213) ; bacteriological examination of, 134 ; clinical examination of, 124 ; clinical significance of the chemistry of, 127 ; fats, 124, 128 ; lactose or milk-sugar, 126, 129 ; microscopic examination, 126 ; mineral matter, 126, 129 ; pro- teids, 125, 129, 200 ; specific gravitv, 124, 128 ; water, 128 ; variations, 132 -laboratories, 184, 189 ; apparatus for transportation of modified milk, 193 ; Babcock fat-tester, 191 ; milk-room, 190; modifying-room, 191; separa- ting-room, 191 ; separator, 191 ; ster- ilization of the milk, 196; still, 191; ventilator, 191 ; wash-room, 197 of cows, as compared with woman's milk, 180 ; attenuants, 179 ; average analysis, 173; bacteriology, 180; fats, 175 ; lactose or milk-sugar. 176 ; milk plasma, 176 ; mineral matter, 178 ; proteids, 177, 200 ; reaction, 174 ; specific gravity, 175 of mao-nesia, dose of, 805 Mirror writing, 932 Mitral insufficiency, 741 orifice, lesions of. in congenital disease, 726 stenosis, 741 Modification of milk, materials for, 195; practical limits of, in the milk-laboratories, 199. ( Vide, also, Formulae, Home modi- fication, and Feeding. ) Modified milk, the emulsion in, 203 Molluscum contagiosum, 358 Monoplegia, 953 Morbus maculosus Werlhofii, 999 Morphine, doses of, 505, 824 Mouth at term, 29 ; care of the, 107 ; in syphilis, 527 diseases of the, 615 ; nomenclature, 615 ; table of classification of, 616 -wash, 653 Mucous polypi of the nose, 643 Multiple neuritis, 985 Mumps, 613; submaxillary, 614 Murmurs, heart, congenital, 727 ; func- tional, 749 ; organic, 749. ( Vide, also, the especial valvular lesion. ) Muscular atrophy, progressive central, 989 ; progressive neural, 990, 991 dystrophies, atrophic form, 995 ; classi- fication of the, 993 ; Erb's juvenile form, 993, 995 ; Landouzy-Dejerine type, 993, 995 ; pseudo-hvpertrophic form, 994 rheumatism, 1001 tremors in exophthalmic goitre, 906 Mutton broth, preparation of," 245 Myalgia, 1001 Mycelium, 626, 628, 629 Myelitis, acute, 958 Myelocytes, 875, 878 ; eosinophilic, 875 ; neutrophilic, 875 Myocarditis, interstitial, 733 ; parenchyma- tous, 733 Myoclonia, 925 Myomalacia, 734 Myopathies, 990 ; primary, 993 Myotonia congenita, 924 Myotonic reaction, 924 Myxcedema, 901 ; acquired. 901 ; congenital, 901 ; operative, 901 Myxoma of the brain, 978 N. Na?vus, 325 Nails in svphilis, 526, 538 Napkins, 39, 84, 87, 793 Nasal irrigation, 473 Naso-pharvnx, 47 ; at term, 27 ; diseases of the, 645" Natiform skull in late hereditary syphilis, 537 Neck, at term, 24 ; development of* the, 42 diseases of the, in the new-born, 295 Nephritis, acute, 853 ; acute diffuse, 853 ; catarrhal, 852 ; chronic interstitial, 857 ; chronic parenchymatous, 855 ; subacute glomerular, 855. ( Vide, also, Kidney. ) pathology of acute degenerative, acute glomerular, acute hemorrhagic, acute interstitial, 549-553, 853 INDEX. 1017 Nerves and nerve ganglia in cerebro-spinal meningitis, 434 Nervous disturbances affecting the milk, 121 system, diseases of the, 910 in cerebro-spinal meningitis, 438 Nettle-rash, 367 Neuralgia, 970 Neuritis, multiple, 985 Neutrophils, 87-3 Neutrophilic, 87-3 New-born, the, acute fatty degeneration of, 31:2 ; asphyxia in, 312 diseases of, 282 ; erysipelas of, 498 ; extremities in, 310 ; general diag- nosis, 285; general diseases. 312; general etiology, 283 ; general pathology, 283 ; general prog- nosis. 285 : general symptoms, 284 : head in, 286 ; hemorrhage in the, 317 ; hemorrhagic disease of, 317 ; infectious hamioglobi- naemia of, 314; infectious hemo- globinuria of. 314; inheritance in. 282 ; malformation in, 282 ; maternal impressions as a factor in. 285; neck in, 295; paralysis of, 968 ; syphilis of, 521 ; trau- matism in, 282 ; trunk in, 296 New growths of the intestines, 814 ; of the larynx. 660; of the liver, 837; of the stomach, 783, 789. ( Vide, also, Tumors. ) Nipples, 118, 188 Nitrate of silver, strength of. in local appli- cations, 869 Nitroglycerin, doses of, in children, 470 Noma, 629; in measles, 593 Normal development, 39 infant, the, at term, 18 maternal conditions, 116 salt solution, dose for subcutaneous in- jection of, 504 Normoblasts, 874 Nose, diseases of the, 640 Nursery, the, 93 ; bed, 94 ; closets and drawers, 94 ; curtains, 94 ; draughts, 95 ; floor, 93 ; furniture, 94 ; heating and ven- tilation, 95 ; papers and carpet in, 93 ; picture mouldings, 93 ; pillow and mat- tress, 94 ; rugs, 93 ; scales, 95 ; sun and windows, 93 ; toys, 94 ; walls and ceil- ings, 93 Nursery-maids, 107 Nursing, 117 ; irregularity in, 136 Nutrition, diseases of, 326 ; relation of weight to, 73-81 Nutritive period, first, 116 ; second, 241 ; third, 245 Nux vomica, dose of, 805 Nystagmus, 944, 988 O. Oat-jelly, preparation of, 239 Obstetrical paralysis, 968 O'Dwyer's tubes in intubation, 476 (Edema of the larynx, 662 ; neonatorum, 323. ( Vide, also, symptoms of the especial disease. ) (Esophagi tis, 767 (Esophagus, congenital dilatation of the, 769 ; diseases of the, 767 ; foreign bodies in the, 768 Oldium albicans, 626 Oligocythemia, 875 Omodynia, 1001 Onychia, 526, 538 Ophthalmia neonatorum, 294 ; catarrhal, 294 ; purulent, 294 Opium, doses of the tincture of, 823 Orchitis, 870 Ossification of the sternum, 30 ; of the thorax, 51 Osteomalacia, 343 Osteomyelitis, acute infectious, 511 Osteoperichondritis in hereditary syphilis, 524, 528 Osteoperiostitis in hereditary syphilis, 523 Otitis media. ( Vide Ear. ) Oxyphiles, 875 Oxyuris vermicularis, 829 Ozama, 643 P. Pachymeningitis, 981 Palsies, birth. 951 ; extra-uterine,- 951 ; in- fantile cerebral, 950 Paludism. ( Vide Malaria. ) Pancreas, the, at term, 38 ; in childhood, 57 ; development of the function of, 83 ; diseases of the, 840 ; tuberculosis of, 430 ; in syphilis, 523 Pancreatic diabetes, 1005 Paralysis, bulbar, 985 ; caused by caries of the spine, 967 ; cerebral, 950 ; hereditary spastic, 989 ; in cerebro-spinal meningitis, 437 ; infantile spinal, 958 ; in measles, 593 ; in tuberculosis of the spine, 429 ; Landry's, 986 ; obstetrical, 968 Paramyoclonus multiplex, 925 Paramyotonia, congenital, 925 Paraplegia, 953 Parasites. ("Vide Animal parasites.) Parotitis, 613 Paroxysmal gasping, 946 Parrot's disease, 528 Pavor nocturnus, 941 Pectus carinatum, 334 Pediculosis, 357 Pediculus capitis, 357 Peliosis rheumatica, 998 Pelletierine, dose of, 832 Pelvis at term, 36 Pemphigus, 361 ; neonatorum, 361 ; puru- lent, 362 ; syphilitic, 525 Peptonized milk, 241 Percentage combinations for premature in- fants, 274 feeding, illustrative cases in, 206; prin- ciples of prescription writing in, 197 ; use of whey in, 200, 201 ; whey-cream mixtures in, 201 Perforation in typhoid fever, 448, 450 Pericarditis, acute, 754 ; diagnosis, 759 ; dry, 755; etiology, 754; in measles, 593; plastic, 755; paracentesis in. 762; pa- thology, 754 ; physical signs, 755 ; in pneumonia, 682 ; treatment 762 ; with exudation, 755 1018 INDEX. Pericarditis, chronic adhesive. 764 Pericardium, diseases of the, 719, 754 Perinephritis, 862 Peritoneum, diseases of the. 840 ; tubercu- losis of the, 401 Peritonitis, acute, 840 ; acute pneumococcus, 842; chronic, 843 ; congenital, 843; gen- eral suppurative. 817; of the new-horn, 842 ; periappendicular, 817 ; with septi- caemia, 818 Peritonsillar abscess, 654 Perles of Laennec, 673 Pernicious anaemia, 890 Peroneal tvpe of progressive muscular atro- phy, 991 Persistent vomiting, 774 Pertussis, 505 ; complications, 508 ; diagno- sis, 509 ; etiology, 505 ; incubation, 506 ; in measles, 590 ; pathology, 506 ; progno- sis, 509 ; prophylaxis, 510 ; symptoms, 506 ; treatment, 510 Petit mal, 925, 926 Petro-squamosal suture, 47 ; at term, 30 Peyer's patches, in typhoid fever, 448 Pharyngeal tonsil, 48 ; at term, 28 ; hyper- trophy of, 645 Pharyngitis, 654 ; acute follicular, 655 ; acute simple, 654 ; chronic, 655 ; elonga- tion of uvula in, 655 Pharynx, diseases of the, 649 Phenacetine, dose of, in infants, 701 Phimosis, 870 Phlebitis umbilicalis, 301 Phosphate of soda, dose of, 805 Phthisis, fibroid, 695 Pigeon-breast, 334 Pilocarpine, dose of, 574 Pityriasis, 375 maculata et circinata, 375 ; rosea, 375 ; rubra, 375 Plaques muqueuses, 528 Plasmodium malarias, 483 ; sestivo-autumnal parasite, 484 ; tertian parasite, 484 ; quar- tan parasite, 484 Pleura, diseases of the, 707 ; tuberculosis of the, 399 Pleurisy, acute, 707 ; acute dry or plastic, 708 ; etiology, 707 ; primary forms of, 707 ; secondary forms of, 707 ; with purulent exudation, 713 ; with sero- fibrinous exudation, 708 chronic, 716 Pleuritis in measles, 591 Pleurodynia, 1001 Pleuro-pneumonia, 708 Pneumococcus lobar pneumonia, 675, 676. ( Vide Pneumonia, pneumococcus lobar. ) of Fraenkel, 675, 676 Pneumonia. 675 ; abortive, 681 ; acute croupous, 675 ; acute fibrinous, 675 ; apex, 681 ; aspiration, 691 ; central, 681 ; cerebaal, 681 ; definition of, 675 ; deglutition, 691 ; hypostatic, 705 ; massive, 681 ; mio-ratorv or creeping, 681 lobar, due to other organisms than the pneumococcus, 690 pneumococcus lobar, 675, 676 ; compli- cations and sequela?, 682 ; crisis in, 679 ; delayed resolution, 681 ; diag- nosis, 683 ; etiology, 676 ; pathology, 676 ; physical signs, 680 ; prognosis, 685 ; symptoms, 677 ; treatment, 685 ; varieties, 681 Pneumopericardium, 754 Pneumothorax, 717 Podophyllin, dose of, 574, 801 Poikilocytes, 874 Poikilocytosis, 895 Polioencephalitis, 985 Poliomyelitis, anterior acuta, 958 Polychromatophilic, 875 Poly nuclear leucocytes, 875 neutrophiles, 878 Polvpi of the nose, 643 ; of the rectum, 814 Posthitis, 870 Posture, defects of, 108 Percentage feeding, 184 modification, theory of, 231 Porencephalus, 951 Pregnancy in disturbed lactation, 139 Premature infants, 257 ; abdomen, 259 ; air, 262 ; animal heat, 262 ; appearance at birth, 264; amyolytic function in, 261; B reek's feeder for, 272 ; circulation, 262 ; determination of the age of, 257 ; digestion in, 261 ; feet, 260 ; gastric capacity, 260 ; head, 259 ; incubator for, 266 ; intestinal contents, 262; kidney, 262; light, 263; normal development of, 259 ; prognosis, 275 ; pulse, 263 ; respirations, 263 ; skin, 259 ; sound, 263 ; sweat-glands, 259 ; tem- perature, 263 ; thorax, 259 ; touch, 263 ; treatment, 264; weight, 265 Prescriptions for home modification, 226 ; for whey-cream mixtures, 201 Prescription- writing in percentage feeding, 197 Primary anaemia, 890 Proctitis, 815 Progressive interstitial hypertrophic neuritis of infants, 993 Prolapse of rectum, 813 Prominent sternum in the new-born, 298 Protargol, strength of, in local applications, 869 Proteids in cow's milk, 200 ; in human milk, 125, 127, 129, 200; determination of, in human milk, 125 Prurigo, 373 ; ferox, 374 ; mitis infantilis, 373 Pseuclo-bulbar paralysis, 985 Pseudo-leuksemic anasmia of infancy, 887 Psoriasis, 372 Pulmonary artery in infants, 56 ; transposi- tion of, 721 Pulmonary orifice, the, lesions of, in con- genital disease, 724 ; atresia, 725 ; insuf- ficiency , 745 ; stenosis, 745 ; stenosis of the conus arteriosus, 725 Pulse, at term, 36 ; in infancy and child- hood, 71, 72. ( Vide, also, symptoms of the especial disease. ) Purpura, 998; fulminans, 1000; haemor- rhagica, 999; Henoch's, 999; rheumatica. 998; simplex, 998 Pyaemia of the bone, 511 Pyelitis, acule, 862; chronic, 864 Pyelonephritis, acute, 862 Pyonephrosis, 864 INDEX. 1019 Q. Quartan parasite, 488. 484 Quinine, dose of, in malaria. 489 R. Rachischisis, 301 Ranula. 293 Reaction of degeneration. 962 Rectum, imperforate. 307 : malformations •about the, 307 : reflex symptoms of the. 949 Red blood-corpuscles, 877. 880 Reflex cough, 947 Reflex symptoms, of the bladder. 948 ; of the ear. 944 ; of the heart. 948 ; of the larynx. 944 : of the lung-. 946 ; of the rectum. 949 ; of the stomach 948 ; of the vagina. 948 Retarded speech, 938 Retropharyngeal abscess. 656 Respirations at term, 30, 36, 72; in infancy, b'l : in infancy and childhood, 72 Retinitis in scarlet fever, 573 Rhachitis, 326 : acute, 333 ; congenital, 342 ; diagnosis. 338 ; foetal, 342 ; late. 827 ; of adolescence. 827; pathology, 829; prog- nosis. 340 ; rosary, 884 : symptoms, 332 ; treatment. 341 Rhagades in hereditary syphilis, 528 Rheumatic fever, 514; subcutaneous flbrous nodules in. 519 Rheumatism, acute articular, 514; chronic, 1003 ; muscular. 1001 Rhinitis. 640 ; acute. 640 ; atrophic, 643 ; hypertrophic, 642 ; purulent, 642 Rhus toxicodendron. 364 venenata, 364 Rickets {ride Rhachitis), 326 Ringworm, 359 Ritters disease, 362 Rontgen light, 253 Rosary in rhachitis, 334 Rose-spots in typhoid fever, 450 ; typhoid bacilli in the, 452 Rotclrs experimental work on pericarditis, 757 Rotheln. ( Vide Rubella. ) Rubeola. ( I r ide Measles. ) Rubella, 593 Rupia, 526 Salicylates, dose of the, 517 Salivarv glands at term, 38 ; development of, 83 Salt solution, normal, dose for subcutaneous injection of, 504 Santonin, dose of, 830 Sarcoma of the brain, 978 Scabies, 355 Scanning speech, 987 Scapulodynia, 1001 Scarlatina, vide Scarlet fever ; sine erup- tione, 566 Scarlet fever, 543 ; contagium, 545 ; eti- ology, 543; incubation, 554; pathology, 546 ; pseudo-relapses in, 365 ; recrudes- cence, 566 ; reinfections, 365 ; relapses, 365; sine eruptione, 566; variations in the type, 554 Scarlet fever, benign form of, 554 ; compli- cations of 568;. desquamation, 555 ; diagnosis, 557 ; efflorescence, 555 ; isolation and disinfection, 562 ; prodromata, 554 ; prognosis, 557 ; prophylaxis. 558 : symptoms, 554; treatment, 559; variations in the type, 565 malignant form of, 578 Schonlein's disease, 998 School, influence of, on the child, 108 Sciatica, 970 Sclerema neonatorum, 322 Scleroderma, 379 Sclerosis, insular or disseminated. 987 Scoliosis in rhachitis, 336 Scorbutus, 344 Scrofula, 390, 432 Scrofuloderma, 432 Scurvy, 344 Sebaceous glands at term, 38 Seborrhoea capitis of infants, 359 Septic endocarditis, 739 Senna, dose of, 832 Separated milk, definition of, 223 Shoes for children, 102 Sight, function of, at term, 37 Sigmoid flexure in infancy and childhood, 70 Simulated diseases, 935 Skeletons, infantile, 87 Skin, 81 ; at term, 21 ; diseases of the, 355; in cerebro-spinal meningitis, 435, 438 ; in measles, 581 ; in scarlet fever, 546 ; in syphilis, 525 ; in tuberculosis, 432 Skoda's resonance, 710 Sleep, amount of, for infants and children, 106 Small intestines at term, 36 ; development of, 68 Small-pox, 595 ; modified, 599. ( Vide Varioloid. ) Smell, function of, at term, 38 Snuffles in hereditary syphilis, 524 Soft palate at term, 29 Spasmus nutans, 944 Spastic paralysis, hereditary, 989 Specific infectious diseases, 381 Speech, retarded, 938 Spigelia, dose of, 832 Spina bifida, 298 Spinal meningocele, 288 Spinal paralysis, infantile, 958 ; temporary, 961 Spine, the, 39 ; at term, 22 ; curves, 41 ; flexibility, 40; length, 40; surface anat- omy, 41 ; in rhachitis, 388 ; tuberculosis of, 429 Spleen, diseases of the, 840; in childhood. 57 ; in cerebro-spinal meningitis, 435 ; in rhachitis, 331 ; in syphilis, 523 ; in ty- phoid, 450 ; in tuberculosis, 431 Splenic myelogenous leukaemia, 882 Spondylitis, tubercular, 407 Spray for throat, (>oo Status lymphaticus, 1000 Sternum, the, at term, 80 Stomach, the, at term, 34; capacity. 58: development, 58 ; developmental diseases, 774 ; malformations, 774 ; malpositions. 774 1020 INDEX. Stomach, diseases of the, 773 ; American Pe- diatric Society's classification of the, 769, 773 ; general considerations, 773 functional diseases of the, 774 ; acute gastric indigestion (acute dyspepsia), 778 ; acute nervous vomiting, 774 ; chronic gastric indigestion (chronic dyspepsia), 779; cyclic or persistent vomiting, 774 ; eliminative, 782 ; gas- tralgia, 777 organic diseases of the, 783 ; acute gas- tritis, 789 ; chronic gastritis, 792 ; contraction, 783 ; dilatation, 783 ; new growths, 789 ; ulcers, 787 reflex symptoms of the, 948 Stomach-tube, use of the, 781 Stomach- washing, technique of, 780 Stomatitis catarrhalis, 617 ; exanthematica, 617; gangrenosa, 629; herpetica, 620; hj^phomycetica, 626 ; mycetogenetica, 625 ;• pseudo-membranosa, 629 ; simplex, 617 ; traumatica, 617 ; ulcerosa, 622 Strawberry tongue in scarlet fever, 555 Stridor, congenital, 660 Strychnine, doses of, in children, 470 Subarachnoid space, 47 Sudamina, 365 Sugar in human milk, 126, 127, 129 Sugar-measure, 225 Suprarenal capsule at term, 33 ; in child- hood, 57 Sweat-glands, the, at term, 38 ; development of, 82 Sydenham's chorea, 916 Synovitis, acute purulent, of infants, 511 Syphilis, 520 ; acquired, 520 ; cerebral or intracranial, 978, 980 ; congenital, vide Syphilis, hereditary ; immu- nity, 522 ; lesions of the skin, 525 ; miscarriages in, 521, 534 ; mouth in, 527 ; of the new-born, 521 ; retarded, 521 ; pseudo-paralysis of the new- born in, 528 ; wet-nurse in cases of, 531 hereditary, 520; Colles's law in, 521; inheritance and transmission in, 521 ; pathology, 522 ; post-con- ceptional, 521 ; retro-infection in, 521 early manifestations of, 524 ; cranio- tabes in, 524, 529 ; efflorescence, 529 ; snuffles, 524 ; symptoms, 524 ; plaques muqueuses, 528 ; diagnosis, 529 ; prognosis, 530 ; treatment, 530 late manifestations of, 536 ; Hutch- inson's teeth in, 526 ; symptoms, 536 ; treatment, 538 Syphilitic gumma of the brain, 978, 980 Syphilitica hemorrhagica neonatorum, 526 Syringomyelia, 989 Syringo-myelocele, 298 Tabes mesenterica, 392 Tachycardia in exophthalmic goitre, 906 Taenia mediocanellata-or saginata, 832 solium, 832 Taste, function of, at term, 38 Teeth, the, at term, 29 ; development of, 49 ; in syphilis, 526. ( Vide, also, Dentition. ) Temperature at term, 36 ; in infants, 70. ( Vide symptoms of the especial disease. ) Temporary amnesia, 937 * aphasia, 937 Teratoma, 978 Tertian parasite, 483, 484 Testicle, the, in syphilis, 523 ; tuberculosis of, 431 ; tumors of, 307, 870 ; undescended, 306 Tetanus neonatorum, 496 Tetany, 942 Thomsen's disease, 924 Thorax, the, at term, 30 ; development of, 51 ; diameters of, 51 ; ossification of, 51 ; in rhachitis, 334 Throat, the, in diphtheria, 461 ; in scarlet fever, 547, 568 ; in variola, 599 Thrombosis of the cerebral sinuses, 975 Thrush, 626, 628, 629 Thymic asthma, 907 Thymus gland, the, anatomy and relations of, 53, 908 ; at term, 32 ; diseases of the, 907 ; tuberculosis of, 430 Thvroid gland, the, 85 ; congenital absence of, 901 ; diseases of, 899 ; dose of the ex- tract of, 902 ; enlargement of, in exophthal- mic goitre, 906 ; hyperemia of, 900 ; in measles, 592 ; tuberculosis of, 430 ; tumors of, 907 Tinea circinata, 359 ; favosa, 360 ; tricophy- tina, 359 ; tonsurans, 359 ; versicolor, 360 Toes in the new-born, 310 Tongue at term, 29 Tongue-tie, 292 Tonsillitis, 649 ; acute, 649 ; acute crvptic. 649 ; acute follicular, 649 ; chronic, 652 Tonsils, 28 ; hypertrophied, 652 Topographical anatomy of the earlv periods of life, 88 Torticollis, acute, 1001 Touch at term, 38 Trachea, diseases of the, 665 Tracheitis in measles, 593 Tremor, 942 Tricophyton tonsurans, 359 Tricuspid insufficiency, 744 ; stenosis, 745 Tricuspid orifice in congenital disease, in- sufficiency of the, 726 ; stenosis of the 726 Trional, dose of, 457 Trousseau's symptom, 943 Trunk, the, disease of, in the new-born, 296 Tubercle bacillus, mode of entrance. 382 Tubercular dactylitis, 430 meningitis, 406 ; infantile form. 410 ; recurrent, 421-423 Tuberculin test, 385 Tuberculosis, 381 ; bladder, 431 ; brain, 406, 978; cerebro-spinal system, 405; gastro- enteric tract, 399 ; general diagnosis, 385 ; general etiology, 381 ; general pathology, 383; general symptomatology, 385; gen- eral treatment, 386 ; hip, 429 ; in acute broncho-pneumonia, 700 ; intestines, 399 ; joints, 427; kidney, 431; knee, 429; larynx, 393 ; liver, 431 ; localized, 389 ; lungs, 393 ; meninges, 978 ; in measles, 592 ; pancreas, 430 ; peritoneum, 401 ; predisposition to, 383 ; prophylaxis, 384 ; INDEX. 1021 skin. 432; spine, 429: spleen. 431; tes- ticle. 431 : thymus gland, 430 ; thyroid gland, 430 : trachea. 393 Tuberculosis, acute miliary, 387 ; of the lung, 395 ; simulating infantile atrophy, 388 : simulating typhoid fever, 387 general. 386 ; chronic, 389 of the lymph-nodes. 389 ; bronchial. 392 ; cervical. 390 : mesenteric, 392 relation of bovine, to human tubercu- losis. 381 Tubular indigestion, 798 Tumor albus, 429 Tumors, intracranial. 978 Turpentine stupe. 4-30 Typhoidal ileo-colitis. 447 Typhoid bacillus in cerebro-spinal fluid, 450 Typhoid fever. 447 ; complications and se- quela?, 451 ; diagnosis. 451 ; diazo-reaction in, 450 ; differential diagnosis, 452 ; etiol- ogy, 447 ; incubation. 449 ; in infancy and early childhood. 447 ; in the foetus, 447 ; pathology. 448 ; prognosis, 454 ; symp- toms. 449 : treatment. 454 ; Widal reaction in. 450 Typhus fever. 459 U, Ulcers of the stomach, 783, 786 Umbilical arteries, post-natal changes in the, 55 cord, 21, 39, 82 hernia, congenital, into the cord, 302 ; in the new-born, 302 vein, post-natal changes in the, 55 Umbilicus, fungus of the, 302 ; polvpus of the, 302 Unclassified diseases, 997 Undescended testicle, 306 Uremia in acute diffuse nephritis, 855 ; in chronic interstitial nephritis, 858 ; treat- ment of, 574. ( Vide, also, symptoms of the especial disease.) Uric acid infarction at term, 34 Urine, at term, 39, 85 ; diazo-reaction in the, 452 ; in acute cystitis, 867 ; in active hy- peremia, 851 ; in acute pyelitis and pyelo- nephritis, 863 ; in acute diffuse nephritis, 854 ; in amyloid infiltration, 859 ; in chronic cystitis, 867 ; in chronic interstitial nephritis, 858 ; in chronic parenchymatous nephritis, 856 ; in chronic pyelitis, 864 ; in chyluria, 850 ; in diabetes insipidus, 1004 ; in diabetes mellitus, 1006 ; in gly- cosuria, 851 ; in hematuria, 849 ; in herna- globinuria, 849 ; in hydronephrosis, 865 ; incontinence of, 871 ; in infancy and child- hood, 85 ; in passive hyperemia, 852 ; in physiological albuminuria, 847 ; in scarlet fever, 556 ; in subacute glomerular nephritis, 856. ( Vide, also, symptoms of the especial disease. ) Urotropin, dose of, 867 Urticaria, 367 Uterus at term, 36 Uvula at term, 29 elongation of the, 655 V. Vaccinia, 601 Vaccination, 601 Vagina, occlusion of the, 307 ; reflex symp- toms, 948 Varicella, 605 ; complications, 608 ; diag- nosis, 608 ; etiology, 605 ; gangrenous, 606, 608 ;. pathology"; 606 ; prognosis, 609 ; symptoms, 606 ; treatment, 609 Variola, 595 ; complications, 599 ; confluent form, 598 ; diagnosis, 600 ; discrete form, 597 ; etiology, 595 ; hemorrhagic form, 598 ; incubation, 597 ; modified form, 598 ; pathology, 595 ; prognosis, 601 ; symptoms, 597 ;< treatment, 601 Varioloid, 599 ' Veins at term, 32 Ventricular septum, defect of the, 724 Vermiform appendix, 815 (vide, also, Appen- dicitis) ; in infancy and childhood, 70 Vernix caseosa, 21 Verruca?, 375 Verrucous endocarditis, 721 Vertigo, 940 Vitality at term, 37 Voice, function of, at term. 37 ; develop- ment of, 82 Volvulus, 811 Vomiting, acute nervous, 774 ; cyclic or per- sistent, 774. ( Vide, also, symptoms of the especial disease. ) Von Jaksch's pseudo-leukemia of infancy, 887 Vulvo vaginitis, 868 W. Warts, 375 Waxy rigidity, 935 Weaning, 157 Weight, at term, 36 ; development of, 55 ; general figures of, 79 ; of infants and chil- dren, 73; of premature infants, 265; rela- tion of nutrition to, 73-81 Westcott's general formulae, 235 ; tables of dilutions of creams, 232 Wet-nurses, 162 ; diet of, 163 ; in cases of syphilis, 531 Wheat-jelly, 240 Wheat-water, 240 Whey, definition of, 223 ; average analysis of, 223 ; formule for cream and, 238 ; in percentage feeding, 200 ; preparation of, 235 ; with dilutions of cream, 233 Whey-cream mixtures, prescriptions for, 201 Whey-proteids. ( Vide Lactalbumin. ) White blood-corpuscles, 881 Whiskey, doses of, 456 Whole milk, definition of, 223 ; average analysis of, 223 Whooping-cough, 505 Widal reaction, 451 Winckel's disease, 314 71 PT OCT ~0 km