ffisB$H*8t& fflfiSHfefl : II 8®$ *fi£ rage MfflmraBBSBaT IS&SHBRRr MAR 2? 1885 A GUIDE TO THE DISEASES OF CHILDREN. PRACTICAL TEXT-BOOKS AND MANUALS, FOR PHYSICIANS AND STUDENTS. Yeo's Physiology. 300 Illustrations and Glossary. Cloth, $4.00; Leather, $5.00 Roberts' Practice oi Medicine. Illustrated. 5th Ed. Cloth, $5.00; Leather, $6.00 Reese, Medical Jurisprudence. Cloth, $1.00; Leather, $5.00 Biddle's Materia Medica. 9th Edition. Cloth, $4.00; Leather, $1.75 H old en ' s Anat. and Manual of Dissections. 200 Illust. 5th Ed. CI. $5.00 ; Lea. $6.00 Rindfleisch, Elements of Pathology. Ed. by Prof. Tyson. Cloth, $2.00 Bruen's Physical Diagnosis. Illustrated. 2d Edition. Cloth, §1.50 Byford's Diseases of Women. Illustrated. 3d Ed. Cloth, $3.00 ; Leather, $6.00 Gilliam's Essentials of Pathology. Illustrated. Cloth, $2.00 Heath's Minor Surgery and Bandaging. 115 Illustrations. 6th Ed. Cloth, $2.00 Kirke's Physiology. Illustrated. 11th Edition. Cloth, $5.00 Marshall and Smith, Chemical Analysis of Urine. Cloth, $L.OO Meigs and Pepper, Diseases of Children. 7th Ed. Cloth, §6.00; Leather, $7.00 ?Quiz-Compends? 11 Students' Aids. Each, Cloth, $L.OO Richter's Inorganic Chemistry. 3d Edition. 90 Illustrations. Cloth, $2.00 Richter's Organic Chemistry. 4th Edition. Illustrated. In Press. Roberts' Compend of Materia Medica and Pharmacy. Cloth, $2.00 Tanner's Index of Diseases and Their Treatment. Cloth, $3.00 Tyson's Examination of the Urine. Illustrated. 4th Edition. Cloth, $1.50 Van Harlingen, Skin Diseases and Their Treatment. Illustrated. Cloth, $1.75 P. BLAKISTON, SON & CO., No. 1012 WALNUT STREET, PHILADELPHIA. A GUIDE Diseases of Children. JAMES FREDERICK GOODHART. M.D..F.R.C.R. ASSISTANT PHYSICIAN TO GUY'S HOSPITAL, AND LECTURER ON PATHOLOGY IN ITS MEL ICAL SCHOOL; PHYSICIAN TO THE EVELINA HOSPITAL FOR SI3X CHILDREN. REVISED AND EDITED LOUIS STARR, M.D., CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL IF THE UNIVERSITY OF PENNSYLVANIA; PHYSICIAN TO THE CHILDREN'S HOSPITAL, PHILADELPHIA. WITH FORMULAE. PHILADELPHIA: P. BLAKISTOX, SOX & CO. 1012 Walnut Street, i 88 v \S Copyrighted, 1885, by P. Blakistox, Son & Co. PREFACE TO THE AMERICAN EDITION. In preparing this edition of Dr. Goodhart's work on Dis- eases of Children, the editor, without altering the author's graphic text, has made such additions as, in his judgment, seemed to make it more valuable to the American reader. This new matter has been either inclosed in brackets ( [ ] ) or inserted as foot-notes. It is the author's evident intention that his book shall cover the, hitherto unoccupied, ground between the too brief handbook on the one hand and the exhaustive treatise on the other. This object the editor trusts he has been able to further, through his" experience of the wants of junior practitioners and students. His thanks are due to Henry D. Harvey, M.D., for efficient aid, both in the preparation of the text and index. Louis Starr. 1922 Spruce Street, Philadelphia, April, 1885. AUTHOR'S PREFACE. Many medical students have expressed to me their want of a Manual upon Diseases of Children. To this, and to a request from the publishers that I would fill up a gap that appeared to exist in books on this subject, the appearance of the present volume is due. As regards the scope of the work — in writing a book upon the diseases of children I have not considered it my function to write one on general medicine, but so far as possible I have kept in view the diseases which seemed to be incidental to childhood, or such points in disease as appear to be so peculiar to, or pronounced in, children as to justify insistence upon them ; and if the book meets the want it aims to supply, it will be due, I think, as much to its omissions as to its contents. For example, in dealing with pneumonia and bronchitis, there will be found no minute description of physical signs ; in heart disease, no consecutive account of such general symptoms as are common to all ages of life. I have taken for granted that the student already possesses some knowledge of general medicine, and have dwelt upon such points as belong peculiarly to childhood. This will explain a certain amount of disconnectedness which runs through the 5 PREFACE. volume; and if beyond this it still be thought that I have been less precise than is desirable, I would reply that it is always difficult to be at the same time dogmatic and exact. " Knowledge brings doubt and exceptions and limitations, which are all hinderances to vigorous state- ment." Moreover, what may be considered a fault in some ways, is not without some and perhaps equivalent advan- tages ; not the least being the fact that this conception of the student's wants has enabled me to follow more closely my own bent than would have been possible in a more systematic treatise. I am not without hope that in thus acting I may have accomplished at least one aim — viz., to supplement, not to supersede, the admirable text- books already existing on the diseases of children. My obligations to these already published works I cannot attempt to sum, unconscious memory playing so large a part in the thought of every one of us. But this much I can say, that it gives me no common pleasure to confess how much I owe to West, Rilliet and Barthez, Hillier, Eustace Smith, Henoch, Gerhardt, Steiner, Meigs and Pepper — amongst others — and last but not least to two of the most realistic writers of our own day, Dr. Samuel Gee and Dr. Thomas Barlow. I have also availed myself of the observations upon the incubation of some of the exanthemata, which have from time to time appeared in the Lancet during the last few years from the pen of Dr. Clement Dukes, of Rugby. Dr. Dukes's work in this direction is some of the most valuable that exists. Of others who have more immediately helped me I ^ PREFACE. 9 must thank Dr. Newnham, our present resident medical officer at the Evelina Hospital, for aid on several occasions. Mr. Collier, head of the dispensing department at Guy's Hospital, has been kind enough to revise the Appendix of Formulae, and my brother, the Rev. C. Alfred Goodhart, of Sheffield, and Dr. Lewis Marshall, Surgeon to the Hospital for sick children at Nottingham, have been at much trouble in revising and criticising the proof-sheets. Of the labor thus ungrudgingly bestowed I alone can fully appreciate the value. James F. Goodhart. CONTENTS. CHAP. PAGE Introduction, ,. .13 I. Dentition, 28 II. Diet of Children in Health, ..... 32 III. Diet Diseases: Atrophy — Flatulence— Colic— Con- stipation, 46 IV. Diarrhcea — Entero- Colitis — Cholera Infantum, . 60 V. Stomatitis — Thrush— Cancrum Oris, .... 88 VI. Diseases of the Digestive Tract, . . . .105 VII. Diseases of the Digestive Tract [continued), . .114 VIII. Worms, . . . . . . . . .135 IX. Intussusception, . . . . . . . . 143 X. Measles, 157 XI. Scarlatina, . . .172 XII. Rotheln — Roseola, 203 XIII. Diphtheria, 210 XIV. Varicella — Vaccina — Vaccination, . . . . 240 XV. Mumps, 249 XVI. Whooping-Cough, 255 XVII. Typhoid Fever, 279 XVIII. Malarial Fever, 291 XIX. Diseases of the Respiratory System, .... 294 XX. Laryngeal Spasm — Laryngitis — Warty-Growths — Foreign Bodies in the Trachea, Etc., . . . 303 XXI. Bronchitis and Bronchiectasis, 327 XXII. Pneumonia, ^^7 XXIII. Atelectasis — Phthisis, 354 XXIV. Pleurisy, 373 XXV. Acute Tuberculosis, 393 XXVI. Scrofula — Leukaemia — Bronchial Phthisis, . . 398 XXVII. Tabes Mesenterica and Tubercular Peritonitis, . 410 XXVIII. Peritonitis and Ascites, 418 1 2 CONTENTS. CHAP. PAGE XXIX. Diseases of the Spleen, 429 XXX. Diseases of the Liver, 433 XXXI. Diseases of the Genito-Urinary Organs, . . .441 XXXII. Diseases of the Nervous System, .... 455 XXXIII. Tubercular Meningitis, 464 XXXIV. Hydrocephalus, 474 XXXV. Intra-Cranial Tumors, 485 XXXVI. Hypertrophy of the Brain — Cerebral Hemor- rhage — Thrombosis of the Cerebral Sinuses, . 490 XXXVII. Disorders of Movement, 496 XXXVIII. Motor Disorders {continued), 517 XXXIX.' Infantile Convulsions — Epilepsy — Night Terrors, . 536 XL. Functional Nervous Disorders — Headache, . . 545 XLI. Idiocy and Cretinism, 550 XLII. Chorea, 557 XLIII. Rheumatism, 578 XLIV. Heart Disease— Paracentesis of the Pericardium, . 595 XLV. Purpura — Haemophilia — Scurvy— An.emia, Etc., . 623 XLVI. Rickets and Bone Softening, 633 XLVII. Infantile Syphilis, . 663 XLVIII. Diseases of the Skin, 677 Appendix of Formula, 703 Index, 717 1 THE DISEASES OF CHILDREN. INTRODUCTION. What is a child, and how the diseases of children differ from the diseases of adult life, are questions which must have confronted all who have written upon the ailments of childhood, and not a little puzzled them for an answer. By the pathologists, indeed, it may well be doubted if any valid reason can be given for separating diseases of children from others, for there are but few morbid changes found in child- hood that are not to be seen at one time or another in the bodies of adults. If we run over the various regions of the body, the brain, heart, lungs, lymphatic glands and so on, few, and those but minor, differences can be pointed out between the pro- ducts of disease in the child and of the same disease in an adult. Some diseases are more common at one time of life than at the other ; but should they overstep the limit of age usual to them, they appear in their old form, or with but slight modifications, such as would certainly not justify any one in devoting a "manual " to their description. The bones form the most notable exception to this rule: in rickets, acute ostitis, and some forms of enchondroma we have examples of constancy of peculiarity of morbid deposit ; 14 THE DISEASES OF CHILDREN. of constancy of limitation to the growing age; of constancy of peculiarity of distribution of the disease, and so on. Cer- tain diseases of the skin artd teeth might equally be advanced, but having said even this, we should still be at fault for ma- terial for a book. The difficulties and differences which render it advisable that these diseases should receive special study are mostly those of semeiology and treatment, and from the fact that the student when first introduced to this branch of practice finds himself thrown upon his own re- sources. ' In the adult he can ask questions and obtain clues to the furtherance of his diagnosis. With infants and chil- dren he must find out what he can for himself — the history is faulty or often quite wanting — and here he fails. For instance, it is a common occurrence in hospital practice to find that no account is forthcoming from the clinical clerk of some child that has been admitted since the last visit. He has not yet seen the mother, is the explanation of the remissness which is offered. Supposing now that we change the venue, so to speak, of this illustration to that of the veterinary surgeon, and one of the lower animals, and such an answer, were it conceivably possible, would be ludicrous. Yet, there is not so very much difference between the student who has to investigate the diseases of children and one who has to do with diseases of the lower animals. In both cases the diagnosis will chiefly rest upon the doctor's mere ob- servation and examination. In both intelligible speech is wanting. I am by no means desirous of underrating the history which a parent or relative can give ; on the contrary, an intelligent mother and nurse are to be listened to patiently and attentively — they are often acute observers of early signs of ill health, or changes in the symptoms. All I wish to enforce is, that the previous history occupies a subordi- nate, not the chief, position, and the student is at all times to consider himself as independent of it. Any help that can INTRODUCTION. 1 5 be obtained in this way is all well and good, but it is to come after, not before, a personal examination. Supposing now that a child iff before us, what is to be done in making a thorough examination ? Our first care will be not to frighten the child, a task which at once calls into play tact, patience, and control of feeling. A strange face is alone sufficient to make a child cry, but when that face belongs to the doctor, a word very early added to the child's small repertory, and when these are associated in- delibly with memories of castor oil or Gregory's powder, inexperienced nature can hardly be expected not to revolt — and revolt it often does, regardless sometimes of the most exquisite tact. But much can be done to soothe matters by the expenditure of a little trouble; never be in a hurry; take time, that the child may become accustomed to you ; talk to it, play with it, show it any glittering thing that may be at hand, and give it the stethoscope to play with. Any instru- ment that it may be necessary to use should first be made a plaything, the subsequent examination being often much facilitated by so doing. Do not touch a child till it has had a good look at you. Plenty of occupation is afforded in the meantime by talking to the mother or nurse. Then, with regard to special instruments, the thermometer, for instance, which is constantly in use, put it into the axilla and hold it there gently, with your eye on the column of mercury, talking to the child all the while, and even drawing its at- tention to it. If the forearm is not restrained it will be possible to do this for a minute or two, during which you may watch the mercury quickly rise to a certain height, and then proceed more leisurely. If the child become restless, withdraw it; the half degree or so which it may rise after- wards will be of little importance to you in drawing conclu- sions, whereas a fit of. crying or any fright will render all further observations difficult. [In infants, however, it is best 1 6 THE DISEASES OF CHILDREN. to take the temperature in the rectum, since the surface heat varies greatly with that of the surrounding atmosphere, and since it is difficult to maintain quiet long enough for an axillary observation. The well-oiled bulb of a thermometer should be gently inserted through the anus, and kept in place for three minutes. The normal temperature in this position is about 99 F.] With the ophthalmoscope again try to get it to consider the instrument as a toy, the examination a game of play, and — with plenty of patience, for a child's eye partakes of the restlessness of its whole muscular system, and no fixed look at any object, however attractive, can be counted upon for more than a second or two — there are few children or infants in whom the optic disks may not be seen. It is essential to success in many cases not to touch the child. As soon as a finger is placed on the forehead to steady the lens used for the indirect method, many a child will rebel. The same remark applies still more forcibly to pulling up the upper lid to obtain a view of the pupil. The attention must be attracted by playing the light on and off the eye; and skill will come with practice in ascertaining the state of the fundus by repeated momentary glimpses rather than by any one prolonged view. Even the haemacytometer, for which it is necessary to prick the finger, may be used with- out making a child cry, by making a rapid prick with a needle and showing the resulting drop of blood to the child as a wonderful thing. Let me next say that the child is to be restrained as little as possible in any examination that may be necessary. The mother or nurse will often hold its hands or its legs, or both, as the firs? step to auscultation, and there is nothing which a child resists more than restraint of this kind. Let it kick about, if it will, till it becomes unmanageable, and this will but seldom be the case if we take care not to make it so. Let it play with the end of the INTRODUCTION. 17 stethoscope, if it likes; it is quite possible to distinguish the respiratory sounds, and after a time those of extraneous origin can be as readily ignored as can the noise made by a crying child. The fact that the child is crying is no excuse for not examining the chest — crying necessitates deep res- piration, and is often advantageous for this reason. All that we need is more patience. In auscultation, also, it is often necessary to listen to the respiratory or heart sounds in snatches, and to fill in by repeated observations what is not permitted by continuous examination ; and in many cases it is advisable to examine the back of the chest first. Having given these few hints upon what to avoid, a few may follow concerning what has to be done — and first we must be careful to maintain an attitude of close observation. The points to be observed are often apparently trivial and difficult to keep in mind in any systematic way. There is the complexion of the child ; the formation of its bones ; the state of its skin and muscle — is it fat, spare, firm, or flabby; its size in proportion to its age; its general build; the shape of its head ; the state of its fontanelle ; the relative proportions of head and face ; the condition of corneae and pupils ; the lines upon the face ; the state of the nostrils ; the gums, the teeth, the tongue; the ears; the shape of the chest and its movement ; the abdomen and its movement ; the character of the cry and the state of the nervous system. All these facts and many more, indicating as they do points negative and positive which are absolutely essential to the formation of a diagnosis, and for forecasting the issues of the case, and for treatment, must yet, being but preliminaries, often be taken in hurriedly, almost at a glance. To allow of this being done in any sense completely, it is well to take each step in a regular method. Start where you like, adopt your own plan, but proceed as much as possible upon this plan : and while rapidity of execution comes with practice, 1 8 THE DISEASES OF CHILDREN. abundant compensation will be obtained for any trouble that may be involved, in the frequency with which, by so doing, conclusions will be arrived at, and results obtained, which had not previously been expected, and would in all proba- bility have been missed by less methodical observation. It is impossible, in a short manual, to go much into detail in a preliminary chapter, but one or two points may be selected to illustrate the importance of what has been said. For instance, the cry of a child may help to distinguish the ailment under which it is laboring, There is the noisy, passionate cry of hunger; the wail of abdominal disease; the whine of exhaustion ; the short, sharp shriek of cerebral disease ; the hoarse, whispering cry of laryngitis. Much may be learned by a glance at the shape of the head. The hydrocephalic head is one which bulges in all direc- tions. The forehead projects, the temporal fossae become convex ; the fontanelle and vertex more vaulted ; even the occiput becomes more rounded, and, in this general tendency towards the assumption of a globular form in place of an ovoid, the inter-ocular space is widened outwards, and the eyes are rendered too divergent. The rickety head is an elongated one, and often laterally compressed, and although the forehead may be overhanging, it wants the width and general rounding seen in hydrocephalus. [More frequently the rachitic head is square, being flattened anteriorly, poste- riorly, superiorly, and laterally. The frontal eminences are prominent, and the sutures are depressed, and with the fontanelle late in closing. There is also apparent enlarge- ment, due to comparative smallness of the face from arrested development of the facial bones ; actually the cranium measures about the same as for the corresponding age in health.] The head of the syphilitic child is sometimes of irregular shape, almost lobulated in appearance, and betrays its component bones by the position of the enlargements. INTRODUCTION. 19 The disease is one of osteophyte growth, which forms upon the bones round the anterior fontanelle, and spreads thence over their surfaces. The fontanelle may thus appear to lie in a hollow, the frontal bone # being unusually prominent, and the inter-frontal suture converted into a vertical ridge, from the exuberant bone formation along it; while the parietal bones become bossed irregularly. This skull has been called the natiform skull, from the appearances pro- duced by the bony elevations. It is still an open question whether the osteophytic growth is due to syphilis or to rickets. The scaphoid skull is a narrow skull, in which the frontal region is boat-like, and slopes away from the median line, betokening the small brain of an imbecile or idiot. The fontanelle, by bulging, may indicate excess of blood or cerebro-spinal fluid within the cranium ; by its size it may indicate defective ossification, and so rickets ; but of more importance, because of almost invariable significance, is the depressed fontanelle of starvation and exhaustion : it indicates the immediate necessity of food or stimulants. Then we might take the face, and mention that shades of pallor are most suggestive — a dirty white stands for con- genital syphilis ; a sallow white for splenic disease ; a pallor with a sub-tint of blue for tuberculosis ; a livid, leaden, or earthy tint for collapse from abdominal disease. There are certain markings upon the face, Jadelot's lines, as they are called, from the French physician, who has de- scribed them very fully. [These lines are: 1st. oado-zygo- matic, indicating disease of the brain. This begins at the inner angle of the eye, and extends outward beneath the lower lid, to disappear a little below the projection of the malar bone; 2d. The nasal, pointing to gastro-intestinal disorders, or affections of the abdominal viscera. This rises at the upper part of the ala of the nose, and passes down- ward, to form a semicircle around the corner of the mouth ; 20 THE DISEASES OF CHILDREN. 3d. The labial, denoting disease of the lungs and air-passages. Beginning at the angle of the mouth, this line runs outward and downward, to be lost at the lower part of the face.] Then there are the various complexions which are supposed by many to indicate particular diatheses or tendencies to disease — the pretty, thin-skinned children of tubercular pro- clivities; the sallow, muddy appearance of children prone to glandular abscesses ; the dark-haired, pallid, but, on the whole, well-liking children of nervous habit, and so on. Of these, though they have in former times occu- pied much of the attention of writers of books, I shall say but little, because there is now considerable want of una- nimity upon the subject, and because their importance is hardly measurable by facts, but depends upon observations, the accuracy and worth of which the student must test for himself. There is the sunken eye, the dark-colored and depressed areola around it, indicative of collapse ; the dilat- ing alae nasi of acute lung disease; the lividity of lips of chronic lung disease ; the puffy, congested eyelids, and ecchymosed face of whooping-cough. For the chest, we have the immobility of pleurisy; the unnatural praecordial bulging of a large heart; the sinking in of the lower ribs of atelectasis. Of the abdomen, it may be said that enlargement is not necessarily due to disease. Children will constantly be brought to you for " consumption of the bowels," because they have diarrhoea and a large stomach. In the great majority of cases, the enlargement is due to flatulent distension from defective feeding, sometimes to displacement of the liver and spleen by distortion of the thorax in rickety children. In many such there will be but few cases of organic disease, and of mesenteric disease, it may be said that it is but seldom associated with any abdo- minal enlargement sufficient to attract the attention of the child's mother, and in my experience there has not often INTRODUCTION. 21 been any disease of the glands that could be felt by palpa- tion. Increase in size of the abdomen, when the result of disease, may be due to a large liver or spleen, sometimes to ascites, sometimes to tumors connected with the kidney. When we come to the more personal examination of the child, I would still inculcate the necessity of routine. It matters not how we proceed, so long as some definite plan is reguarly followed. Supposing, as is probable, that some idea of the nature of the case has been gleaned from the pre- liminary survey, it is a good plan to start with the organ which we suspect to be involved. If there be any reason for suspecting disease of the nervous system, it is as well at once to examine the eyes with the ophthalmoscope, lest any subsequent action on our part may frighten the child, and render the fundus oculi inaccessible. It is impossible to make any satisfactory use of the ophthalmoscope if the child is, or has been recently, crying. This done, and the state of the pupil and movement of the eyeball ascertained, the sight and hearing can be tested by a watch ; and the pre- cision of the various muscular movements of the extremities, by giving the child something to hold or pick up, and by making it walk, if old enough, or by watching the move- ments of the limbs in infants too young to walk, as they lie on the mother's lap. The gums can be examined, and the progress of dentition ascertained by gently rubbing the sur- face of the gums with the finger. The chest and abdomen should be examined in all cases. Some advise that the child should be stripped for this purpose, and this is a necessary measure in some cases. I do not advise it as a rule, for the reason which I have adopted throughout these suggestions, viz., that the child is to be frightened or put out of temper as little as possible. Children, all but the youngest infants, resent the process of undressing, and it is usually sufficient for our purpose, that all the clothing be loosened. The 22 THE DISEASES OF CHILDREN. greater part of the front and back of the chest can be, by this means, exposed, and a thorough examination made. Percussion must be light or it will mislead. A light vertical tap with one or two fingers upon a finger of the other hand placed flat upon the chest is all that is necessary, and special attention is to be paid to the intervertebral grooves, as parts which are more frequently implicated in children than in adults. In auscultation it is very essential to make careful comparison of the two sides ; of the bases with the apices; and to remember that it sometimes happens that the more abnormal sounds are heard in the healthier lung. A student will often describe as bronchial breathing, the exaggerated, puerile respiration of the over-acting, but sound lung, and consider as healthy, the soft and deficient vesicular murmur of the diseased side, and indeed there is abundant excuse for his so doing. Again, disease maybe ascribed to the apex of the lung from the existence of bronchial breathing, whereas the primary disease is really at the base. Therefore, the whole of the chest must be auscultated : above and below the clav- icles ; the supra-spinous fossae behind ; the intervertebral grooves and bases ; and we must be on the alert to detect even slight differences between the two sides. The examination of the abdomen is chiefly conducted by means of palpation — enlargement of the spleen and liver are ascertained in this way. So, also, other abdominal tu- mors. But there are other points of detail which are well worth attention. In the first place it is often worse than useless to put a young child on its back and uncover it for examination. It will kick and scream, put its muscles into a state of rigidity, and nothing can be made out. One must often be content with an examination while it is sitting up and by placing the hand beneath its clothes. It is equally useless to poke the abdominal wall with the tips of two or three fingers, as the muscles are provoked to action by this INTRODUCTION. 23 means also, and nothing can be felt behind them. Palpa- tion can only be properly conducted by placing the warm palm perfectly flat and open upon the abdominal wall and making pressure at any part that requires examination with the flat of one or two fingers. Any abnormal tumors can in this way be readily detected, and their edges defined — be they hepatic or splenic or what not. Splenic and renal tumors are best examined by one hand being placed flat beneath the body supporting the hinder wall of the abdo- men, while the other, flat and open as before, makes pres- sure from above upon the abdominal wall supported by the hand behind. [The pulse, in infancy, ranges from 90 to 130 beats per minute; the least muscular effort or emotion of anger or fright being sufficient to increase the frequency of the heart's action from the former to the latter figure. As a test of physical strength, the pulse, at this age, is far less reliable than the condition of the fontanelle. After the age of two years, it becomes a more valuable guide. In health it rarely counts more than ico during the waking state, and is some 10 or 20 beats slower in sleep, when, too, it is often irregular in rhythm. An increase to 130 occurs with any trifling fever, and is consequently not a serious symptom. Abnor- mal slowing, on the contrary, is a grave feature, a reduction to 40, for example, frequently attending tubercular menin- gitis. The respiration varies in frequency with the age. At birth, the average is 40 per minute; from two months to two years, 35; and from two to twelve years, 18 during sleep, 23 while awake. The movements should be dia- phragmatic; if superior-costal, a painful abdominal disease, as peritonitis, is indicated ; if abdominal, pleuritis or pneu- monia. Very rapid breathing attends cardiac disease and inflammatory affections of the lungs or pleura ; slow, sigh- 24 THE DISEASES OF CHILDREN. ing respiration, interrupted by long pauses, tubercular men- ingitis. The normal ratio of respiration and pulse is I to 3 or 3.5. Should this be changed to 1 to 2, pneumonia or pulmonary collapse may be suspected.] The ejecta of children should all be examined, whether they be vomited or passed from the bladder or rectum. The sleep of a child should be watched if opportunity offer. A child sleeps quite calmly when in health, and for a long time at a stretch when the first few months are passed over and the necessity of frequent suckling has gone by, but it is quickly disturbed in ill-health of all kinds. Slight attacks of fever, gastro-intestinal derangements, dentition, brain disease, etc., all make the sleep uneasy, although not much differentiation of disease can be accomplished by ob- servations of this kind. The manner of deglutition is an- other feature which often conveys an indication of disease. For in any interference with the freedom of respiration a child will take a few snatches of food and then turn away and splutter, or cough, or cry. If children refuse food with- out any definite reason, the mouth and throat should always receive a careful examination ; stomatitis, tonsillitis, and even more serious troubles, such as post-pharyngeal abscess may otherwise go unrecognized. By persistently following out the spirit of these prelim- inary suggestions in the way that seems best suited to the individual examined, it will be but seldom that a very refrac- tory child is met with, or that you fail to make a satisfactory examination. Treatment. — I had purposed to devote a chapter to spe- cial points in the treatment of children, but thinking the matter over, the necessity, nay even the wisdom, of so doing may be doubted. For, after all, the dosage for children, the one great dread of students, is a matter which, if stated with precision in a posplogical table, is never handy for reference, INTRODUCTION. 25 and is hardly reliable if it be. [Nevertheless, as a guide to the student, Cowling's rule is serviceable ; namely, the pro- portionate dose for any age under adult life is represented by the number of the following birthday, divided by twenty- four, i.e., for one year A = A; for two years A = i, and so on]. With one or two exceptions, every one must make his own table in his own memory, and must feel his way. Herein is one of the advantages of experience, which can hardly be gained in any other manner. Opium has been a great bugbear in this respect. All powerful drugs must naturally be given with caution to children ; but opium is perhaps the only one which requires excessive precaution. It must be given to infants in infinitesimal proportions, and there are some practitioners who evade its use at this time of life as much as possible. Still, combined with castor-oil, it is a useful drug in bad cases of flatulent colic, and perhaps one drop to a two-ounce mixture, of which a drachm may be taken, is an average dose in the first six weeks of life. This quantity may have to be lessened, but it will certainly, in many cases, be necessary to increase it, and after the first two or three months the extreme susceptibility to the drug disappears, and half a drop may then be given for a dose. At two or three years old, two-grain doses of Dover's powder may be given, when requisite, without fear. Bromide of potassium, a most valuable remedy in many of the diseases of children, must be given to infants with watchfulness. It sometimes, even in small doses, produces severe local inflammation of the skin, and localized patches of soft, warty growths. This is, however, of infrequent occurrence, and cannot be avoided when, as is sometimes the case, the idiosyncrasy is so pronounced that three or four grains suffice to produce the eruption ; but, for the reason that there is a risk, the drug should not be continued for any length of time, except under close supervision. 26 THE DISEASES OF CHILDREN. Belladonna and arsenic are illustrations of an opposite tendency, for children are very tolerant of these drugs, par- ticularly of belladonna. A child four or five years old will take fifteen to twenty drops of tincture of belladonna without any inconvenience whatever.* And in such cases as it is necessary to give arsenic,*usually in children six years and upwards, a dose of seven drops of the liquor arsenicalisf may be given at the onset three times a day, and a considerable increase on this be attained if necessary. But children do not often require a very energetic treatment with drugs, and probably he will be the best practitioner who lets Nature make for cure without heroic measures. Proper feeding ranks first in all treatment in early life. It is not unnecessary to add that all drugs should be made as palatable as possible. Castor oil and Gregory may be very good remedies, but, except to babies, they are very disgusting, and there are now at hand numberless substitutes, and methods of disguising nasty remedies, which should be studied. Some maybe put into lozenges, some into syrups, some mixed up into a palatable emulsion, and so on. I must, however, allude to baths for children, because their sphere of usefulness is large. It would probably be difficult to enumerate the variety of diseases in which a bath is use- ful. As a general rule when a state of pyrexia is recognized, the child is likely to be smothered to keep it warm. For the same reason, the linen which is not actually soiled by the excreta, is not changed for fear of chill. But children of all ages* perspire freely, and in the course of a few hours will get exceedingly uncomfortable under these circum- stances, fretting and becoming restless, whilst the mother wonders why sleep does not come. Put the child into a * It must be remembered that Tincture of Belladonna Br. P., is only about half as strong as the same preparation U. S. P. — Ed. f Equivalent to liquor potassii arsenitis, U. S. P. — Ed. INTRODUCTION. 27 warm bath for a few minutes, and with fresh linen and a comfortable cot it will probably soon be at rest. Then, too, in most states of fever, sponging is of value — warm, or tepid, or cold, according to the necessities of the case — and a bath, even a warm bath will reduce the temperature if it be very- high. Tepid or cold baths may be administered to children in high fever, if requisite, but if cold the bath must be of short duration. A fall of temperature is set going by the immediate shock, not necessarily by prolonged immersion, and the latter is liable to induce a state of collapse and ex- haustion, such as is not often seen in adults. The tender skin of a child should always be a matter of attention. Poultices and hot bottles easily scald, and ban- dages are very liable to cut or excoriate if not carefully applied, and frequently readjusted. Poultices are in frequent use for cases of thoracic and abdominal disease. They should never be so hot as to be in any degree painful. But I discard them as much as possible. They soon become cold, hard, and uncomfortable, and they are often heavy. A warm fomentation, by means of spongio-piline, well covered in by cotton wool, is in every way preferable, at any rate, for diseases of the thorax. [A layer of cotton, covered with oiled silk, by condensing the insensible perspiration, and becoming moist, acts jn the same manner, and is preferable to a poultice, in both thoracic and abdominal diseases, since it does not require changing, and is always warm.] 28 THE DISEASES OF CHILDREN. CHAPTER I. DENTITION. The milk teeth are cut in the following order : The two lower central incisors from the seventh to the ninth month, often later and sometimes earlier. After a lapse of five or six weeks come the two upper central incisors ; next come the two lower lateral incisors, followed by the upper lateral incisors. After an interval, the four front molars appear, followed again by the four canines, and last of all by the four posterior molars, the whole set being cut by about the end of the second year. [The following table shows in months, the usual times of appearance of the twenty milk teeth : Molars. Canine. Incisors. Canine. Molars. 24-12 18 9-7-7-9 I iS I 12-24. The lower jaw is ordinarily a little in advance of the upper.] But it must not be supposed that there is any strict time- keeping in the appearance of the teeth, for, although there is a pretty definite order of occurrence, the lower central incisors may appear early or late, and the others may follow, sometimes several at once, sometimes with long intervals between them. It often happens that the four central incis- ors come, then follows an interval, and then steadily onwards come all the rest save the last four molars, the appearance of which may, even in healthy children, be deferred for three or four months over the average age of two years. Dentition is usually held to be the cause of many ailments, but to what extent it is really so is doubtful. The time of dentition is one of transition. A uniform and bland diet is changing for one of greater variety, and the febrile attacks — DENTITION. 29 diarrhoea and vomiting, which are so rife at this time, are more satisfactorily explained by indigestibility of food than by some occult influence of tooth-cutting. This much, however, maybe allowed: that the growth of a child is one of stages; that there are periods during which unusual progress is made ; and that the period of dentition is one of these. Increased activity of all the physiological processes at work, necessarily implies greater risks of friction between one organ and another, or even of a regular break-down. Excessive energy, if not properly regulated or adequately expended, is liable to lead to an explosion of ^ome sort or another. Some such general hypothesis as this, must hold good for the instability of working which is common in all the viscera during the first dentition, and to a less extent during the second dentition, and in the years which usher in puberty. In this general sense, the time of dentition is, no doubt, a time of peril. The mortality is high, and disorders of many kinds — convulsions, bronchitis, pneumonia, diar- rhoea, etc. — each claims its victims. But this is not as a consequence of the eruption of the teeth, but as part of a general activity of growth and development, to which den- tition and morbid phenomena both in a sense respond. Still there are, no doubt, certain minor evils attending dentition, which require at least a mention. Some chil- dren are remarkably susceptible to "colds" under such circumstances — that is to say, as each tooth comes through the gums the child suffers from coryza; the eyes run, the nose also; there is much sneezing, and perhaps a little cough. There may be at the same tim£ pyrexia, and the bowels become irregular — now confined and now relaxed. Some get a sharp attack of fever (temp. 103 or 104 ), the lips and tongue becoming a bright red, the child becoming rest- less and fretful. Others have diarrhoea at these times ; others, again, have convulsions, and a still larger number 3 30 THE DISEASES OF CHILDREN. have threatenings of them in the form of wildness and ex- citement of manner, more irregularity of muscular move- ment than usual, temporary carpo-pedal contractions or strabismus. Most children have an excessive dribbling of saliva, are frequently biting anything they can put their hands to, and there may be a little superficial ulceration of the mouth. Indigestion is common. The child suffers from heartburn and offensive eructations, while lichen urti- catus (strophulus) appears upon the skin. Convulsions are not a common ailment of dentition, and it is the opinion of West, Henoch, and many other observers, that they are but seldom seen except in association with rickets. Those whose fits commenced with infantile convulsions, form, however, so large a proportion as seven per cent, of the whole number of epileptics. For the treatment of these varied conditions, to be fore- warned is to be forearmed, and the timely management of slight disorders in all probability arrests more serious evils. To control the excess and irregularity of muscular move- ment, is probably to avert the development of a pronounced convulsion. The " cold " neglected becomes a bronchitis or pneumonia; the indigestion leads to vomiting and diar- rhoea ; the slight feverishness to severe pyrexia. The treat- ment may seem somewhat empirical, nevertheless simple means suffice in most cases; carpo-pedal contractions and other threatenings of convulsion, will often speedily subside on the action of some mild aperient — a small dose of cal- omel, or a couple of grains of hydrarg. c. creta with a sim- ilar dose of p^ulvis rhei. The coryza is suitably treated by a little ammonia and ipecacuanha. The fever by a drop of tincture of aconite, or a little salicylate of sodium with ace- tate of ammonium (F. 2), and so on. If the pyrexia be severe, and there be any threatening of convulsions, and a tooth seems to be worrying the gum close DENTITION. 31 beneath the surface, there can be no harm in using the gum lancet to relieve the upward pressure ; at the same time bromide of potassium and some saline, such as citrate of potassium, should be given internally, either as a nocturnal draught or twice or three times a day. The second dentition commences about the seventh year, with the eruption of the first molars ; thence onward come the central and lateral incisors, the first bicuspid, the second bicuspid, the canines and second molars, at invervals of a year or so. . [The thirty-two permanent teeth are cut in the following order, the figures representing years : Molars. Bicuspids. Canine. Incisors. Canine. Bicuspids. Molars. 25-I3-6 I IO-9 I II [ S-7-7-8 I II I 9-IO [ 6-13-25 I .] Some have thought that this also, is a time of hazard to the child, but there is less evidence of risk now than even during the first dentition ; nor is there, indeed, the same reason for the occurrence of any special disorders. There is no change of diet, no special development which begins at this time, at all comparable to that which takes place during the first dentition. It is a time when education begins in earnest, when growth in most cases is proceeding rapidly, and therefore a time when there are many risks, though probably in most cases independent of dentition. Dr. Gowers, from an analysis of a large number of cases of epilepsy, shows that the numbers rise at seven years of age — the commencement of the second dentition — and fall again in the next few years, preparatory to a further rise at puberty. Still it seems not unlikely that this should be referred to the extra calls which, at this time of life, are made in any case, upon brain and body, rather than to the process of dentition; and, apart from epilepsy, chorea, and neurotic diseases gen- erally, there are none which attach themselves peculiarly to this period. 32 THE DISEASES OF CHILDREN. CHAPTER II. DIET OF CHILDREN IN HEALTH. The student often starts in practice with such limited no- tions on the subject of diet, that many a mother knows more of what is actually required than he does. True, indeed, the fundamental rule upon which all practice is founded, that the mother's milk, and that only, should form the infant's food for the first few months of life, is a choice stock in trade, but we soon find out how very limited, and often at fault is this statement of the matter. Many mothers cannot, many mothers will not, nurse their infants at all, and many more are so situated through the calls of society, or of busi- ness, that this, the chief of maternal duties, can only be fulfilled in part. Thus it early becomes a question for all of us, What is to be done under each or any of the circum- stances which this enforced neglect entails ? It will be well to attend to the following suggestions : The infant should be fed from its mother's breast, if not for the full period of lactation, at least as long as possible, and if not entirely, then partially — that is to say, the breast should supply at least one or two meals daily. If the mother be able to suckle it entirely, no other food is to be given to the infant. It is to be put to the breast every two hours for the first five or six weeks, between the hours of six a.m. and ten p.m., and afterwards the interval between the meals is to be lengthened gradually, till a three- hour interval is reached.* It is said that a healthy child * Should the mother be affected with either syphilis or advanced phthisis, this rule does not hold. — Ed. DIET OF CHILDREN IN HEALTH. 33 will sleep all through the night hours, but in the first five or six weeks of life, it will require food several times during the night. Even when infants are some months old one meal in the middle of the night may be necessary, and to this there is but little objection. The digestion of a healthy infant is rapid, and, while it should not be allowed to have food too often, any lengthened fast is equally to be avoided. The interval between meals is to be strictly enforced for all infants that are healthy. Children are creatures of habit, and soon learn their proper meal-times. They will often, indeed, begin to cry punctually at the time. But they also are easily educated in faulty habits. It is the custom of many mothers to pacify crying at all times with the breast or the bottle — and a more pernicious practice it is impossible to conceive. The more the crying the more the feeding, and the more the feeding the more they cry, and what between crying and sucking the day and night are spent in misery. These are the cases which form the great majority of the thin, pining, pitiable mites who are brought to a hospital " for consumption of the bowels," but with bad feeding only to blame. And what wonder} if grown-up persons were to be always eating, who among us would not be dyspeptic, and who would not be quite as miserable, if less demonstra- tive than the infant ! Now let it be remembered that there are many children who in the first week or two of life, when the stomach is, as it were, unfolding to its duties, cry a good deal. They are a source of great discomfort and pajn in a household — sucking at something will almost certainly quiet them, and other methods of treatment, food, doctoring, and so forth, often fail. It is very important in such cases to impress upon the mother and nurse that if they quiet a child by this means, they are but sowing the wind to reap an in- evitable whirlwind. If they bear with it for a short time the child soon becomes accustomed to the habits enforced; it 34 THE DISEASES OF CHILDREN'. must sleep after a while, and the first lesson of its life is learned. Whenever there is much crying, however, attention should be directed to the quality of the milk. It may be poor in quality or deficient in quantity, and the child cries because its stomach is full of flatus. Sometimes, again, it is over-plentiful, and the child taking it too greedily is troubled in consequence with colic. [This latter trouble can be pre- vented, should the milk flow too freely, by slight pressure by a finger above and below the nipple.] If it be necessary to make any addition to the breast milk, good cow's milk* may be tried first, and it is to be diluted with an equal part of water, or equal parts of milk and lime-water slightly sweetened with sugar of milk or lump sugar, six tablespoonfuls to be given at a meal. The breast may be given night and morning, and the milk and lime-water in the meantime, or the two may be made to alternate. The milk may be boiled in hot weather, or if it disagree; and to one or two of the meals in the day, some- times to all of them, a good teaspoonful of cream should be added. The mixture of milk and lime-water is not by any means always suitable. In some cases, where the milk is still too much for the child, and is most of it vomited in large curds, it may be further diluted. In others, where it appears to lead to flatulence and abdominal pain, a mixture with thin barley-water will be found to agree better. Barley- water has also the advantage of acting as a gentle laxative, a very valuable property, inasmuch as many children fed upon cow's milk and water, or cow's milk and lime-water, are much troubled with constipation, the motions being very large, lumpy and hard. Barley-water acts most beneficially in many such cases, but its use is to be watched, as infants * Cow's milk should be faintly acid or neutral; of sp. gr. 1026 to 1030 ; and should contain an amount of cream which is variously stated by different writers to be from 5 to 10, or even 14 per cent. DIET OF CHILDREN IN HEALTH. 35 are very sensitive to the administration of starch in any form, and I have repeatedly known an eczematous eruption to appear upon the buttocks after only one or two meals of milk treated in this way. In very young infants the mixture of milk and water, or milk and lime-water, may be attended with vomiting or with abdominal pain. In such cases the milk must be diluted till it forms only a third part of the whole, equal parts of milk, water, and lime-water being given, sweetened as before with milk sugar. But there are many cases where this fails to secure the child's health and com- fort. It is griped with pain after each meal, and it remains thin, while the motions are still pale and lumpy, often con- taining undigested curd. It is probable that, under these circumstances, the curd of the cow's milk, which is larger and firmer than that of the mother's milk, is the element at fault, and barley-water will often remedy this. By mixing it with the milk the casein curdles in a state of more minute subdivision, and more closely resembles the thin, small flocculent curd of human milk. Meigs and Pepper advise a little arrowroot in addition. Thin gelatin jelly, a teaspoon- ful to half a pint of milk and water, may be mixed with the milk instead of the barley-water, for the same purpose. Some Infant's Foods may be used for the same purpose also. These are, for the most part, combinations of farina- ceous food in which the starch has been converted into dextrine and grape sugar by the mode of preparation. In this state they are easy of digestion, and may, therefore, with due care, be used to thicken the milk. Starch, which has undergone no such changes, is unsuitable, because in the first three months of life the salivary and pancreatic juices are wanting, and consequently there are no facilities for its digestion. Mellin's food, Liebig's infant food,* Nestle's * See foot-note, p. 39. 36 THE DISEASES OF CHILDREN. food, Savory & Moore's food, and others, are all useful in certain cases. Sometimes one will suit, sometimes another. The proper one for a particular case must always be some- what a matter of experiment. A teaspoonful is added to each meal. Nestle's food requires boiling. Condensed milk of some good brand is often useful at this period of life, and many infants thrive well upon it. It possesses some advan- tages, chief of which is its freedom from any tendency to turn sour. Care must be taken not to give too much of it. A small teaspoonful to a teacupful of water is quite sufficient for a meal, and after two or three months it should, in most cases, be replaced by cow's milk, or combined with some infant's food. [Condensed milk possesses the advantages of keeping the bowels open, and making very fat, hearty-look- ing babies. The disadvantages are, that it gives little strength to resist disease, and infants fed upon it cut their teeth late, and otherwise show the symptoms of a moderate rachitic tendency.] As regards quantity, it has been estimated that the mother supplies to her baby a pint of milk in the twenty-four hours in the first week or two, and that this quantity gradually increases until in the later months of lactation about three pints is reached. Some such quantity, therefore, distributed over regular intervals, should be the daily allowance to a child from birth onwards. But infants vary much in respect of the quantity which they will digest. Some are habitually small feeders. Therefore, provided that the child grows, that its flesh is firm, and it is happy, there should be no absolute insistance upon a minimum of two pints. [The quantity is rather large. The average, according to J. Lewis Smith, for children under five weeks being about 12.5 fluid ounces in the twenty-four hours. This average is about doubled between the first month and the first year.] In some cases, notwithstanding all the care and skill that DIET OF CHILDREN IN HEALTH. 37 are lavished upon them, cow's milk cannot be digested. Till lately, goat's milk or asses' milk has been resorted to, either of which resembles the human milk more nearly in its poorness of curd. They may be given either undiluted or diluted — as in the case of cow t 's milk — with water or lime-water, or even diluted with barley-water. Whey, with a tablespoonful of cream added to each meal, is another very useful food when milk disagrees; and, of late, two other valuable additions have been made to an infant's dietary in peptonized milk and artificial human milk. The directions for making these are given in the Appendix of Formulae. One other food still requires mention, that which goes by the name of " strippings.'' All infants digest cream w r ith facility ; the curd, on the other hand, is with all an obstacle. Strippings, obtained by remilking the cow after its usual supply is withdrawn, is rich in cream and poor in curd, and consequently has much to recommend it as an infant's food. - Dr. Eustace Smith commends it highly, diluted with water or barley-water, in cases where other combinations are assimi- lated with difficulty. As a last resource a wet-nurse must be obtained. In selecting her attention should of course be paid to her appearance and state of health. Inquiries should be made for any previous symptoms indicative of syphilis ; the skin and throat should be examined for scars, etc. It may per- haps be advisable that, where there is a choice, a nurse should be chosen of similar complexion to the infant. The state of the breasts must be examined, their distension, the state of the nipples, and the quantity and quality of the milk. It is well, too, to be prepared with a second nurse, as the first selection may after all fail in some way or another. Infants, as w r ell as their parents, have unaccountable likes and dislikes. [In selecting a wet-nurse one who has previously suckled 4 38 THE DISEASES OF CHILDREN. an infant, but who is yet young and robust, and whose child is of nearly the same age as the one to be nursed, should be chosen. The slightest tendency to phthisis is cause for rejection. A woman of violent or quick temper should not be engaged. The character of the breasts and milk are also to be considered. Blondes make better nurses than bru- nettes. The nipples then will be rose-colored, and should be prominent. The breast need not be large, but should show large veins, marbling the skin. The milk of a healthy woman is of a bluish-white or pure white color. It should be examined in reference, 1st, to its reaction; 2d, its specific gravity; 3d, to the amount of cream. The reaction should be neutral or slightly alkaline; the specific gravity 1030 to 1032. The cream should be in the proportion of 3 per cent.] While upon this subject, however, it may be as well to say that in my opinion — so long as we have to do with chil- dren who have not persistently wasted for some time — care- ful artificial feeding will seldom fail. This is the more to be insisted upon both as a hope, and as a motive for persever- ance, since wet nurses are in many families — perhaps in most — an impossibility. They are difficult to get at the proper time ; they are a considerable expense ; they intro- duce a sudden and dominant influence into a household, for which it finds itself unprepared — not to mention the moral considerations, which cannot be altogether ignored — so that it generally comes to be a question of what artificial food is the best. Suppose now that by the aid of one or more of these suggestions the infant has safely reached the age of eight months, the time arrives for some addition to its diet. In the case of a child fed entirely upon the breast milk, two meals a day of cows' milk should now be introduced, a tea- cupful at each meal. Should any discomfort be experienced DIET OF CHILDREN IN HEALTH. 39 after them it may generally be remedied by boiling the milk or by the addition of a third or fourth part of lime-water — a r ter three or four weeks — first to one, and then to two meals daily, one of the many infants' foods is to be added. Nestle's food, Liebig's* or Mellin's agree well with most children — a teaspoonful is to be well mixed with a teacupful of hot milk. Nestle's food should be boiled with the milk. The food may be varied by, or alternate with, Chapman's entire wheaten flour. This form is more suitable than white bakers' flour, because it contains the pollard or outer part of the grain of wheat, and this is rich in nitrogenous matter, fat and salts, and also in the cerealine, which exercises a diastatic action upon the starch, turning it into sugar. The finest dressed white flour contains less nitrogen and more starch, and is therefore less wholesome, for reasons previously stated. The entire flour needs prolonged boiling for its preparation in order to break up its starch and convert it into dextrine or grape sugar. This may be done by put- ting it into a basin, tying it over with a cloth, and then immersing the whole in a saucepan of boiling water for some hours; or, by tying it up tightly in a pudding-cloth and boiling. Eustace Smith orders a pound to be heated thus for ten hours, and then removed, the outer soft part to be cut away, and the inner hard part grated and used as meal * The following directions are given by Dr. Pavy for the home preparation of Liebig's food : Take half an ounce of wheat flour, half an ounce of malt flour, and seven and a quarter grains of the crystallized bicarbonate of potash, and after well mixing them add one ounce of water, and lastly, five ounces of cow's milk. Warm the mixture, continually stirring, over a very slow fire till it becomes thick. Then remove the vessel from the fire, stir again for five minutes, put it back on the fire, take it off as soon as it gets thick, and finally let it boil well. It is necessary that the food should form a thin and sweet liquid previous to its final boiling. Strain before use to separate the fragments of husks. Barley malt is to be used, and a common coffee-mill will grind it into flour, which is to be cleared from the husk by a coarse sieve. — Pavy on M Food and Dietetics," second edition, p. 192. 40 THE DISEASES OF CHILDREN. — a teaspoonful at a time, well mixed with cold milk, to which a quarter of a pint of hot milk is added before serv- ing. Should the child have already taken to artificial feeding, according to the rules laid down, all that will be necessary at seven or eight months, will be to increase the quantity of milk and food which has already by experience been found to suit the particular case. After nine months old, further variety may be introduced. A cup of beef-tea; or, mutton, chicken, or veal, broth; or the yelk of an egg should be given occasionally. All these things are, however, only accessories to the main article of diet — i.e., good milk, of which a healthy child should con- sume a pint and a half or two pints daily. At this time of life it should have five meals during the day, thus : At eight a.m., a teacupful of warm milk thickened with a teaspoonful of Nestle's food, or entire flour. At eleven a.m., a break- fast-cupful of warm milk, or the yelk of an egg well beaten up in a teacupful of milk, or a teacupful of veal broth or beef-tea. At two p.m., a breakfast-cupful of warm milk. At six p.m., a teacupful of milk with a teaspoonful of Nestle's food or baked flour. At eleven p.m., a teacupful of warm milk. If the child sleeps through the night, well and good. But there is no objection to a night meal of a teacupful of milk about three a.m., if it be wakeful. At a year old the breakfast may consist of a teacupful of milk, a slice of bread and butter, and the yelk of an egg lightly boiled. At eleven, a teacupful of rnilk and a rusk. At two, a teacupful of broth or beef-tea with a little bread. And at six, a breakfast-cupful of milk, with bread and but- ter. The meals may be varied by substituting a teaspoon- ful of oatmeal, well boiled, in a breakfast- cupful of milk; or bread and milk for the egg at breakfast; and a table- spoonful of custard pudding may be added to the dinner. DIET OF CHILDREN IN HEALTH. 4 1 The child may next have a little well-mashed potato, or well-cooked cauliflower or broccoli added to its dinner — a tablespoonful well soaked in gravy. After eighteen months, or when the double teeth begin to appear, it may begin with meat, and the meal-times may be somewhat altered. At eight a.m. breakfast, a breakfast- cup- ful of bread and milk or milk with thin bread and butter and the yelk of an egg lightly boiled. Thin porridge may be substituted on some days. A drink of milk with a rusk may be given if necessary during the morning. At half-past one dinner, a tablespoonful of pounded mutton, with some mashed potato and gravy, or a cup of beef-tea in which some vegetable has been stewed, and a little toast and water to drink. At five, a breakfast-cupful of milk, thin bread and butter, and stale sponge-cake. No other meal will be necessary, but a little milk may be at hand in case of need. After two years meat may be given daily, and fine minc- ing may be substituted for pounding. Light farinaceous pudding may also constitute part of the daily mid-day meal; the other meals remaining as before. I have often been asked, in the case of older children, to draw out a diet table, but it is quite unnecessary. All chil- dren should have plenty of milk, and bread and butter for breakfast and tea ; and roast or boiled meat with gravy and light vegetables for dinner, with some light farinaceous and egg pudding well sweetened. With regard to quantity, the only rule I would enforce is this — let some reliable person be always present at meal-times to see that the food is taken leisurely, and properly masticated, and if this is done I believe that very few children will take too much. Some children require more than others, but, if the meals are not hurried, the healthy appetite is satisfied at the proper time and is a far better indicator than any arbitrary rule can ever be. Food-bolters are the children that get into trouble from 42 THE DISEASES OF CHILDREN. over-feeding. They steal a march upon their stomachs, and before they feel satisfied they have taken too much. For such, the old adage to leave off with an appetite is needful, but it is not the teaching of physiology. In the same way with children's likes and dislikes ; if the rule given above be observed, what a healthy child likes it will usually digest, what it dislikes will disagree. I am of course assuming that its experience lies well within the range of wholesome arti- cles of diet. Take the case of fats and sugar, for instance. Nearly all children dislike fat, and are equally fond of sugar. It is an unquestionable fact that rich articles of food easily upset them; what, therefore, can be the sense of insisting on children eating fat ? The liking for it comes at the proper time. On the other hand, children are fond of sugar, and make up with it where they fail in fat, and there is no evidence whatever that sugar is harmful when taken at proper times. To take sweets at all hours of the day at the expense of the proper meals is one thing, and to be strictly forbidden ; the moderate consumption of saccharine material at meal-times, whether it be in the form of sugar or good wholesome pre- serve, is quite another thing, and as certainly to be recom- mended. No doubt there are some children the functions of whose stomachs seem to be topsy-turvy. Everything they ought to like disagrees with them, and they live — 1 will not say thrive — upon most unwholesome diet. Some will be almost entirely carnivorous, some cannot take milk, others resent farinaceous puddings, and so on. But it will generally be found that where this is so the early education of the stomach has been at fault, and patient correction will bring it round. Mothers and nurses will say a child cannot take this and that, because they have administered the thing im- properly. But if the medical man insists on a return to such diet under strictly detailed conditions — nay, sometimes it DIET OF CHILDREN IN HEALTH. 43 may be necessary to make it one's business to see a child at its meals, and what it is eating — no difficulty whatever will be experienced in its digestion. One or two points concerning the administration of food to infants may be alluded to here, as akin to the question of diet, and upon which the success of all diets depends. In the first place it is necessary to insist upon the observa- tion of the most scrupulous cleanliness. No one would believe, without actual experience, how difficult it is to keep a feeding-bottle and its tube sweet. But so difficult is it, even with the greatest care and the closest supervision, that it is advisable to simplify the apparatus as much as possible. For this reason I discard bottles for habitual use, the food being placed in a cup or other w r ide-mouthed recep- tacle. From this it is taken by black rubber tubing of yfc inch bore, with a nipple fitted on to the end by one of the simple earthenware joints in common use. The tube and nipple are to be separated after each meal, and kept in a weak solution of salicylate of sodium gr. iv ad §j of water,* and to be replaced by new ones directly there is anything unpleasant about either when placed close to the nose — a test which is to be frequently applied by the doctor himself. Small brushes are usually sold with the bottles for cleansing purposes, but as regards the tubes it is safer to proceed upon the assumption that they cannot be thoroughly cleansed by this or any other means, and to provide new ones at frequent intervals. Similarly all joints and valves are to be eschewed ; they fulfil, no doubt, their immediate purpose by preventing reflux of the milk, and so keeping the tube full, but they are of very little use at any time, and even the simplest of them, made as they are of metal, are impossible to clean, and emit an unpleasant odor after very little use. The feeding-bottle * A valuable suggestion made by Dr. Lewis Marshall of Nottingham. 44 THE DISEASES OF CHILDREN. which best fulfils these conditions is one invented by Mr. Day, of the Royal Hospital for Children and Women, Waterloo Road ; in it all joints are done away with, and a small vent is made in the bottle to secure ease of suction. This bottle is as near perfection as any such contrivances can be; but even superior to it, in my opinion, is the old- fashioned slipper, with its simple india-rubber nipple — for there is no tube to be cleaned, and it necessitates the con- stant attention of a nurse during the meal. No child should be left to take its meal as it wills. Some infants are invet- erate bolters, and will consume a bottle of milk in three minutes, which should take them at least ten. The rate of supply must be controlled by the nurse, otherwise vomiting and colic will result. [Tubes should never be used. They cannot be kept clean any length of time, even when the greatest care be exercised, and, when slightly neglected, as is too frequently the case, are often the cause of digestive troubles. The bottle and nipple are much to be preferred. Of these there should be two each. The nipples should be soft and flexible, of a conical, not bulbous, shape so that they maybe easily everted. After each nursing the nipple must be immediately removed from the bottle, cleansed externally by rubbing with a stiff brush wet with cold water, and then everted and treated in the same way. It must then be placed in cold water and allowed to stand in a cool place until the following nursing. The bottle for an infant under three months ought to have a capacity of four to six fluid ounces and be of flint glass. Immediately after using, it must be scalded and cleaned with a brush. It should then be filled with a solution of one of the salts — bicarbonate or salicylate — of sodium and allowed to stand until next required. It should then be thoroughly rinsed with cold water.] DIET OF CHILDREN IN HEALTH. 45 Of food warming and food preservation it may suffice to say that of all food warmers Grout's is the simplest and the best. It consists of a well, sunk in a cubical hot water tin, and in it food or water can be kept at a comfortable heat all night, without any supervision whatever. But like all appa- tus of this kind it is a good incubator ', and food placed in it may become sour. The best plan to adopt, perhaps, is to keep the water hot by this means, and to add the water to the milk at the time of its consumption. It may be sometimes necessary to preserve milk for some hours for a journey, etc. The best plan for carrying out such an object is to fill soda-water bottles with boiling milk, and immediately to cork them tightly. [Condensed milk is here of the greatest value. In travel- ling either by cars or by steamboat, hot water can easily be obtained, so that the child has the advantage of the same quality of food from the beginning to the end of its jour- ney.] 46 THE DISEASES OF CHILDREN. CHAPTER III. DIET DISEASES: ATROPHY— FLATULENCE— COLIC— CONSTIPATION. The consideration of the diet fit for a healthy infant up to the period when it can, with certain limitations, take food in common with its parents, leads on naturally to the con- sideration of those diseases which are dependent upon imperfections in the diet, whether of quantity or quality, and to the treatment which is most efficacious for their cure. These diseases are both numerous and important, whilst their heterogeneity involves us in some difficulties of arrange- ment. Perhaps the best plan that can be adopted is to take them in the order in which they seem to arrange themselves: I . Simple wasting ; 2. Diseases of the digestive tract, includ- ing colic, flatulence, constipation, diarrhoea, vomiting, indi- gestion, or gastric fever, and stomatitis. There are other diseases which are also diet diseases, such as rickets and certain of the diseases of the skin ; but it is more conve- nient to consider these at a later period. Simple wasting or atrophy is due to insufficient or im- proper food. If the food is bad — and by that I mean indi- gestible — the wasting is generally associated with symptoms of intestinal disorder, which may be best treated under the head of diarrhoea, colic, and so on. Naturally enough the two conditions, insufficiency and indigestibility, are com- monly associated in practice. Nevertheless, it is well to remember that amongst the number of infants who require dietetic treatment, the total number of cases due to simple starvation is not inconsider- DIET DISEASES I ATROPHY — FLATULENCE COLIC, ETC. 47 able. The diagnosis must, for the most part, be arrived at from the absence of symptoms indicative of any local disease. The infant does not get on, or gradually loses the plump- ness it has gained, becomes pale and thin and is always cry- ing. Still it fails to attract notice by any definite signs of illness ; on the contrary, it is not unusually bright looking and intelligent, it is easily attracted and pacified for the moment, doubtless solaced with the hope of the coming meal which is to bring freedom from its pangs. These children are pale, sharp featured, the fontanelle depressed, the arms and legs and buttocks thin, the muscles flabby, and the skin cool and moist. They are always crying, the cry being noisy and passionate, and in the best-marked instances alternates with vigorous sucking at anything within reach, sometimes at the thumbs till they are raw. The meals "are taken ravenously, and as soon as they are finished, or in the intervals of the sucking, crying is repeated, or in very young infants, from the absence of that pleasurable stimulus which should be conveyed by suitable food, the child dozes at its meals. In the worst cases, when exhaustion is extreme, it may even be persistently drowsy. The viscera must be carefully examined in every case, and should show no sign of disease. [Besides the above-mentioned symptom we find that the child takes little or no notice of what is going on about him, but from time to time moves his head restlessly on the pillow, and mutters low, fretful moans. This condi- tion may proceed to stupor. There is general hyperaesthesia, so that the least movement causes whimpering. The eyes become sunken, and the fontanelle depressed. The abdomen is soft and generally natural in shape. There is most fre- quently a tendency to diarrhoea. The pulse is compressible.] But inasmuch as even very young infants are not exempt from insidious complaints such as empyema, or broncho- pneumonia, and wasting may be their only noticeable sign, 48 THE DISEASES OF CHILDREN. the diagnosis cannot be reliable until a thorough examina- tion has been made. To take one example out of many, a child of eight months old was brought to the Evelina Hos- pital, for wasting. It had been fed upon bread and milk since the age of eight weeks. No wonder it had always been thin and lately had got thinner ! The bowels acted regularly and there was nothing about the face to indicate local disease, and without examination it might readily have passed for a case of atrophy from bad feeding. It lay in its mother's lap in a passive condition, and the mother had in fact become concerned about it, because the wasting had now gone to that extent that sitting up seemed a trouble to it. An examination of the chest revealed the existence of extensive broncho-pneumonia, which had not even been suspected. The chest was dull over the base of the lung on both sides; tubular breathing extended up to the spine of the scapula on the one side, associated with bronchophony, and on the other was audible in patches, with much brdn- chitic crepitation in the larger tubes. Treatment. — A careful attention to the rules laid down for dieting healthy infants will in most cases prove successful. Inasmuch as the child has usually been improperly fed, it is generally advisable to give a few doses of some mild aperient, and none is better than castor oil, which, sweetened with sugar, most infants take readily. It may be given as a mix- ture twice or three times a day (F. 3), a mode of adminis- tration which I prefer ; or as a single larger dose of half a drachm to a drachm. Insufficient food must of course be met by increasing its quantity, but caution is necessary in doing this. The stomach of an infant who has been persistently starved for some weeks, or even months, will not tolerate an immediate return to the quantity of food which would be suitable for a child of its age under natural conditions. The increase is DIET DISEASES: ATROPHY FLATULENCE — COLIC, ETC. 49 to be made by stages ; if not, the stomach, which is an organ which in early life is most punctilious in resenting any sudden departure from its recognized custom, will cer- tainly relieve itself by vomiting. An infant which has been taking perhaps half a pint of milk in the twenty-four hours with bread, and so forth, may have half a pint of milk sub- stituted for the bread, and the pint is to be day by day slowly increased till the proper quantity (two to three pints) is reached. Nor is it uncommon for such children to re- quire an amount of dilution of the milk out of proportion to their age. Educated upon faulty principles as it has been, the stomach adheres to them with pertinacity, or becomes so irritable that even proper feeding does not seem to suit, and the child can only be saved by the most patient and attentive, even quick-witted, regulation of its diet. Use what care we may, whenever a child has continuously wasted for some weeks, the prognosis must be doubtful until it has begun to mend under the treatment adopted. Such cases indeed, but for the objections, often insuper- able, which have already been alluded to, should always be wet-nursed. When this is not possible, cow's milk prepared in such a way as to be as nearly like human milk as may be* is to be given ; or failing this, some one of the other foods which have been mentioned in the previous chapter. For * Dr. Arthur V. Meigs, who has made careful analyses of human milk and cow's milk, gives the following directions for the preparation of the latter so as to resemble most nearly the former. Seventeen and three-quarters drachms of pure milk-sugar are to be dissolved in a pint of hot water. This should be kept in a cool place, as it is apt to sour in hot weather. When the child is to be fed, the nurse should mix together two tablespoonfuls of cream, one of milk, two of lime-water, and three of the milk-sugar solution ; when the whole has been warmed, it is ready for use. This quantity, at a feeding, will satisfy a healthy infant for the first few weeks, after which it is necessary to double the quantity of each ingredient. The milk and cream should be such as are ordinarily obtained in large cities, and not rich Jersey milk or cream. —Ed. 50 THE DISEASES OF CHILDREN. the worst cases still further departures may be requisite. Whey, with a tablespoonful of cream added to it, will suit some ; whey and barley-water, or barley-water and cream, others. Sometimes artificially digested milk, or peptonized milk as it is now called, may be necessary ; sometimes a little beef juice. Any one of these, with or without a little alcohol, may in one case or another enable the child to turn the corner, and when this is effected, a more natural diet can be gradually resumed. Flatulence and Colic are amongst the most frequent digestive disorders in infancy. They are so commonly associated that it is unnecessary to discuss their separate symptoms. Flatulent colic is recognized in most cases by its relation to meals. Soon after food a child becomes restless, kicks its legs about, begins to grunt, and then perhaps utters a piercing, or sometimes a prolonged and harsh cry. At the same time its stomach is rigid, its face turns pale, and after a time eructations take place, and perhaps some vomit- ing of curd. As digestion proceeds the pain ceases. The physics of flatulence are not easy of elucidation, but the con- dition is associated either with poorness or small quantity of milk on the part of the mother — when it is reasonable to suppose that it is due to emptiness of the stomach — or with indigestible food. It is frequent where cow's milk is given, and in that case is due to the formation of firm curd in the stomach, and ceases as soon as the curd is disposed of either by vomiting or the process of digestion. If it persist, speaking generally, it indicates that the stomach is still empty, or that the meal remains undigested. It is often associated with, and aggravated by, irregularity of the bowels ; constipation being usual, with an occasional attack of diarrhoea. Where the bowels are constipated the motions are pale, lumpy, often very large and hard. They are evacu- ated with much straining, accompanied by a little blood, DIET DISEASES : ATROPHY — FLATULENCE — COLIC, ETC. 5 I which comes from the lower end of the bowel, and is due to the abnormal consistence and size of the motion and to the straining necessary for its evacuation. Some infants appear to be hyper-sensitive to the contact of food with the mucous membrane of the stomach and in- testine, and, even though it be in all respects proper, flatu- lence and griping are excited. Others there are whose bowels are from the first sluggish and prone to constipation. It is by no means an uninteresting subject for study, how far such idiosyncrasies foreshadow the temperament of after- life — the nervous or phlegmatic, for example ; but apart from this, it is no more than might be expected that in the first few weeks or months of infant life — when the stomach and intestine are called upon to perform functions to which they have hitherto been unaccustomed, and when they have no more than the transmitted capacity for their performance to rely upon — the functions should be performed less regularly and perfectly than afterwards, when they have become stereotyped and easy by training. And if this be the true way to regard the often recurring improprieties of function met with in infantile disorders of the digestive system, a rational mode of treatment recom- mends itself spontaneously. The details as applied to any particular case may require some skill in their application, and may even fail ; but the principles upon which they must be based admit of the clearest insight. For example, when dependent upon the want of training, flatulence and colic are best treated by carminatives ; in such case, stomachic stimulants, or charmers away of flatulence, possess a perfectly rational basis of action which their title does not suggest. A stimulant applied to the stomach when it is already strug- gling with a meal which it knows not how to dispose of, is not unlikely to make matters worse ; unless it should pro- voke vomiting, which is by no means a desirable issue in 52 THE DISEASES OF CHILDREN. such cases. The drugs which are successful in so many cases as to warrant the name carminatives, are all impreg- nated with some volatile oil of strong flavor, and impart a sense of warmth to the nerve filaments to which they are applied. Afferent nerves, when employed in conducting any powerful impression, are for the most part so fully occupied as to be incapable of attending to other weaker excitors, and the stronger stimulant will at anytime displace the weaker. In flatulent colic some dill, fennel, or cinna- mon water is given ; the attention of the nerve filaments is attracted by its diffusibility and pungency, and diverted from the food. Time is thus allowed for the gastric juice to act and for digestion to proceed. In due course the irri- tating matters are broken up and disposed of; and the pain ceases till the next meal. Any of the aromatic waters may be given, though perhaps the aqua anethi* is in most re- quest. A tablespoonful or more is to be put into each bottle of food, or a similar quantity — sweetened with a little powdered white sugar — may be given afterwards. The Flatulence of Emptiness. — If the flatulence be due to the poorness of the milk — which must be ascertained by an examination of the mother's breasts — it may be remedied by feeding the infant during the day, and putting it to the breast only night and morning ; and if with this reduction there is still but a scanty meal for the child, hand-rearing must be taken to altogether. The flatulent colic of indigestible food may be prevented by further dilution of the milk ; by the addition of an alkali, such as lime-water or bicarbonate of sodium; or by the addition of barley-water or gelatine. Those things which tend to thicken the food slightly are most successful, prob- f Aqua anethi closely resembles in taste and properties Aqua Anisi U. S. P. —Ed. DIET DISEASES: ATROPHY — FLATULENCE — COLIC, ETC. 53 ably, as Dr. Eustace Smith states, by preventing the forma- tion of large masses of curd. When the pain is very severe the colic may be relieved by warming the feet ; by a warm linseed-meal poultice to the abdomen ; by twenty or thirty drops of brandy in a little warm milk-and-water ; sometimes by a teaspoonful of aqua chloroform!. Where there is any suspicion of the retention of irritating material in the intestine, some castor- oil must be given. This may usually be prescribed after the formula already given (F. 3), but if it be also accom- panied by griping, it may be associated with a minute dose of opium, three drops of the tincture in a three-ounce mix- ture, a drachm to be given twice or three times a day (F. 4) to a child of nine months to a year old. If the collapse be severe, the bowels should be evacuated at once by an enema — the child being well wrapped in blankets the while. In all cases of flatulent colic it is essential to see that the child is kept warm. It is not only neccessary to encase the legs and abdomen in flannel, but to see that the wraps are retained in position. It often happens that a flannel binder is put upon the abdomen, and sewn on, as it is thought, securely. It quickly slips up, and the abdomen is left quite uncovered, as may easily be proved by putting the hand under the clothes of half a dozen babies consecutively. Again, the feet are wrapped in worsted socks, and are allowed to get wet with urine; so that whilst having the semblance of being cared for, appearances are belied by facts. The clothing of infants is adapted for the most part to the exigencies of urination, etc. They are so constantly wet, that anything elaborate in the way of clothing for the loins and Jegs is less convenient than the time-honored napkin. Hence it comes that while the thorax is well clothed in four or five layers of raiment, the abdomen and legs are practically naked — save for such melancholy pro- 5 54 • THE DISEASES OF CHILDREN. tection as is afforded them by some overhanging petticoat. But the lower part of the body requires as much care as the upper. It is as sensitive to chills and as liable as other parts to receive and promulgate harmful impressions. There- fore, when long clothes are discarded they should be re- placed by a pair of loose flannel drawers, such as can be fixed to the wraps, covering the chest, and will go outside the necessary napkins, being tied loosely either over or under the socks at the ankles. Dr. Lewis Marshall, of Nottingham, has combated the objections to the usual underclothing of infants by a special knitted jersey, admir- ably adapted to its purpose, and which it may be hoped will in time displace the flannel hitherto in vogue. Constipation may be due to malformation about the anus, more frequently to fissure, but most frequently, of course, of all to something amiss either in the tonicity of the bowel, the material it contains, or both. It is with the last group of cases that we are here concerned. The faeces are almost always paler than normal, or even gray like those of jaun- dice. Constipation may prove troublesome even from birth, and I have notes of several cases where the bowels acted only every seven or eight days for some weeks. Some rec- ommend that when this is the case the suckling should be treated through the mother. But this is a plan which is neither pleasant for her, nor very successful in overcoming the constipation. If it be desirable to treat the case so, a seidlitz powder may be given, or some Carlsbad salts, or two drachms of bitartrate of potassium may be dissolved in barley-water, flavored and sweetened, and taken as a drink during the day. For the infant castor-oil (F. 3) is as good a medicine as any. Sometimes a little fluid magnesia twice or three times a day answers the purpose, or five grains of the sulphate of magnesium dissolved in syrup of ginger and DIET DISEASES: ATROPHY FLATULENCE — COLIC, ETC. 55 dill water (F. 5). Manna may be given (F. 6), or a powder of two grains of rhubarb and three of soda every night. [Some of these remedies have but a temporary effect, and may even, by their secondary action, increase the tendency to constipation. The following prescriptions are better: JJ. Mannre Opt., Magnesii Carb., aa.^j. Ext. Sennae Fid., f^iij . Syr. Zingiberis, fgj. Aquae, q. s. ad f^iij. M. S. Two teaspoonfuls once, twice, or three times daily, for a child of two years. Or, R. Resin. Podophylli, gr. y^. Spt. Vini Rect., "nixv. Syrupi, q. s. ad fgj. M. S. One teaspoonful for a dose.] When a few months have passed over, or if the child be brought up by hand, better than all medicines by the mouth is the plan of attempting to modify the diet, or of exciting the lower bowel to expel its contents by enema or supposi- tory. A teaspoonful of fine oatmeal may be added to the morning meal, or barley-water may be mixed with each meal. Friction should also be applied to the abdomen, morning and evening, either by the hand alone or combined with an oily embrocation. The barley-water is given as in previous cases. The oat- meal should be given, a teaspoonful well rubbed up with a little cold milk till it is of the consistence of cream ; hot milk to the required amount for the meal is then to be added, and the whole boiled for a few minutes, when it is ready for use. [As boiled milk is constipating it is better to prepare the oatmeal as follows : Take a teaspoonful of finely ground Bethlehem oatmeal, add to two fluid ounces of water, and heat without boiling but with stirring for five 56 THE DISEASES OF CHILDREN. minutes, remove from fire, add the same quantity of milk, two teaspoonfuls of cream, and half a teaspoonful of sugar of milk. This preparation is suited for an infant six weeks old.] If it be necessary to add an alkali, a grain or two of bicar- bonate of sodium can be used, as being devoid of the con- stipating tendency often observed with lime-water. For an enema all that is necessary is to take two or three ounces of warm water and lather a little yellow or curd soap into it, and inject it by means of a caoutchouc bottle syringe. A drachm or two of castor-oil may be added to the soap and water if necessary. An enema may be administered every morning, or even twice a day if necessary, and I know no objection to its daily use as long as may be requisite. It is never to be given unnecessarily, but if the bowels do not act spontaneously the action should be en- sured by an enema, and this may be done without any fear of inducing such a habit as would require its permanent use. It is but seldom that the bowels fail to act properly when the diet becomes more varied. Should the constipation be associated with much flatulence and pain, a teaspoonful of fluid magnesia may be given com- bined with a little spirit of nitric ether and sulphate of mag- nesium iF. 7). If associated with heartburn, which may be known by hiccough, which causes the child to cry or make faces, at the same time that it performs certain gustatory movements, bicarbonate of sodium is to be given, and it may be combined with tincture of nux vomica, as recom- mended by Dr. Eustace Smith | F. 8). This combination is also useful when the bowels are persistently sluggish, from the nux vomica which it contains. A little glycerine may be added with advantage. The bicarbonate of sodium is also useful when the eructations are sour-smelling from fer- mentation going on in the stomach. It may be usefully conibined with bismuth and carminatives I F. 9, 10). DIET DISEASES: ATROPHY FLATULENCE — COLIC, ETC. 57 Other remedies may occasionally be found useful. Aloes powdered and dissolved in milk is recommended by some; five or six grains of Socotrine aloes may be given three or four times a day till the bowels act; or it may be made into a syrup, a drachm of the aloes to an ounce and a half of syrup with some liquid extract of liquorice ; or a small dose of euonymin (best administered in a powder with white sugar, gr. ^ of the drug) ; or a drop or two of the tincture of podophyllin : but they will not be required often if atten- tion be paid to the causes of the constipation, if the diet be carefully regulated, and the general hygiene of the nursery — warmth, bathing, cleanliness — be kept at the right stan- dard. In children past the age of babyhood constipation is an occasional and somewhat troublesome affection, It is more common in girls than in boys. The subjects of it are usu- ally thin and plaintive, wayward in temper, without anything definitely wrong ; their appetites are capricious, the breath often offensive, and they are supposed to have worms. Children they are who do no credit to good living, and who trouble the doctor because they are somewhat tardy in answering to his remedies, and because some of the symp- toms may lead him to suspect the onset of the formation of tubercle. Henoch* mentions even more extreme cases in children of seven and nine years in whom the constipation gradually leads to extreme distension of the whole abdo- men, with pain and tenderness, so as to simulate peritonitis. For constipation in older children, regular habits must be enforced. It is at least as necessary that a child should go to the closet regularly, as that she should do certain house- hold duties, or perfect herself in certain accomplishments with regularity. But this is a matter that many mothers * Loc. cit., p. 449. 58 THE DISEASES OF CHILDREN. never think of. In the next place, cases of this kind are not adapted for the exhibition of purgatives. Some gentle alkaline laxative may be given for a day or two, and if it were not so nauseous to most palates, none is better than the old-fashioned rhubarb and soda (F. 11). Hospital out- patients take this, and even like it, but other children very seldom do, and a dessert-spoonful to a tablespoonful of the liq. magnesii carbonatis is taken by them with less repug- nance. The sulphate of magnesium maybe rendered fairly palatable with raspberry vinegar (F. 12). There is no objec- tion to the administration of a single purgative of more drastic nature if it be only to insure that the intestinal canal is cleared of all irritating contents. A grain of calomel, with six or eight grains of compound jalap or scammony powder, is efficient for such a purpose for a child of seven to ten years old; or a quarter to half a Tamar Indien lozenge may be given instead, the remedy being more pleasantly administered in the lozenge form. But drugs of this kind are to be given with this* one distinct object in view, and they must not be resorted to repeatedly. When all such preliminary difficulties are cleared away, the con- stipation is to be cured by plenty of exercise in the open air; by a diet of plain nutritious food, with green vegetables and fruit ; by insisting upon the proper mastication of all food, and by drugs which act* as hepatic stimulants and tonics ; strychnia may be given as a tonic to the bowels and arsenic and iron as blood restorers. Euonymin and podophyllin in small doses are useful members of the former class. (F. 13, 14, 15, 16, 17.) [The tincture of aloes and myrrh acts well in these cases, as a stomachic, laxative, and tonic to the mucous mem- brane of the bowels.] Constipation, when it is unassociated with other symp- DIET DISEASES! ATROPHY FLATULENCE — COLIC, ETC. 59 toms, is not a condition which does much harm, and it may- be remedied by patience and a little management. Constipation, when it is associated with sickness, always requires careful investigation, and the possibility of intussus- ception or of brain disease should be remembered. Constipation, when it is obstinate from birth, demands an examination of the rectum. Narrowing of the canal from the presence of some partial septum or other congenital malformation, though rare, is for that reason apt to be over- looked in its less extreme phases. And other forms of malformation, such as internal stricture of some portion of the small intestine, and even hernia, occasionally exist. But such cases are very rare. Lastly, constipation in young children is by no means uncommonly associated with small fissures about the anus. The pain of defaecation is so severe in these cases that the sphincter contracts tightly and prevents any successful ex- pulsive efforts. If there be an anal fissure, the bowels must be kept slightly relaxed, to obviate any stretching of the part, and the fissure should be treated locally by keeping the lower inch of the bowel and anus well greased with an ointment composed of equal parts of lead, zinc, and mercurial oint- ment, or it may be dusted with equal parts of calomel and oxide of zinc. Occasionally it may be necessary to paint it with nitrate of silver, and once or twice it has been necessary to stretch it forcibly with the fingers, on the same principle as the surgeon finds it necessary in the adult to divide the superficial sphincter with the knife. 60 THE DISEASES OF CHILDREN. CHAPTER IV. DIARRHCEA. " When the alvine excretions are abnormally liquid, fre- quent and profuse, whether they consist of the residue of undigested or incompletely digested food ; of the product of the secretions of the intestine, the pancreas or the liver ; whether they contain blood or not, or the debris of the mucous membrane, we say that there is diarrhoea."* Some writers have described many forms of diarrhoea, and would thus make the subject a complicated one for the student ; but there is no corresponding morbid anatomy for the dif- ferent kinds of looseness of bowels, and the results of treat- ment suggest a very simple division. Diarrhoea is the symptom of disordered or excessive function on the part of the neuro-muscular apparatus of the intestines, and any organ which depends for its action upon organic muscular fibre is liable to such functional derangements as may by their continuance become confirmed as a habit, and yet have no appreciable morbid anatomy. The uterus may persis- tently abort time after time from the irritation of a syphilitic foetus, for example, and show in itself no reason for so doing. The stomach may repeatedly cast its contents in similar fashion, and in children, and less frequently in adults also, diarrhoea may continue for months, resisting all treat- ment without adequate cause in any structural lesion. The student must not therefore conclude, as he is often inclined to do, that the diarrhoea being chronic and intractable, it is * Trousseau, " Clinique Medicale," 1868, vol. iii., p. 98. DIARRHCEA. 6l due to ulceration of the bowel ; much less that not only is there ulceration, but that that ulceration is tubercular. The arrangement I propose to adopt as simple, and according with practice, is into acute and chronic diarrhoea, and in limine this generalization may be made : Looseness of bowels which has existed any length of time should be closely investigated, as it is pretty sure to prove troublesome to stop, and may indicate serious disease of the intestine and mesenteric glands; Avhile the diarrhoea, which comes on suddenly, is associated with vomiting, and prevails to such an extent in the hot season of the year that it has received the name of summer diarrhoea, though by no means wanting in its more special dangers, need give rise to no such anxieties, being usually readily curable by simple means. Acute Diarrhoea. — Of late years summer diarrhoea has been thought to be an index of the sanitary condition of large towns, and to be due in larger measure to filth and putrefactive processes than, as had been previously thought, to simple atmospheric disturbances, the nervous activities of dentition, and so on ; and this view is probably correct. The very existence of large towns implies the presence of more or less material which possesses the power of origi- nating putrefaction of all sorts. Aggregation is necessarily more favorable to the transmission of septic material than isolation can be. The subjects of this complaint are all under five and most of them under two years of age, that is to say, they are in great measure milk-feeders, and milk is a fluid which is very sensitive to contamination.* It may * I may remind the reader that all organic liquids, though under ordinary- circumstances liable to decomposition, remain absolutely unchanged as long as they are protected from particulate contagion, and there is good evidence that the various kinds of fermentation and putrefaction are due to the intro- duction and growth of various kinds of bacteria. Of milk in particular I 62 THE DISEASES OF CHILDREN. therefore be very readily supposed that whatever tends to lessen the risk of this — and what more so than paying attention to the sanitary condition of a town ? — will by lessening the risk of decomposition to which milk is liable, by so much lessen the amount of summer diarrhoea. But the whole subject is not wholly embraced by this statement. There are some children, and some adults too, who are readily affected by alterations of barometric pres- sure, electrical atmospheric disturbances, and so on. Loose- ness of bowels is noticed in such subjects on any sudden fall or rise of the mercurial column, any sudden change from one extreme to the other of heat or cold, or in thun- dery weather. What such reactions may indicate etiologically ; how far, that is to say, such conditions indicate changes in the food, and how far act immediately upon the system, it is impos- sible to say, and happily for the purposes of therapeutics, though the facts are worthy of recognition, the treatment is unaffected. Diarrhoea is supposed, and probably correctly 1 so, to own many other causes, such as chills, over-feeding, improper feeding, dentition, pyrexia of all sorts, rickets, syphilis ; and some of the reputed causes are associated with certain signs which, as I have said, have justified to some the description of many varieties. It is, however, sufficient to say that in some cases of diarrhoea there is more or less fever, in others perhaps vomiting ; in others may quote from Sir Joseph Lister, whose researches in this domain are well known (*■ On Lactic Fermentation,*' Trans. Path. Soc. of Lend., vol. xxix., p. 45; : "I once met with a bacterium, but only once, that would not live in milk ; for extremely numerous as the varieties of bacteria appear to be, almost all of them seem to thrive in that liquid." The outbreaks of such diseases as typhoid fever, scarlatina, diphtheria, and even of epidemic diarrhoea, which have of late years been traced to a milk source, must, according to present knowledge, be explained in this way, although the actual bacterium of germ has not as yet been demonstrated. DIARRHCEA. 63 there are lumpy motions of undigested food : a want of bile ; an excess of bile ; a rice-watery discharge. In other cases the evacuations are of peculiar color, pink or green. Some are peculiarly offensive. In one form or another during the summer months the out-patient room of any children's hospital is overrun with cases of diarrhoea, mostly infants of four or five months old and upwards. The complaint varies much in severity. To take a common case : the child has perhaps been vomiting and purged for some days with little apparent disturbance of its health. There is a certain amount of pallor, a little fret- fulness and restlessness, and slight rise of temperature. It is usually thirsty, will drink any quantity of cold water, and milk is vomited undigested in curds. The mouth is some- what dry; the tongue redder than natural, and its papillae are prominent. There may be some erythema about the buttocks, and the motions are usually liquid, green, and offensive. Sometimes the evacuations are bright yellow; in others again pale. Suddenly perhaps, the temperature runs up to ioi° to 103 , and the evacuations speedily be- come colorless, profuse, and watery, with an odor which is rather sickening than foully offensive, or pinkish in color like meat juice. The profuse watery evacuations are liable to be accompanied by extreme collapse, the temperature falling in proportion, and death may result within a few hours. Sometimes a healthy infant is suddenly seized with profuse purging and vomiting, it becomes of a leaden pallor with cold surface, moist skin, depressed fontaneile and sunken eye, so closely resembling a case of Asiatic cholera that such attacks have received the name of Cholera Infan- tum. The evacuations in these cases have been subjected to microscopical examination, but only to find them containing 64 THE DISEASES OF CHILDREN. epithelium and vibriones such as may be found in most cases of diarrhoea. I shall say no more as regards varieties ; acute diarrhoea may be of all grades of severity. Any more minute de- scription would but tend to confuse and throw the student off his guard, perhaps upon the first occasion on which he fell upon his own resources ; but this much may be insisted upon, that in order that he may have some reliable notion of the severity of the case it is essential that the doctor should see for himself what is passed by the bowels. The late Mr. Hilton was in the habit of saying to his dressers — " Never lose an opportunity of examining a rec- tum." With equal force it may be said to the student of diseases of children, " Never miss an opportunity of exam- ining the alvine evacuations." The appearances of the excreta will often give a valuable suggestion for treatment, while they will often puzzle us if we have not made our- selves familiar with them. Morbid Anatomy. — Nothing definite can be described. In many cases there is no morbid appearance of any sort ; in others there is some slight swelling of the solitary glands and Peyer's patches ; rarely some ulceration of the follicles and glands; a streaky ecchymosis here and there; or an unnatural pallor of the mucous membrane, with an excess of mucus along the canal. But these are all such appear- ances as may be equally present without diarrhoea, and cannot therefore be taken as certainly indicative of the dis- ease the child has succumbed to. On the other hand, more pronounced lesions are sometimes found, more especially in those cases that are associated with fever. The symptoms may not have been very definite during life, and yet after death the mucous and submucous coats of the bowel are swollen, ecchymosed, covered with an adherent layer of DIARRHCEA. 65 false membrane, and infiltrated with yellow gelatinous lymph or semipurulent fluid. Diagnosis. — But few mistakes are possible. An acute enteritis may possibly be overlooked and the case considered one of simple diarrhoea. This is most likely to be avoided by paying attention to the temperature, which is more likely- to be high in enteritis, and to the tongue, which is more red and furred also. Much fulness of the abdomen and abdominal tenderness might also in certain cases put one on his guard. But no dogmatic statement can be made. It is conceivable also that intussusception might mislead at its onset. There is sudden vomiting, and rather profuse purging may accompany it till the lower part of the large intestine is cleared out and blood comes. But in acute intussusception faecal evacuations should soon cease and blood and mucus alone be found. This, the persistence of vomiting, the probable existence of the sausage-like tumor in the abdomen, and the presence of a palpable polypoid mass in the rectum, should* in most cases be quite sufficient to prevent mistakes. Prognosis. — This must depend upon the amount of col- lapse. Severe collapse is always most dangerous. The presence of continued fever, with a red dry tongue, is also an unfavorable sign. Treatment. — In uncomplicated cases of no more than average severity, and where there is an absence of collapse, a laxative, such as castor-oil or fluid magnesia, should be given, and the diet restricted to easily digestible fluids. Formula 3, 5, or 7 will in most cases be successful, and milk and lime-water or milk made alkaline with a grain or two of bicarbonate of sodium, or thin broth, will form a suitable food for twenty-four or thirty-six hours. When the purging is profuse and very liquid, associated with vomiting and much collapse — the symptoms which speci- 65 THE DISEASES OF CHILDREN. ally indicate infantile cholera — a warm bath and sometimes a mustard bath should be given at once; if the latter, about a tablespoonful of mustard to the gallon of water is used, and the child is kept in it till the nurse's arms tingle. It 'is then to be wrapped in blankets and kept very warm in the •nurse's arms or by hot bottles. Sometimes the choleraic symptoms are associated with very high temperature, 105 ° to 108 , in which case the tepid bath is to be employed fre- quently. The child may be put into a bath of 85 ° to 90 , and the temperature of the water lowered to 8o°, and may be kept in it five or ten minutes, then wrapped in a blanket, and the process may be repeated every three or four hours if necessary. The cold bath was recommended by Trous- seau as a means of subduing nervous symptoms, and lately its employment has again been advocated in these bad cases of summer diarrhoea associated with high fever. The in- ternal treatment will depend upon the existence or not of urgent vomiting. If this is not very severe, small doses of castor-oil may still be given. They will speed onward any noxious matters in the intestine without increasing the state of collapse. If the vomiting is incessant, half-grain dose of hydrargyrum c. creta or one-sixth grain doses of calomel should be given every hour for three or four doses. Henoch speaks highly of hydrochloric acid in small doses and also of creasote (F. 18). Brandy must be given in doses of twenty to thirty drops every two, three, or four hours, as may be necessary. Ether may be substituted in drop doses in syrup, and for hospital patients I usually order rectified spirit. It can be given either with the medi- cine or mixed with an aromatic water separately. In the worst cases a speedy temporary rally maybe obtained and time gained by a subcutaneous injection of ten drops of brandy diluted with water. Food is to be administered in the smallest quantities, and of all others whey, if it can be DIARRHOEA. 6 7 procured quickly enough, is the best. Barley water, the eau albumineuse of Trousseau,* or thin veal or chicken broth, are all useful in their turn. The point in giving directions for the feeding is to beware of doing too much and so bringing about a recurrence of the vomiting. A teaspoonful is a small quantity, but a teaspoonful retained is better than a tablespoonful vomited. One exception may be made to the inclusion of all forms of acute diarrhoea under one head. Diarrhoea is occasion- ally associated with considerable fever, quick pulse, and a thickly furred tongue. Under these circumstances the abdomen is usually full and rather tender, the motions are liquid, or partly liquid and partly lumpy, faecal or green in character, but mixed with an excess of mucus. Such cases occur at all periods of the year, sometimes during dentition, sometimes after some improper food ; in symptoms they correspond tx> what has been described as acute dyspepsia, infective gastritis, or muco-enteritis, and they should be treated -by a preliminary dose of castor-oil ; followed by a simple alkaline mixture, or by demulcents, such as almond oil, sweetened with glycerine, and made into an emulsion with gum tragacanth (F. 20). A few drops of ipecacuanha wine may be added to either mixture with advantage. In some cases a minute dose of Dover's powder with bismuth relieves the pain in the abdomen, and procures sleep. In the more severe cases, with pronounced intestinal inflamma- tion, the chief aim must ever be to sustain the child by suitable nourishment, and if need be by stimulants, so as to allow the disease to run its course and reparative action to take place. [There are two forms of summer diarrhoea of such prominence in American cities that they demand a more * The white of two eggs is diluted with a pint of water and sweetened and flavored by some aromatic. 68 THE DISEASES OF CHILDREN. detailed description. These are entero-colitis and cholera infantum. Entero-colitis. — This is by far the more common of the two, and chiefly affects children in their " second summer," and those belonging to the poor, who are doomed to pass the hot months in crowded, ill-ventilated and filthy locali- ties of large cities. Anatomical Lesions. — There is hyperaemia of the intesti- nal mucous membrane, commonly limited to the ileum and colon and most marked about the ileo-caecal valve and in the sigmoid flexure. The isolated glands are enlarged, appearing like grains of white sand scattered over the mucous surface, and the Peyer's patches are tumid, pro- jecting and punctated. The peritoneum over the inflamed glands shows areas' of arborescent injection, and the mesen- teric glands are moderately enlarged. The stomach is either normal, or the seat of catarrh, the mucous membrane being thickened, softened and reddened. Should the disease assume a chronic form — the "-chronic diarrhoea " of our author — the glands break down and super- ficial rounded ulcers are formed ; there may be, also, linear ulceration of the mucous membrane at the points of deepest congestion. Etiology. — The main causal factors are : a. Residence in large cities ; especially in those quarters where, the streets being narrow and ill-kept, and the houses overfilled and dirty, there are accumulations of organic matter to be decomposed and contaminate the atmosphere with noxious gases and bacteria, b. High temperature, particularly when associated with a moist air. The disease, almost absent in winter, begins to be noticed about the middle of May, gradu- ally increases to rage in epidemic profusion in July and August, and disappears with the cool weather of the latter part of September, c. Improper food. Babies hand-fed DIARRHCEA. 6 9 from birth and those who are weaned early suffer most. Impure and sour milk, farinaceous preparations in excess, " tastes " of table food and fruit are most potent in producing an attack, d. Age. The majority of cases occur between the ages of six and eighteen months, one-fourth as many from eighteen to twenty-four months, and a smaller propor- tion between birth and the sixth month. After the second year attacks are much less common. Symptoms. — The actual attack is preceded by restlessness, disturbed sleep, partial anorexia, sour-smelling eructations, slight increase in the number and decrease in the consist- ency of the faecal evacuations, and heat of the palms of the hands and soles of the feet. In one or two days, vomiting and diarrhoea begin. The former is more or less obstinate, and the ejecta consist of sour, badly digested food. The stools range from six to twenty or more in twenty-four hours, and vary greatly in character from time to time. They may be semi-solid, yellow, with a faecal odor ; " or liquid, green and acid; or contain mucus or blood; or, finally, be almost serous and very offensive. The act of defecation is preceded by pain, and there may be tenesmus and slight rectal prolapse ; in the latter condition blood is most apt to appear in the stools. The tongue is dry, red at the tip and edges, with a light white coating in the centre, appetite is diminished, thirst increased, and the abdomen is distended and sometimes tender to pressure. The surface is hot and dry, the ther- mometer indicating a moderate pyrexia continuous for the first three or four days, but afterward remittent. The pulse is feeble and runs up to 120 or even 140 per minute. The urine is scanty, high-colored and muddy, and passed at long intervals. Early in the course of the disease — after a single day if JO THE DISEASES OF CHILDREN. the diarrhoea be severe — the face becomes pale, the eyes are sunken, lustreless and surrounded by dark rings, the nasal lines of Judelot appear, the fontanelle, if membranous, is depressed, the body wastes, the muscles grow flabby, the skin of the buttocks and inner surfaces of the thighs is reddened by the acid stools and concentrated urine, and there is excessive prostration. When death approaches the patient either becomes drowsy, apathetic and cold, or fretful, with incessant vomit- ing, dry burning skin, rolling of the head from side to side, and perhaps unilateral or partial convulsions. If there be a tendency to recovery, the vomiting stops, there is more appetite, the skin grows moister and cooler, the urinary excretion is re-established and the langour and apathy diminish. Diagnosis. — There is little difficulty in distinguishing entero-colitis. The fever, the vomiting, the number and appearance of the stools, the age, season and locality of occurrence, and the almost epidemic prevalence of the dis- ease are characteristic. Prognosis . — While a large proportion of cases recover under proper treatment, the outlook is always grave, and particularly so in the children of the poor, with whom it is impossible to practice the most efficient means of cure, namely, removal to the fresh-air of the country or sea- shore. Relapses are apt to occur, and the disease is liable to become chronic when it is very difficult to manage. An attack may prove fatal in four or five days ; it may however be protracted for two weeks, the last is the usual duration of severe cases ending favorably. Treatment — People who have not the means to take their families to a place of safety in the country or at the sea- shore for the summer months, may yet do much in the way of prevention by keeping their children, during the day, in DIARRHOEA. J I the fresh air of public squares and parks, by bathing, by- proper and clean clothing, good food, and attention to the cleanliness of beds and sleeping rooms. Clean streets are apparently too much to expect in the present state of our municipal governments, but there is no question that any improvement in this respect would lessen the frequency and mortality of summer diarrhoea. When an attack occurs the patient must, if possible, be sent at once from the city, the resort selected being near at hand, lest the journey be too fatiguing, but such as to afford a decided change of air. The effect of such a change is rapid and almost magical ; it is necessary, though, to make a long stay, since if the child be brought back to town in hot weather, a relapse is almost certain to occur. If the parents be too poor to afford this, they must keep their child out of doors in the cool of the morning and evening, or spend the day with it in a public park, or still better take it for a short excursion in a river steamboat. The heat of the day should be passed in as cool a spot as can be obtained. It is well to let the child rest on a cool clean bed, and to forbid its being constantly nursed on a hot lap or shoulder.- The clothing must be as thin as possible provided always that woollen is worn next the skin. Several times a day in the early stages of the attack, the whole surface of the body ought to be sponged with water at 8o° F. and carefully dried with gentle friction ; after prostration has set in, full warm baths are to be employed. In ordering the diet, quantity as well as quality must be definitely stated, for the increased. thirst causes much more liquid food to be taken than can be digested. It is better to meet this demand by bits of cracked ice and moderate quantities of iced filtered water, and to proportion the amount of food to the enfeebled digestive powers. 72 THE DISEASES OF CHILDREN. This may be readily done with nursing babies by restrict- ing the intervals of feeding to two or three hours, according to the age, and by reducing somewhat the duration of each sucking. With hand-fed children it is still easier to fix the quantity ; as to quality, good sound cow's milk must form the basis of every food. The following is a good preparation for a child of twelve months : Milk, ...... six tablespoonfuls. Cream, ...... one tablespoonful. lime-water, ..... five tablespoonfuls. Sugar of milk, ..... one teaspoonful. Mix in a clean tin cup, pour into a clean bottle, adjust tip, and warm by plunging into hot water. Should it be impossible for the child to retain this quan- tity, one-half, or even one-fourth of it only may be given. It is always worth the trouble to see that the infant's milk is received and kept in a perfectly clean and special vessel ; that the bottles and tips (no tubular arrangement should ever be used) are also perfectly clean, and that each meal is prepared separately at the time of serving. In very hot weather, and when ice is scarce, it is a good plan to boil the whole day's supply of milk, when it comes in the morning, to keep it from souring, but under no circumstances should the meals for the day be mixed en masse. When the milk preparations are vomited, or passed un- digested in the stools, whey mixtures, strippings, or meat- juice have to be resorted to. The medical treatment, should the case be seen early, may be begun by a laxative, as one teaspoonful of castor oil with five drops of paregoric* Afterwards, while the stools are * All the prescriptions given in this section are proportioned for children one year old. DIARRHCEA. 73 yellow, homogeneous, and have a faecal odor, alkalies and astringents are demanded ; as : R. Sodii Bicarbonatis, ...... gr. xxxvj. Syr. Rhei Aromat., f,? ss - Aq..Menthae Pip., .... q. s. ad f giij. M. S. — One teaspoonful every two or three hours. When the stools are green, acid, and numerous, alkalies with opium do best : R. Tr. Opii Deod., mvj. Bismuth. Subcarb., . ..... gr. lxxij. Syrupi, ........ f^ss. Misturae Cretae, .... q. s. adfgiij. M. S. — One teaspoonful every two or three hours. Good results, too, are sometimes obtained in tedious cases by minute doses of calomel with opium and chalk. It is not advisable to continue these longer than one or two days. Very frequent and serous stools require more powerful astringents, as nitrate of silver internally and by enema, or sulphuric acid. For the latter, the following is a good for- mula: R. Acid. Sulph. Aromat., TUxxiv. Liq. Morphise Sulph., f^j. Elix. Curacoae, ...... f^ij. Aquae, q. s. adfgiij. M. S. — One teaspoonful every three hours. Counter-irritation by mustard plasters to the belly is use- ful. Stimulants are required when prostration sets in, and must be given in doses and at intervals adapted to the de- mands of the case. Applications of oxide of zinc ointment, with cleanliness, cure the intertrigo of the buttocks and thighs most quickly, or, at least, keep it in check until the cause is removed. 74 THE DISEASES OF CHILDREN. Attention to diet and hygiene is not to be relaxed when convalescence is established, and after the measures calcu- lated to check diarrhoea are unnecessary, digestants, as wine of pepsin, and tonics, as the ferrated elixir of cinchona, are still required to restore the health. Cholera Infantum is the analogue of cholera morbus in the adult. Anatomical Lesions. — In typical cases, the gastro-intestinal mucous membrane is congested, thickened, and softened, and the glands, both solitary and agminated, are enlarged. When the patient survives the choleraic stage, and dies sub- sequently of a more protracted diarrhoea, there is more in- tense inflammation, with ulceration of the intestinal mucous surface. In addition, the sympathetic nervous system is so involved as to allow the transudation of serum from the bloodvessels into the intestines, and lead to alterations in the functions of the heart, lungs, and kidneys. Etiology. — Infants from six to twelve months are the most ready subjects, but it may occur at any age up to two years. In other respects, the causation is identical with that of en- tero-colitis. Symptoms. — The onset of cholera infantum is sudden, whether it occurs in the midst of health or during the course of an ordinary diarrhoea. The first symptom is the expul- sion of very large watery stools ; these may be so serous as to soak away into the napkins without leaving any more stain than healthy urine, or they may contain yellow or green flocculi and little masses of mucus ; or, again, they may be composed of dirty-brown liquid. In the first two in- stances they are odorless, in the last they have a peculiar musty, putrid smell, which clings to the body and clothing of the patient. The number of evacuations varies from ten to thirty in twenty-four hours. Soon the stomach becomes intensely irritable; everything DIARRHCEA. 75 is vomited almost as soon as swallowed, and there is severe retching. The appetite is lost, there is intense thirst, the tongue is dry, pasty, and protruding, and the abdomen is flaccid. There is great restlessness ; the temperature runs up to 105 or even 108 , the pulse is small, and counts from 130 to 150- per minute, the breathing is irregular, and the urine almost suppressed. After a few hours the infant seems to have melted into a mere shadow of himself; his face is pale and pinched, his eyes and cheeks sunken, and the lids and lips parted from muscular relaxation. The fat of the body melts away, the muscles grow soft, and the skin, dry and cadav- erous in color, hangs in loose inelastic folds. Next, there is rapid collapse, with cold extremities and breath ; thready, uncountable pulse, unequal respiration, drowsiness, apathy, and totally suppressed urine. As death draws near, the vomiting stops, the skin is clammy, the face set, and the patient sinks into a condition of semi-coma. The end comes quietly, or is preceded by slight convulsive movements. The attack may prove fatal in from one to four days, or the type may change, and death occur later from secondary entero-colitis ; sometimes recovery takes place. Diagnosis. — The character of the stools, the extreme irri- tability of the stomach, intense thirst, high temperature, disturbed respiratory rhythm, and rapid emaciation and collapse, are distinctive features. There is a certain re- semblance between this disease and sunstroke, but the two conditions have little in common beyond the fact that they both occur in hot weather. The prognosis is very unfavorable. Early removal to the country or sea-side offers the best chance for recovery. Otherwise daily airings and steamboat excursions must be resorted to. Treatment. — To replace the great waste, food and water j6 THE DISEASES OF CHILDREN. must be given in such quantities as can be retained — even a teaspoonful at a time — and at intervals corresponding in frequency with the smallness of the amount. The quality of the food must be the same as in entero-colitis. To check the purging, astringents and opium are necessary, the sulphuric acid mixture, given on p. 73, is very efficient. At the same time, an enema containing two or three drops of tincture of opium should be administered every three hours. Mustard draughts should be applied to the abdomen three times a day, or a flax-seed poultice warmed with a dash of mustard may be worn constantly, and the body must be sponged several times daily with water at a temperature of 95 . The patient should lie upon a bed, not in the lap ; perfect cleanliness of person, diapers and clothing is essential, and the sick-room must be as large, cool and airy as can be commanded. Stimulants are necessary from the first. Five or ten drops of whiskey in a teaspoonful of lime-water may be given every two hours in the beginning, and increased as circum- stances demand. Carbonate of ammonium may be combined, if the stomach permits, in bad cases. In collapse, the temperature must be kept up by hot flan- nel wraps, and hot-water bottles, and quiet in a horizontal position maintained. In this stage opium is to be used with caution, on account of its tendency to increase the stupor. In the fortunate favorable cases, secondary diarrhoea is to be treated carefully, and the general strength built up by good, digestible food, tonics and fresh air.] Chronic Diarrhoea is very generally insidious in its origin. It often happens that not till months after its commencement, and not till emaciation has made some progress, is the child brought for treatment. In reply to questions, we are told DIARRHOEA. 7J that the bowels have always been loose — perhaps what began as an acute diarrhoea has become perpetual. Some- times the attack has been the outcome of one of the exan- themata ; but however this may be, the child is brought because " as soon as any food is taken it goes through him, ,, and for some imaginary enlargement of stomach, these be- ing indications to the mother of " consumption of the bowels." It is but seldom, however, that this popular diagnosis is correct ; and in at least nine cases out of every ten, consumption of the bowels means no more than the disorder attendant upon improper feeding. , Causes. — Chronic diarrhoea occurs for the most part in the ill-kept children of the poor of large towns ; in infants whose mothers are out at work all day long, and who are conse- quently fed on anything on a week-day, and probably, as a treat on Sundays, on a little of everything that the parents eat; in the ill-washed, with a skin choked with perspiration, dirt, and urine ; in the ill-clothed, with a surface repeatedly exposed and chilled , — in all, in fact, who breathe bad air and are fed on bad food, and live under conditions hygieni- cally faulty. [Entero-colitis is also the cause of a certain proportion of cases of chronic diarrhoea occurring in children from six to eighteen months old.] In the children of the well-to-do, it usually results from improper feeding — not necessarily from food intrinsically bad, but rather from food which is not adapted to the particular case. In many of the children in this class of society, the greatest care and forethought has been exercised; still, there is something wrong in the food or in its method of administration. Chronic diarrhoea is also specially frequent in rickety and •syphilitic children, and is also liable to begin in any who may be recovering from measles, whooping-cough or other debilitating disease. Symptoms. — The early history of cases of chronic diar- 7 78 THE DISEASES OF CHILDREN. rhoea can but seldom be obtained from that class of society which furnishes the most abundant examples; but from such children as have been under careful observation, it would appear that an acute attack of diarrhoea, acute dis- ease of one kind or another, or exposure to cold, are its usual precursors. There are many children, moreover, who are voracious from birth, who take their food with great rapidity, take more than is requisite, and who show symp- toms of indigestion and suffer pain afterwards. Any of these conditions will lead to diarrhoea. The motions are at first abundant without being very abnormal. Very gradually they lose their color and consistency, the child losing its plumpness, and dwindling. The motions may at first be pultaceous and abundant, lumpy, with a quantity of mucus, or grumous and more like pus ; but in the late stages they become more and more frequent, amounting sometimes to twenty or thirty in the twenty-four hours; more liquid; more offensive ; and the color changes to reddish or to a dirty-brown water containing green particles — " like chopped spinach," an apt comparison — which are considered to be altered blood. The child meanwhile slowly wastes. For a long time, by a negative rather than a positive process, the infant grows older but not larger. For long it is supposed to be rather bad-tempered than ill, for in the interval of the abdominal pains it may be bright and cheerful ; but by-and- by the emaciation cannot be overlooked — it becomes con- tinuous, till in extreme cases only a living skeleton remains. The skin is brown and dry, hanging in folds upon the body and wrinkling the brow ; the buttocks become covered with an eczematous rash; the face is pinched and monkey-like; the cry, a hardly audible whine; the tongue red and dry, rasp-like from the prominences of the papillae, and covered with thrush; and the abdomen, moderately distended by flatus, shows the intestinal, coils visible through the thinned DIARRHOEA. 79 parietes, and the peristaltic action clearly discernible. Visible peristalsis has not the same signification in children that so often attaches to it in adults. It may mean the excessive activity of the muscular coat of the bowel, but not that the muscular coat is hypertrophied ; it may be seen in many an emaciated child without any intestinal obstruction being present. If the diarrhoea be not arrested by treatment, the child gradully becomes more feeble, and sinks into a semi- comatose state. The temperature falls below normal; the feet and hands are cold and cedematous ; and it either suc- cumbs to gradual exhaustion, or else some complication occurs — perhaps convulsions, perhaps broncho-pneumonia or pleurisy. The* child is, however, often in so feeble a condition before the final event that such things create few if any fresh symptoms, and they are liable to pass unrecog- nized, until a post-mortem examination reveals them. Be- sides these, there is a liability to eczema, impetigo and ecthyma ; and even gangrene of parts of the surface has been recorded. Such is the history of chronic diarrhoea in infants — an affection that may last from three or four weeks to as many months, or even longer. In older children — that is to say, from two years upwards — it is found under three conditions of somewhat different import: 1st. As a state of irregularity of bowels rather than diarrhoea, the motions being often loose, but not unfrequently confined and lumpy. The diarrhoea stool is bulky, loosely pultaceous, dark brown in color, and offensive. This is due to want of regularity in diet, and in certain cases where undigested food appears in the evacuations, has received the name of lienteric diarrhoea. This form is often associated with thread- worms. It is associated also with a certain flabbiness of muscle and fat, but hardly ever with any serious wasting. 2d. There may be much wasting and abdominal discomfort, the abdomen being a little full and the motions muddy and offensive ; in SO THE DISEASES OF CHILDREN. which case it is due to ulceration of the intestines and tabes mesenterica. [Tubercular ulceration, a lesion which fre- quently precedes inflammation and caseation of the mesen- teric glands or tabes mesenterica, occurs mostly in children over three or four years of age, especially when these are subjects of the tuberculous or scrofulous diathesis. The seat of the disease is the ileum, the parts affected Peyer's patches and the solitary follicles. The ulcers are circular or oval with uneven ragged edges in which careful examination reveals the presence of miliary nodules. They are more numerous in the neighborhood of the ileo-caecal valve, over which region there is tenderness on pressure, with a certain amount of tension of the parietes. The stools are composed of dirty-brown fluid with a deposit of flaky matter, small black clots of blood, pus and mucus, and are exceedingly offensive. The temperature is usually elevated in the even- ing, and should the ulceration be marked the mesenteric glands are apt to be enlarged.] 3d. There may be little wasting, but more pain — the griping coming on almost as soon as any food is taken into the stomach, and the evacua- tions consisting of undigested food and mucus — -a condition which appears to be primarily associated with some disorder of innervation {Diarrhee nervcase of Trousseau), although excited immediately by the contact of food with the gastro- intestinal mucous membrane. [This variety, the true Lien- teric diarrhoea y is met with in children from three to nine years of age, and is due to an unnatural briskness of the peris- taltic action, on account of which whatever food is taken is at once hurried through the alimentary canal, with a rapidity that allows of but slight digestive change. The stools contain little faecal matter, and are composed of almost unaltered food so mixed with mucus as to present a slimy appearance. They number three or four a day ; the first occurs in the morning after rising, the others immedi- DIARRHCEA. 81 ately after or even during a meal. Each motion is preceded by griping pain, and the call is most urgent, so much so that the child with difficulty waits for the chamber or reaches the closet. The tongue is red at the tip and edges, lightly coated or clean over the dorsum. There are fre- quent griping abdominal pains with unproductive desires to defecate. Wasting and other evidences of failing health may or may not be present, and special inquiry is often necessary to discover the abnormal condition of the bowels, which by many parents are merely considered to be " nicely opened."] Prolapse of the rectum is liable to occur in any case of chronic diarrhoea, but it is more common in children of two to six years than in infants. Morbid Anatomy. — The coats of the stomach and intes- tines are pale and thin, having suffered from the general atrophy, while the mucous membrane of the lower part of the small intestine and of the colon is covered with black points, giving a cut-beard appearance which is due to altered blood pigment deposited round minute ulcerations of the solitary glands and follicles. There may in addition be more or less superficial erosion of the mucous membrane, a streaky appearance from irregular turgescence of the capil- lary plexuses, with swelling of parts of the Peyer's patches ; and lastly some cases prove to be overlooked examples of tabes mesenterica, with their thick-edged ulcers infiltrated w T ith yellow material, and perhaps with distinct tubercles on the peritoneal aspect. It sometimes happens that a chronic catarrh may end in a more acute process. Thus it is that occasionally the unsuspected presence of acute enteritis is revealed after death. Bronchitis, broncho-pneumonia, or atelectasis are the more common affections found in con- junction with the intestinal lesions. The more or less comatose condition which so often comes on before death has been occasionally found to be due to thrombosis of the 82 THE DISEASES OF CHILDREN. cerebral sinuses ; but this is a rare occurrence, and the symptoms are probably more often due to the slowing of the circulation and the feeble nutrition which ensues, or, possibly, as Parrot has suggested, to toxaemia (" Clinique des Nouveaux-nes ''). Diagnosis. — It is desirable if possible to come to a con- clusion whether the diarrhoea is due to tubercular ulceration or not. The existence of small follicular ulcers cannot be diagnosed with any certainty, but the larger tubercular or scrofulous ulcers may be suspected in any child over two years in whom the diarrhoea is obstinate and there is much wasting. Of late years it has been the custom to teach that tubercle is a much commoner disease in infants than had been thought; and so, no doubt, it is; none the less it re- mains true that of all the cases of chronic diarrhoea met with in children, but few are tubercular under eighteen months. After two years the question of tubercle must be carefully considered. Much pain after taking food, associ- ated with a persistently brown watery offensive motion, is in favor of ulceration, and so also, with other symptoms, is any unusual excess of borborygmi in the intestine. Tuber- cular ulceration of the intestine has so much tendency to mat together the coils of intestine, and thus hamper their action, that some functional disturbances of this kind may certainly be expected. These points, and a careful observa- tion of the temperature, will generally suffice. A polypus in the rectum leads to a discharge of blood and mucus, which is sometimes characterized as diarrhoea by the mother. An examination of the rectum settles the diag- nosis. Prognosis. — This must depend upon the result of treat- ment. If the diarrhoea lessens and the motions become more consistent, then a favorable termination may be hoped for. The older the child the better the chances. Much DIARRHOEA. 83 dryness of the tongue, with redness and enlargement of the papillae, accompanied by thrush ; and any oedema of the feet and ankles ; are of the worst augury. Treatment. — To take the case of older children first, and excluding the possibility of tabes mesenterica, the diarrhoea which is due to irregularity of diet must be counteracted by paying attention to what has before been neglected. Chil- dren thus affected must be strictly treated, but they require some slight preliminary purgation to clear away indigestible and improper material from the intestinal canal. For this purpose Formula 1 1 is a serviceable one, and not unpalatable. A teaspoonful to a tablespoonful of fluid magnesia may be given instead, if preferred, twice or three times in the day ; and for a more active aperient a small teaspoonful of liquorice powder or a piece of a Tamar Indien lozenge may be given. Subsequently a little sulphate of magnesium may be com- bined with sulphate of iron, as such children are often anaemic, and require iron (F. 21). In the prolapsus ani, that is often present in such cases, I have never found it necessary to do more than support the parts by strapping the buttocks tightly together by a broad band of strapping, encircling the hips round the great trochanters ; and, in the worst cases, giving an enema of sulphate of iron and cold water, a drachm to the half-pint, and a third part to be used at a time every morning, or morning and evening, for a few days. More severe measures are sometimes spoken of, but the circumstances under which they can be called for must be very exceptional, and I have never seen a case where they were necessary. For the u nervous diarrhoea" nothing acts so well as small doses of Dover's powder. It is a disease particularly of children five to ten years old. Two, two and a half, or three grains may be given three times a day in a little milk, and an hour or so before meals. A little liquid extract of opium may 84 THE DISEASES OF CHILDREN. be given in fluid magnesia, with sulphate of iron, as a useful way of combining the opium with a tonic, and at the same time avoiding any too costive effect. The iron is precipi- tated as green carbonate, but this does not in any way impair the effect. (F. 22.) Easton's syrup in doses of twenty or thirty drops three times a day, may be given afterwards (syrupus ferri et quiniae et strychniae phos- phatum). It is better than the more usually prescribed Parrish's food under these circumstances, being less liable to upset the stomach. [Lienteric diarrhoea does not yield to ordinary astringents, and is much increased by laxatives, as castor oil. Opium checks it temporarily, but the best remedies are Fowler's solution and tincture of nux vomica in small doses. At the same time a digestible diet must be ordered at regulated intervals.] Chronic diarrhoea in infants requires the expenditure of much thought and trouble if the treatment is to be suc- cessful. It is often obstinate, and improvement even in favorable cases very fitful. The treatment comprises diet, general hygiene, and medicine. The diet must be regulated upon the lines already laid down for children in health. Chronic diarrhoea is so much a disease of bad or too abun- dant feeding, that the first duty will probably be to see that starch is eliminated from the diet, or that milk is taken in re- duced quantities. If milk should disagree, as it is liable to do even when diluted largely with water, or lime-water, milk and barley-water may be tried, and then whey or thin veal broth. But whatever is given must be in very small quan- tities, sometimes only a few teaspoonfuls, so as, if possible, to allow of digestion without starting the intestines into muscular action. If under these circumstances the child gains in weight, and the motions become more colored with bile and more consistent, it will probably get well ; but the DIARRHOEA. 85 food must be carefully regulated, and only slowly increased in quantity. As the gastro-intestinal tract becomes more tolerant, so the quantity of food given may be increased, the frequency of the meals decreased, and milk food be gradually reintroduced. In the worst cases all food must be stopped, and raw meat given instead. The directions given by Trousseau are as follows : Take a lean piece of beef or mutton, and after cutting it into small pieces, reduce it to a thick pulp with pestle and mortar. The pulp so made is passed through a fine colander, which will allow nothing to pass save the juice of the meat and fibrinous matter. This is scraped from the external surface of the colander, sweetened ; and, to begin with, a teaspoonful may be given three times a day; the quantity being gradually increased till five or six ounces may be taken in the course of the twenty-four hours. It will often be found, however, that, except for the youngest infants, who take raw meat with avidity, it creates disgust, even when well sweetened. It is then to be given stirred up in a little cold veal broth or thin barley-water. It will usually be readily taken in this way when refused as a pulp. If not, it may be made into small masses, with confection of roses or currant jelly, or it may be mixed with chocolate made with water. At first the meat appears unchanged in the stools, but this soon alters ; the meat becomes partially and then entirely digested, and the child gains in weight in proportion. In what may be called general hygiene, the child must be kept warm and clean. It should be wrapped in flannel and carefully guarded against cold feet and a cold stomach. It should be kept in one temperature, but in as pure air as possible, and all soiled linen should be removed from it at once. Medicines are comparatively of less value. They are by no means to be omitted, but careful diet and warmth 8 86 THE DISEASES OF CHILDREN. are the essentials. Of drugs, opium is the most generally useful, and this may be well combined with logwood, ipe- cacuanha and chalk, as in the mistura haematoxyli co. of the Guy's Hospital Pharmacopoeia. (F. 23.) A teaspoonful should be given every four hours if the diarrhoea is profuse, and less frequently according to circumstances. Another useful remedy is bismuth. Sometimes astringents are useful — gallic acid, sulphate of copper, acetate of lead, may any of them be used according to the formulae given. (F. 25, 26, 27.) [Nitrate of silver is a most useful drug when the diarrhoea proves obstinate, aphthae appear in the mouth, and there is much thirst and prostration. One twenty-fourth of a grain may be given, suspended in syrup of acacia, every two hours to a child of two years. Stimulants are also necessary to relieve the tendency to prostration. Whiskey is the best, and it must be given in doses and at intervals proportioned to the de- mands of the individual case. Ten drops every two hours is about the average initial dose.] Astringent enemata are recommended by some. They are not often retained, and are but seldom of use. Nitrate of silver, one grain to five ounces of water, is recommended by Trousseau ; but on the whole I am inclined to prefer equal parts of an infusion of ipecacuanha and decoction of starch ; or, starch and tincture of opium — two or three drops of the latter to two ounces of the vehicle. [Injections of nitrate of silver, which by the way are very serviceable, should be given at intervals of twelve hours and preceded by an enema of warm water to wash out the rectum. After being continued for forty-eight hours, they should be discontinued for a day, during which the patient may receive, at the same intervals, injections of tincture of opium in starch water, three drops to half a fluid ounce at the age of two years. DIARRHOEA. 87 When improvement sets in tonics must be employed to build up the general health. One of the best to succeed the treatment directed especially to the relief of the diarrhoea is the solution of the nitrate of iron with a mineral acid, for example : R. Liquor. Ferri Nitratis, Acidi Nitrici Dil., aa f £ss. Syrupi Zingiberis, . . . . . . f §j. Aquae, q. s. adfgiij. M. S. One teaspoonful three times daily, for a child of two years.] Dysentery. — This term is applied in England sometimes to chronic ulceration of the colon, sometimes to acute in- flammation with the formation of diphtheritic membrane. In either case it is a disease which rarely attacks children, and does not differ from such affections in an adult. Ex- tensive ulceration of the colon is almost always due to tubercular ulceration, though it is possible that it may be an occasional result of chronic diarrhoea. I have only once seen a case of acute colitis. The patient was a girl, aged eleven and a quarter, who had been living badly. She was extremely prostrate, pale, and covered with a purpuric eruption. Her temperature was 100.8 . The spleen large. The bowels were confined at first, but the evacuations soon became watery, and pink from the presence of blood, and she sank rapidly; the temperature rising to 105.6 . The blood showed a reduction of more than one-half of the corpuscles and 65 per cent, of the coloring matter. At the inspection, the lower part of the colon and the rectum were the seat of a severe diphtheritic inflammation. The mucous membrane was swollen, coated with thick adherent mem- brane, the surface beneath being ecchymosed and bleeding. Such cases, when they occur, must be treated, like bad cases of acute enteritis, by careful nourishment, stimulants, the dilute mineral acids, quinine, etc. For chronic ulcera- tion the treatment of chronic diarrhoea will apply. 88 THE DISEASES OF CHILDREN. CHAPTER V. STOMATITIS— THRUSH— CANCRUM ORIS. Stomatitis. — Four or five different forms of stomatitis have been described, but no useful purpose is gained by such elaboration. It will be sufficient to treat of — I. Stoma- titis ; 2. Thrush; 3. Cancrum oris. Stomatitis and thrush are often combined. I. Stomatitis. — Children thus affected are brought with the complaint that their breath is offensive, that they are spitting up blood, or that blood stains their pillow during sleep. It is a disease chiefly of the lower classes, which affects boys and girls of any age from two to nine or ten years, and perhaps is more common in the months of March, April, and May than at other seasons of the year. It has been supposed by some to be due to a milk diet, but this I have not been able to substantiate; nor is it easy to prove that it bears any particular relation to dentition; but so far as my own statistics go it would appear to be more common between the ages of two and three and seven and nine. Henoch puts it as most common between the ninth month and the middle of the third year, but has observed it not seldom in older children, and he considers dentition, both first and second, to have much to do with its occur- rence. It occurs in varying degrees of severity, of which I may give examples. 1. The common form is a superficial ulceration of the edges of the gums, the tongue, and the cheeks ; the gums being vascular, and fringed with a yellow margin of decay- ing granulations. STOMATITIS — THRUSH CANCRUM ORIS. 89 E. L., a girl aged nine, had had a sore mouth, with some malaise, for a fortnight. There was superficial ulceration of the gums, mostly in the lower jaw, running along the line of junction of the gum with the teeth. From this there was an offensive sanious discharge. A few circular pus- tular-looking ulcers were present on the mucous membrane of the cheek, and some on the sides, tip, and dorsum of the tongue. In young children this condition may be accompanied with considerable elevation of temperature (102 — 103 ), and I have sometimes thought, from the correspondence of the 13/sis with the commencement of rapid healing of the ulcers and the disappearance of the fur from the tongue, that pos- sibly some cases at any rate might be due to some specific germ. 2. Small circular ulcers are scattered over the tongue and mucous membrane of the cheeks. E. H., a boy aged three years. The tongue was thickly coated, and numerous small circular ulcers with sharp vas- cular margins occupied its sides and the inner surface of the lips. The pulse and temperature remained normal. 3. As a large more or less deep sloughing ulceration of the cheek, but not accompanied with much lividity or sur- rounding induration. S. A., a girl aged six, had been out of sorts for a month. The bowels were confined, with cough and collicky pains in the abdomen. A large unhealthy looking gray slough occupied the greater part of the inner surface of the right cheek. The gums were ulcerated all round the mouth, and many of the teeth were loose. The tongue was superfici- ally ulcerated. Ulcers of this kind are generally of very irregular surface, owing to their size, the superficial swelling, and the pressure of the teeth against them. For the same reasons they cause 90 THE DISEASES OF CHILDREN. a good deal of pain to the child in eating, the swollen sur- face getting between the teeth. They may in this way retard recovery by rendering the child unwilling to take a proper quantity of food. They are usually as amenable to treatment as other kinds, but the teeth are liable to become loose ; occasionally a small piece of bone from the alveolus may exfoliate, and I have once seen cancrum oris follow what I considered to be this form of ulceration at the outset. The child came at first as an out-patient to the Evelina Hospital, and was admitted to Guy's Hospital a day or two after with the major disease. West mentions the possibility of such an occurrence, but considers it one of rarity. [It is better, perhaps, to divide these affections of the mouth into three classes, namely, catarrhal stomatitis, aph- thous stomatitis, and ulcerative stomatitis. Catarrhal stomatitis consists of an erythema of the mu- cous membrane of the mouth, either limited to circum- scribed spots or extending over the whole surface. In the latter case there is much swelling. The papillae of the tongue are enlarged and reddened and its epithelium is abraded, while the mucous glands of the lips and cheeks are prominent and yield on pressure a drop of mucus. The buccal secretion is increased in quantity, acid in reaction, thin, or viscid and flocculent, and runs from the mouth, pro- ducing excoriations of the skin of the lips and chin. The mouth is hot and tender, sucking or mastication are painful and cold drinks are craved. The bowels are apt to be dis- turbed. This condition is produced by hot and irritating food, teething, carious teeth and want of cleanliness ; it may also arise in the course of the exanthemata, or precede and attend more serious affections of the mouth. The treatment consists in keeping the mouth clean by frequent applications of tepid water, lancing the gums in STOMATITIS — THRUSH — CANCRUM ORIS. 9 1 difficult dentition, removing carious teeth, applying a wash of borax or chlorate of potassium, and attending to the digestion both by diet and appropriate medicines. Aphthous stomatitis. — In this affection a number — three or four to twenty or more — of small ulcers appear upon the reddened and swollen mucous membrane of the lips, cheeks, tongue and gums. They are round or oval, usually from one to two lines in diameter, scarcely depressed, with a yellowish white floor and surrounded by a narrow ring of deep redness. Sometimes several of them run together, forming large irregularly shaped ulcers. No cicatrices are left on healing. The mouth is hot and tender, the tongue is heavily frosted, the flow of saliva is greatly increased, and this fluid, now acid in reaction, as it dribbles over the parted lips, excoriates the skin with which it comes in contact. Appetite is diminished, partly on account of the pain incident to sucking or mastication and partly in consequence of asso- ciated gastric catarrh ; cold water is taken freely. There is moderate heat of skin, a tendency to constipation, restless sleep and irritability of temper. Aphthae occur in the course of gastro-intestinal catarrh from improper feeding, during dentition, or with measles, scarlet fever, whooping cough and other acute diseases of infancy. The affection is most common between the sixth and fourteenth month of life, and large crops of cases are apt to arise together. The general treatment comprises careful regulation of the diet and a moderate dose of calomel, followed by pepsin with dilute muriatic acid if there be much gastric distur- bance, or by chlorate of potassium and dilute muriatic acid if the oral symptoms predominate. Locally a wash of chlorate of potassium (gr. x to f Si) should be used every 92 THE DISEASES OF CHILDREN. hour, and if the ulcers do not heal quickly they may be touched once a day with a point of lunar caustic. Ulcerative stomatitis has for anatomical lesions paren- chymatous inflammation of the gums (ulitis) and ulcerative destruction of the investing mucous membrane. The lower jaw is more frequently affected than the upper. First the mucous membrane becomes red and swollen, the portions of the gums between the teeth standing out like little flasks and bleeding on the lightest touch. Next the edges in contact with the teeth turn yellow or yellowish- gray, the tissue softens and gradually breaks down into superficial linear ulcers, having gray floors and red margins. The teeth are loosened, and sometimes the periosteum is destroyed and necrosis of the jaw-bone takes place. After a time the ulceration extends to the cheeks, the lips and the tongue, and occasionally true noma follows. The mouth is hot, the tongue coated, the breath offensive, and streams of viscid blood-stained saliva drivel away. There is much pain on mastication, and upon this, in great part, depends the anorexia. The submaxillary and lym- phatic glands of the neck are usually swollen, and the face is often cedematous. Debility, fretfulness, and disturbed sleep are symptoms, but the implication of the general system is trifling. The course is indefinite. Ulcerative stomatitis is most prone to develop in feeble, rickety and strumous children, in those who are exposed to bad hygienic influences, and in those convalescing from typhoid fever, measles, and scarlatina. It is never seen before the appearance of the teeth, but may occur at any age thereafter. It is not contagious, though large numbers of cases are apt to arise simultaneously. The plan of treat- ment is to improve the diet and general hygienic conditions, to administer tonics and stimulants, to keep the mouth clean STOMATITIS — THRUSH — CANCRUM ORIS. 93 and to make frequent applications of a solution of chlorate of potassium.] The treatment of stomatitis is not usually one of much difficulty. When the ulceration is extensive and deep upon the cheek, the mere size of the ulcer requires time for its closure; and a corresponding ulcer on the tongue, which is not unfrequently present, and is probably due to direct inoculation, may prove a little troublesome. But as a rule the exhibition of chlorate of potassium is followed by cure within a few days. The subjects of stomatitis are usually somewhat out of sorts ; as soon, therefore, as the mouth will bear it the chlorate of potassium may advantageously be combined with a tonic of hydrochloric acid and tincture of cinchona. (F. 28.) When the ulceration is considerable the ulcerated surfaces should be freely swabbed by the medical attendant with a saturated solution of permanganate of potassium. Two ap- plications of this kind, at intervals of two or three days, are generally sufficient; but, if practicable and necessary, such an application might be made daily, and a gargle of the ordinary Condy's fluid, half a teaspoonful to a pint — or a teaspoonful of the pharmacopceial lotion — should be used frequently, either by syringe or gargle as the age of the child may require. Loose teeth should not be extracted until a chance has been afforded them of refixing.themselves in their sockets, or until it is evident that their presence is prejudicial to the healing of the sores. 2. Thrush is a fungus which grows upon the buccal mucous membrane and occasionally extends to other parts of the digestive tract, such as the oesophagus, the stomach, and intestines. The oidium albicans is the name by which it has long been known, but Gravitz has called in question the previous descriptions,* and has shown that it belongs * " Zur Botanik der Sorrs," Deutsche Zeitschr. f. Prakt. Med., 1877, No. 20. 94 THE DISEASES OF CHILDREN. to the wide-spread moulds, and is identical with the mould of wine. It consists of long-jointed threads and spores, which, like tinea upon the skin, are sometimes entangled in the epithelium only, ahd sometimes run down in the folli- cles. Like tinea, it appears to be contagious. Its frequent presence in the mouth is thought to be favored by the acid reaction which so often obtains there. It is generally held to be a form of stomatitis, but it is not necessarily so. To many cases of stomatitis, thrush is superadded. The thrush fungus may no doubt itself be a cause of stomatitis, but it may and does exist without any appreciable inflammation whatever. Tinea of the scalp may exist without exciting any inflammation, and thrush likewise. It is thus that two groups of cases are met with in practice, those in which there is no inflammation, when the disease is readily curable, and those in which there is more or less inflammation, and where it is dangerous either in itself or as indicating a wide-spread disorder of the digestive tract associated with feeble energy. In the first group the affection is prone to attack infants within the first month of birth — the small and spare ones of infancy, who take to the breast badly or are being fed arti- ficially. Looking into the mouth, a layer of thin white membrane is seen covering the arch of the palate ; perhaps a little similar material is dotted in opaque white specks over the sides of the tongue — the mucous membrane around being quite pale and free from inflammatory action. Under the microscope the white layer is found to be composed of oil globules from the milk, squamous epithelium, and the spores and mycelium of the fungus. A better adapted diet — often in the direction of a little added cream — and the frequent application of the glycerinum boracis to the affected parts, will cure the disease. The mouth should be carefully wiped out after each meal with soft rag or well-wetted wool, STOMATITIS — THRUSH CANCRUM ORIS. 95 and the glycerinum boracis applied afterwards in the same way. Cases are on record in which the contagion appears to have been conveyed from one child to another by means of spoons, bottle-nipples, and such like ; and though it is doubtful whether vigorous children are liable to be contami- nated either with tinea or thrush, the possibility of such a thing should enjoin the most scrupulous cleanliness. In the graver cases, which the second group comprises, dryness and injection of the mouth are superadded ; the papillae of the tongue are prominent and vascular, and the fungus occupies a larger area and is of more luxuriant development. The dorsum of the tongue will be more or less covered, and the lips, cheeks and edges of the tongue are also affected with milky-white points of the growth. Superficial ulceration is also often present. In all cases of thrush, but in these bad cases more es- pecially, there is a liability to an erythematous rash, or even a superficial dermatitis, about the buttocks and genitals. Mothers are fond of telling that their children have had the thrush, and that " it has gone through them " — a popular impression which, although not wholly true (for it is but rarely that the fungus is present about the anus, or even in the intestines), is probably not altogether erroneous. What actually happens is probably this : The presence of thrush indicates a disordered state of the secretions of the mouth. The state of the tongue and faucial mucous mem- brane is, to some extent, an indication of disorder all along the gastro-intestinal tract with which erythema, intertrigo, eczema, or superficial dermatitis, by whatever name the dis- ease may be known, is associated. This is supposed to be due to acrid discharges from the bowels and to abnormally irritating qualities of the urine. But I am disposed to think, from the nicety and rapidity with which its recurrence can, in some children, be controlled by the regulation of the starchy 96 THE DISEASES OF CHILDREN. matters in the food, that it is in all probability a general blood condition, which appears in those parts where local conditions — such as warmth, moisture, and irritation — favor its outbreak. There may be some fever with this form of the disease. Severe thrush is usually a sequela of chronic diarrhoea or vomiting, prolonged starvation, and pyrexia of all kinds — but particularly when associated with gastro-enteritis and dentition. It may also present itself after any severe illness, such as any of the exanthemata may produce. This form of the complaint denotes extreme exhaustion, and the general condition rather than the local state calls for treat- ment. It is, moreover, a case rather for dieting than for drugging. The details must be suited to the special circum- stances ; but as a general principle it is not too much to say that the body-heat requires careful attention, and is to be kept up by all possible means. The food must be nutritious, and given frequently in small quantities. Stimulants, such as brandy or rectified spirit, in twenty-drop doses every three or four hours, are generally most beneficial. No care is too exhaustive for such cases. The directions for food, stimulants, drugs, etc., should all be written precisely on paper, and frequent visits should be made during the day to insure that they are intelligently carried out. In addition, small doses of carbonate of ammonium or of chlorate of potassium should be given (F. 28) every three or four hours, and the glycerinum boracis be applied fre- quently, as before described. 3. Cancrum Oris, Noma, or Gangrenous Stomatitis is characterized by the appearance of an indurated swelling in the cheek, which rapidly extends and mortifies, perforating the soft parts, and, if unchecked, destroying all the tissues within its reach. In this way a circular eschar is produced in which the entire cheek may disappear ; the ulceration STOMATITIS — THRUSH — CANCRUM ORIS. 97 extends into the orbit or on to the neck, the underlying bone being killed and the teeth dropping out. The disease commences on the inner surface of the cheek as a livid, red, painful induration, which soon extends through its entire thickness, and appears externally, the skin becoming red, tense, and shining. The area of redness gradually extends, the parts around become cedematous, and the central part gangrenous. An irregular ulcer is now seen in the centre of the affected mucous membrane, covered with a gray or yellowish-gray slough, which, by means of lateral and deep extension, rapidly kills all the soft parts, and ultimately produces a circular perforation in the cheek. The disease often appears to undergo a temporary arrest, but only to begin again shortly in the edges of the ulcer. The indu- rated swelling makes the opening of the mouth a difficulty, and there is copious dribbling of fetid saliva. The gan- grenous aspect of the sore, the blackened teeth showing gums beneath, and the excessive fetor, conspire to make a picture so repulsive that even the death of the child — which hitherto has resulted in over 75 per cent, of the cases — adds but little to its intensity, and comes in most cases as a wel- come relief. After the formation of the slough there would appear to be but little pain attending it; the child is usually prostrate and lethargic. The constitutional symptoms are not always alike. Oc- curring as it does so often in anaemic and exhausted children after measles and such like, malaise and fever (101 to 104 ), though usually present, may be overlooked ; and the drib- bling of fetid saliva and the livid induration of the cheek are the first signs to attract attention, the child soon after becoming prostrate and drowsy. But it occasionally hap- pens that the gangrene may progress even to the destruc- tion of the greater part of the cheek, the child all the while sitting up and playing with its toys ; in such case the fatal :S THE DISEASES OF CHIIX5 result may be due to the poisonous exhalations which the child breathes — perhaps to the putrid saliva which it swal- L:~.vs. In ?. niinrrir." :: :ast5 :he 5.:.:r-.n~ -: ;5 :: .5 arrested by treatment ; the edges of the ulcer granulate, and the child recovers. It is worthy of note that when this happens the gaping wound left by the gangrene will contract to very small dimensions ; but the perfection of the cure is somewhat marred by the frequent occurrence of corre- sponding distortion of the angle of the mouth, or the lower eyelid — or, by the inconvenience caused by adhesion of the :hi::: :: :he j:::. :r : :nes. Morbid Anatomy. — But little can be added to the clinical history. A black-edged, foul-smelling ulcer extends over more or less of one cheek. Its base is formed by what re- mains of the gangrenous tissue of the cheek, by remnants of gum tissue, necrotic jaw, and discolored and even ulcerated tongue. The soft parts being so extensively involved in the sloughing process, and having, in addition, usually received a copious dressing of some strong escharotic, are not in a state favorable to any minute examination ; but, so far as I have seen, there is comparatively little accessory oedema of the parts surrounding the disease after death ; nor need there be any formation of purulent thrombi in the facial or other veins of the neck ; but abscesses in the lungs and :iia from this source are occurrences which are not :r.:re:uer.:. :.r.i s:.:...i z- re:: f niberei :.:\i szi.rz'r.zi :::. Rilliet and Barthez describe the neighboring lymphatic glands as enlarged. The swelling is not usually great, but they may be considerably injected. I should be inclined, :::;:::. :: r.\:.\->o Male, Gerson. Symptoms of obstruc- Not Died. A few Bowel ruptured, and 12 tion, with hemor- mentioned hours. operation aban- weeks. rhage from the bowels. doned. 8 C Spencer Not specified. 4 days. Died. 5 hours Child almost mori- 4 mos. Wells. bund at time of operation. Child. Athol Not specified. Died. Johnstone. 12 Female, Wein- Symptoms of obstruc- 3 days. Died. 6 hours. Died in convulsions ; 6 mos. lechner. tion, with great pain, vomiting, and hemorrhage from the bjwels. peritonitis found at autopsy. 13 Female, Hutchin- Symptoms of obstruc- 1 month. Recov- Disin vaginati n ■2 years. son. tion merely ; intus- ered. effected without susception protrud- difficulty. ed from anus. INTUSSUSCEPTION. iS5 " Inspection of this table shows, in the first place, that there is no encouragement to repeat the operation in very young infants. The only instances in which it has been re- sorted to during the first year of life have all terminated fatally (Gerson, Wells, Weinlechner). But when it is re- membered that of Pilz's 162 cases (all occurring in children), no less than 91 were in infants less than a year old, it will be seen how large a proportion of cases must at once be put aside as unfitted for operative treatment. It is very true that the fatality of intussusception at this early age is enormous, the mortality being according to Leichtenstein's elaborate statistics no less than 86 per cent. But the case is very dif- ferent from that, for instance, of an operation for imperforate rectum, for in this condition there is necessarily no hope but in an operation, whereas in the case of intussusception ex- perience shows on the one hand that, even at this age, a certain number do recover without operation, and that on the other hand, as might be expected, operative treatment is in such cases of no avail. " In the second place, the table shows that in what may be called acute cases, those, namely, in which in addition to symptoms of obstruction there are evidences of strangulation, such as peritonitis and intestinal hemorrhage, a resort to operative interference will be productive of no benefit. These cases are, on the other hand, as justly remarked by Mr. Hutchinson, precisely those in which there is most hope of recovery by sloughing of the invaginated portion. " There remains then a limited number of cases, in not very young infants, in which the symptoms are those of obstruc- tion merely, without intestinal hemorrhage or peritonitis, and in which, when other measures fail, the question of operation may properly be considered."] In chronic intussusception great reliance may be placed on the free administration of opium and belladonna. This I56 THE DISEASES OF CHILDREN. form of intussusception occurs usually in older children, and four or five drops of opium and ten drops of tincture of bel- ladonna may be given every four hours to a child of five or six years old. Should these fail, inflation or water disten- sion must be tried, and as a last resort an operation must be discussed. [In both forms of intussusception it is important to so regulate the diet that the strength may, as far as possible, be conserved. The quantity of food must depend upon the condition of the stomach, and in selecting the quality it is necessary to choose what is readily digested and so as- similable that little residue remains to form faecal masses.] MEASLES. 157 CHAPTER X. MEASLES. Measles (Morbilli). — Rubeola is another term which be- longs to this disease ; but of late and abroad it has also been applied to Rotheln, and had, therefore, better be discarded. Incubation. — By this is meant the time between the actual introduction of the poison and the appearance of the first symptom of illness. This has been established (1) by experiment, measles having been introduced by inoculation in Edinburgh, Italy, and Germany; (2) by the careful ob- servation of outbreaks of the disease in what may be called virgin soil, such as that in the Faroe Isles, by Panum ; (3) from the records of actual practice as it occurs in our own climate. From all these sources it would appear that, though liable to modification within limits of three or four days either way, the incubation period centres around ten days. For instance, E. and F., of eight and ten, were at school from the 10th or nth to the 19th of the month, with a child who then sickened with what was subsequently found to be measles. The child sneezed so much on the 19th that the mistress particularly noticed her. And on the 25th E. began to be poorly ; on the 30th, a punctiform red rash appeared on the palate, and she left school for giddiness ; and on the 31st, the eruption appeared on the face, and quickly spread downwards to trunk and legs. F. was sleepy, and had headache on the 30th ; on the 31st the evening temperature rose to 100.4 , and the symptoms of cold increased; on the 14 I58 THE DISEASES OF CHILDREN. 1st, the punctiform eruption appeared; and on the 3d, the rash was noticed on the skin. These cases may also well illustrate the impossibility that often exists of exactly fixing the date of the introduction of the poison. Both children were at school, E. eleven days, F. eleven or twelve days after the source of infection left, but it is not improbable that the house or room in which they were was infected, and that the actual reception of the poison by F. was of later date than that by E. Prodromal Stage. — This is characterized by what is com- monly called a cold, and lasts about four days. The child is drowsy, sometimes remarkably so, and thus may give an early suggestion of what is coming ; it has headache. Then come redness of the eyes and lids, and running from the nose. Xext there is a dry cough and the evening tempera- ture begins to rise. This coryzal aspect — if the child is poorly, which generally means feverish — is very suspicious. The palate should now be carefully examined, and not infrequently the roof of the mouth behind the hard palate may be seen covered with a sharply-defined red blush, with a number of minute red papules upon it. Described by various independent observers, the value of this blush as an initial symptom preceding the eruption by some hours, is indorsed by Meigs and Pepper, Henoch, and others, and I have seen it well marked in some cases. Barthez and Rilliet do not, however, attach any value to it* Other symptoms are occasional only, and therefore of little value ; chief amongst these are epistaxis and vomiting. Eruptive Stage. — The eruption appears about fourteen days from the date of infection, or four from the first signs of illness. It is first seen about the ears, temples, and face * The punctiform rash above mentioned is almost uniformly present, and in my experience precedes the cutaneous eruption by almost twenty-foui hours. — Ed. MEASLES. 159 in the form of small, dull, red papules tending to cluster more or less in crescentic lines, although not usually arranged with any great regularity. In favorable cases its course is now rapid ; within ten or twelve hours it will have spread to the trunk, and even to the legs, and within twenty- four the Lice will be more or less covered with dull red, raised, and often confluent, blotches which strangely alter, not to say disfigure, the features. The face generally bears the brunt of the attack ; it is not usually so thick on the trunk, and still less so on the legs. The temperature usually mounts, by evening rises and morning falls, for the four s preceding the outbreak of the eruption, and then falls again rapidly when the rash begins to fade in twenty-four or forty-eight hours, and in mild cases it is normal or sub- normal by the third or fourth day from the first appearance of the rash. 2asb : —I :v :? 15. _ , r eruption 4th dav if. t. 1 : : : < , ^ appeared. it, 1 :a.6° 5th day if. T. IC2 : E. t. ior.2- 6th day if. r. ici c 7. 7, : 7th day m. t. 97. 7 : . etc. ? . : : — C 3d day if. 7 normal. f eruption 4th day if. T. 102.3° E. T. io:.S : 5th day iff. T. 102 ,_ : E. T. I02.3 e. t. 00. ; r . etc. I appeared. But no great regularity can be depended upon in the pro- dromal stage ; the temperature may, with only slight dis- turbance previously, run up quickly at, or just before the outbreak of the eruption; or the height of the fever may be reached before the eruption appears. If the temperature remains high after the fourth or fifth day from the appear- ance of the eruption, the chest should be carefully examined and watched. Very commonly some broncho-pneumonia is the cause of this. l6ti THE DISEASES MP CHILDREN. The eruption soon fades, but leaves the skin somewhat marbled by reddish-brown stains for some days afterwards, and it is often followed by slight branny desquamation, most ble about the face and neck, when the rash has been profuse. The pulse is full, soft, and considerably quickened during the height of the attack — I20 c to i-icr — and may even be intermittent for a few hours ; but it speedily recov- ers itself at the first approach of a crisis. The bronchial affection is generally the most persistent part of measles. The disease is ushered in by a dry* cough, and more or catarrh results from this, consequently a loose cough or one associated with an excess of secretion, may linger for some In many cases no more than this happens, the pul- monary* parenchyma remaining healthy throughout, or at most showing no other abnormality than harsh breathing or an occasional rhonchus or rale. In severe cases the c affection is paramount, and we then have to deal with a diffused broncho-pneumonia or capillary* bronchitis, perhaps a sluggishly appearing or retrocedent eruption, pallor of face, lividity of lips, dilating alae nasi, and high lever. Modifications. — It has been the custom to dc hree or four varieties of measles, but it is enough to state that measles, like all other exanthems, is liable to van*. The typical disease is known by fever, a peculiar eruption, and a catarrhal inflammation of the respira: Common sense will tell anyone that in very* mild ; the catarrh may be absent or the eruption all but so. In bad cases, on the other hand, the eruption may be- come very dark-colored or even petechial, and the catarrh, which is a part of the natural history* of the disease, be replaced or added to by a more or I re broncho-pneu- monia. In such cases also, it hardly needs the j, the eruption may be irregular in its progress, or fitful in its MEASLES. l6l appearance, and the general indications from pulse, temper- ature, and nervous system, are likely to be grave in propor- tion. The condition, however, which is described by Bar- thez and Rilliet as rougeole anomale is worthy of distinct mention, because it calls attention under one term to many puzzling cases in which the eruption comes out later or in some lagging fashion, and in parts of the body where we should perhaps not expect it, such as on the abdomen or extremities. Measles may appear first on the buttocks, for example, where eruptions of all sorts are so common, and should the child have been ill for four or five days with acute pneumonia, the real disease might well pass unrecog- nized. Complications aud Sequelae. — Of these by far the most important, because most frequent and most dangerous, are broncho-pneumonia and membranous laryngitis, or croup. Of others may be mentioned marasmus, diarrhoea, whooping- cough, and, as late oncomers in unhealthy children, a tribe of glandular and other affections — discharge from the ear, sup- purating glands in the neck, caseating mediastinal glands, and general tuberculosis. Albuminuria is a rare sequela. I have seen it once in the second week. Broncho-pneumo- nia, being in a measure part of the natural history of the disease, is the most common and the most destructive to life. When it comes on suddenly, as it may do in young children, the eruption may be slight, but the temperature often arises in these cases to 105 ° or 106 , the child becomes pallid or livid, and dies in a semi-collapsed state. Naturally there are all degrees of pulmonary affection between this the most extreme and the milder cases. Membranous laryngitis is another common outcome of measles. It may attack the child at any time ; most usu- ally within a week or ten days after the subsidence of the rash. It is probably epidemic in its occurrence — that is to 1 62 THE DISEASES OF CHILDREN. say, is more prone to occur at special times than to attack all cases of measles indiscriminately. But from its gravity it should never be forgotten, particularly if the laryngeal cough has been troublesome or persistent during the fever. Diarrhoea is another associate which may either usher in or follow the disease, and is described by Henoch as some- times being very profuse and dysenteric in character. It also is epidemic in manifestation. Marasmus I note for this reason, that when very young children — a year to eighteen months or two years old — are attacked with measles, it may happen that the eruption comes out sluggishly, the fever persists, though not to any excessive degree — 102 to 103 — the tongue and mouth be- come dry and ulcerated or covered with sordes, and rapid emaciation takes place. And this, without any pronounced broncho-pneumonia, croup, or other fatal accessory. Whooping-cough is generally spoken of as being espe- cially related to measles, and certainly the impression that is left upon my mind as the outcome of experience is, that the two affections often follow one upon the other. But . when an appeal is made to statistics the association appears to be less common than I had anticipated. Of 305 cases of pertussis of which I have notes, measles is only mentioned as recent in fourteen. There would appear to be some dif- ference of opinion also as to the relation which the two diseases bear to one another. West speaks of measles as following the pertussis. My own experience is contrary to this. In all these fourteen cases the measles came first and the pertussis closely followed. For instance, a girl aged thirteen months, was well till six weeks before admission ; then came measles, and after fourteen days pertussis. But the cough may follow within a day or two of the outbreak of the measles. When measles follows upon pertussis, the characteristics of the latter may temporarily disappear. MEASLES. 163 What the real relation of the one to the other may be, can only be a matter of conjecture, but it is probable that for measles, pertussis, membranous laryngitis, and varicella — all of which seem prone to combine — the presence of any one lessens the resistance which a healthy body manifests, to the infective power of the others. A child therefore with measles would be more susceptible to either of the others should it be epidemic at the time. Noma and necrosis of the nasal cartilages after measles have been recorded. As late results of measles there are many indefinite conditions of ill-health when the disease has been severe or neglected. It is certainly far from uncommon in the out-patient practice of a children's hospital to hear the tale that the child has never been well since the measles. And this in all sorts of affections — marasmus, glandular ab- scesses, skin affections, etc. It is, however, very difficult to arrive at facts, but it is my belief that a very common result of measles is cheesy degeneration of the mediastinal glands, and a subsequent tuberculosis of the lungs. As I shall state elsewhere, one of the commonest forms of chest disease in childhood is this — a cheesy enlargement and softening of the mediastinal glands, and one or other form of lung disease supervening — generally a miliary tuberculosis, but not always. The history of many of these cases credits measles as the source, and nothing would seem to be more probable. Measles with its bronchitis or broncho-pneumonia is fol- lowed, no doubt, in most cases with more or less inflam- matory swelling of the corresponding .lymph glands, which, becoming choked with inflammatory products, undergo cheesy degeneration. Moreover, although less liable than scarlatina to any marked affection in the course of the fever, the glandulae concatenatse frequently undergo some slight enlargement and induration after measles, and no doubt slight changes originate then which, in unhealthy subjects, 164 THE DISEASES OF CHILDREN. or from subsequent neglect, may run on into the' chronic enlargements, cold abscesses, scrofulous ulcers, etc., which are so well known and so much dreaded. Etiology. — Measles exhausts the soil, and, as a rule, oc- curs only once. But in some cases a second attack or re- lapse follows the first after a short interval ; in others a true second infection must occur, the second attack being many years after the first. Sucklings appear to be less liable to infection than older children, and when attacked often have the disease in a mild form. Measles is highly contagious in the catarrhal or pre-eruptive, and also in the eruptive, stage. After this it would appear that the infective power becomes much less active and soon disappears. But there are cases on record of infection being conveyed in the third week after the outbreak of the eruption, and therefore the rule to be pursued is that if possible a month should be allowed to pass from the onset of the eruption before a child is again permitted to mix with healthy children. It is prob- able, however, that very little risk indeed is run at the end of the third week, provided that the child is not surrounded by a more recently infected atmosphere, or by clothing im- properly disinfected. Measles is chiefly conveyed directly from the sick to the healthy ; but it can be, and is some- times, carried through the medium of healthy persons by fomites in the clothing. Such cases, however, usually show cause for copious infection — the medium being either a child coming from an infected house, or somebody who has re- cently been in contact with the sick. As regards isolation in a family, this is not usually prac- ticable in any strict fashion, but it should certainly be car- ried out for healthy children under four years of age, or for delicate children. In healthy children above that age, seeing that the disease so usually runs a favorable course, it is a question whether vigorous measures are worth attempting. MEASLES. I65 Moreover, of isolation let it be remembered that to be ef- fectual it must be put into practice early, not when the erup- tion appears, but at the very onset of the catarrhal stage. This can best be done by the methodical use of the ther- mometer for every child that has been exposed to infection. Morbid Aanatomy. — Nothing is yet known for certain as regards the state of the blood. Quite recently a bacillus has been found in the urine of patients suffering from measles, but at present, though everything points towards future advances in this direction, nothing can be stated with cer- tainty. [Drs. J. M. Keating and Henry F. Formad, in an epi- demic of measles, occurring in the Children's Asylum of the Philadelphia Hospital during the early part of 1882, found micrococci in large numbers in the malignant cases both during life and after death, but none in cases of mild type. They were found in the liquor sanguinis, and in the white blood-corpuscles, acting especially upon the latter.] Drs. Braidwood and Vacher describe minute bodies ob- tained from the breath, and also in the skin, lungs, liver, etc., after death.* The microscopic appearances consist chiefly of more or less injection, perhaps even superficial erosion about the palate and epiglottis, sometimes also of the intestine ; and a diffused broncho-pneumonia. This has no special pattern, and need not be described here, as it is treated in its place as one of the diseases of the chest. Atelectasis is not un- common, and pleurisy is often associated with the pneu- monia. As less common complications, membranous laryngitis, diphtheria of pharynx or conjunctiva, keratitis and colitis, have occasionally been found. As a later con- dition Henoch describes a chronic broncho-pneumonia with dilated bronchial tubes and terminal abscesses in the lungs ; * Trans. Path. Soc. of Lond., vol. xxix., p. 422. 1 66 THE DISEASES OF CHILDREN. but I am not clear that this can be separated from the far more common condition of cheesy degeneration of the bronchial glands and lung with miliary tuberculosis super- added. Some authors describe an acute fatty degeneration of the liver, but this is a change which is not peculiar to measles. [In the previously mentioned epidemic at the Philadel- phia Hospital, death was found to be due to heart-clot, the formation of which was supposed to depend upon the pres- ence of large masses of micrococci in and about the white blood-corpuscles.] Diagnosis. — The cardinal points in the diagnosis of measles are the slow onset and the coryzal aspect. In scarlatina, from which the difficulties chiefly emanate, the child is taken suddenly ill, often with vomiting, and within twenty-four hours the eruption appears. In measles there is less often sickness, and the rash does not make its appear- ance for four days. Of the eruption it is less easy to speak dogmatically — it is true that in a typical case the distinctions are plain, perhaps in few diseases more so — but there are many cases where from the eruption alone an opinion is impossible. For instance, a child, seven months old, was brought with what was clearly measles — coryza of two or three days and a characteristic swelling of the eyes. The eruption is thus described : there is a general red blush of the skin of the entire body, with additional raised small bright red papules, running sometimes in a crescentic pattern. The rash has some of the characters of scarlatina, some of measles. There will come to every one cases in which it is impossible to speak with certainty. In such it is necessary to take note of all the features of the case, and to form an opinion only after due deliberation — in the meantime taking all proper precau- tions. No discredit can attach to indecision when a decision MEASLES. 167 is an impossibility ; and, on the contrary, nothing can be more damaging to the reputation than an ignominious re- treat from a hasty diagnosis of " rose rash," or " German measles," before the developed and cold logic of facts. Treatment. — In the prodromal stage the child should be kept in one room in a regulated atmosphere of a tempera- ture of about 65 °. As the cough becomes more trouble- some, some sedative, such as the compound tincture of camphor, may be given — twenty or thirty drops every three or four hours for a child of four or five years. The diet should consist of plenty of milk and water or barley-water, with any farinaceous food that may be fancied, and bread and butter or toast. When the rash appears the child is to be kept in bed, and in an ordinary case very little more is required. If the skin itches, as it sometimes will, the body may be oiled three or four times a day with carbolic oil (1 +40). If the temperature rise to 103 , a warm bath 98 to ioo° may be given as often as necessary. This acts as a good soporific in many cases. The cough is to be treated by small doses of the compound tincture of camphor or some such expectorant as F. 35. If these means are not sufficient, nothing relieves the hoarse hard cough of measles, which appears to be depen- dent upon an inflammatory condition of the rima glottidis, better than swabbing the fauces and throat with glycerine, or borax and glycerine, by means of a laryngeal brush. At the height of the eruption, the temperature not un- commonly runs up to 104 or 105 ° for a few hours, without any corresponding severity of the other symptoms. There is no need to interfere for a temporary disturbance of this sort, but for a persistently high temperature of twelve hours or more bathing should be resorted to. The first bath may be at a temperature of 95 ° to 98 . The temperature will often fall and sleep come by this means alone. If this fail to 1 63 THE DISEASES OF CHILDREN. reduce the temperature, tepid or cold sponging may next be resorted to, or the chest and abdomen may be covered with an ice pack or by frequent cold compresses. As a last resort the tepid or cold bath must be tried. The child should be undressed as quickly as possible, so as to be worried as little as possible, and then immersed in a bath of the temperature of 90° which then may be rapidly cooled by the addition of cold water to So . Five or six minutes' immersion is usually sufficient. The child is then dried rapidly by a soft towel, and put to bed again between sheets. It is now to be watched carefully and the temperature recorded every two or three hours. The effect of the bath is sometimes very powerful, and the child remains livid- looking and collapsed for some time. In such cases small doses of brandy must be administered in warm milk at fre- quent intervals, and a hot bottle kept to the feet. Some go so far as to say that when the temperature reaches 102 , some one or other of these means are to be resorted to. Such a rule as this seems to me to be a meddlesome practice which, to say the least of it, is unnecessary. There may be cases in which, with a temperature of I02 c , the child is very ill, and the fever may be judged to be more than usually detrimental. For such, a bath, either tepid or cold, or cold sponging, maybe recommended; but for one such case, there are many others which run a perfectly favorable course, with a temperature even higher than this, and in which it may reasonably be asked in what way anti-pyretic applications could have bettered them. Each case must be judged upon its merits. [Should the fever be very high, sulphate of quinia by the mouth or better by the rectum, in two to four grain supposi- tories every three or four hours, will frequently reduce the temperature and, should there be much restlessness, produce sleep. At the same time should symptoms of exhaustion MEASLES. 169 or heart failure appear, tincture of digitalis or carbonate of ammonium with some alcoholic stimulant are indicated. The latter especially may be given freely when the case is malignant.] As regards staying in bed, measles varies so much that no rule can be laid down. It is generally well to keep a child in bed for a couple of days after the temperature becomes normal, and to its room for a week further. It should be kept indoors for three weeks or a month. The room occupied by a child with measles is to be kept well ventilated. In most cases the window may be allowed to be a little open at the top ; all draughts are to be avoided, and in obtaining fresh air the temperature of the room must not be allowed to fall. Broncho-pneumonia, if it exist, must be treated as in other cases. If the child be feeble, a few drops of sal vola- tile or a grain of carbonate of ammonium may be given, and some liquid extract of liquorice; or expectorants, such as squill, ipecacuanha, and compound tincture of camphor may be necessary. Counter-irritation may be applied by mustard-leaf for a few minutes over the diseased part, fol- lowed by a warm fomentation or warm linseed-meal poul- tice at first, and then a cotton-wool jacket. The diarrhoea that sometimes accompanies measles is probably due to some catarrhal state of the gastro-intestinal mucous mem- brane, and the first thing to be attended to therefore is the quantity of food that is being taken. The milk may be too much, and thin broth or cream and whey, or egg albumen, may suit better for a few hours. In severe diarrhoea cold compresses are very useful. Several folds of linen are to I be wrung out of cold water, put over the abdomen and covered with flannel, and changed every two or three hours. For medicines, thirty drops of brandy with some syrup and cinnamon water is a simple and an effectual remedy repeated 170 THE DISEASES OF CHILDREN. every 'three or four hours. A teaspoonful of fluid magnesia is a good thing to commence with, given two or three :: a day, and subsequently, if not successful, a few drops of dilute sulphuric acid may be given with a drop or so of opium. Dover's powder is also useful for such cases, and so also are the liquor bismuthi and the subnitrate of muth. Membranous laryngitis will require a treatment such as that indicated in its special section ; but it may be said here that probably much may be done in measles to avert its onset if the throat and fauces be painted energetically with a solution of boracic acid, or borax and glycerine, every hour or two, whenever the cough becomes at all croupy in character. Other parts require also careful attention. The ophthal- mia which often succeeds to measles needs cleanliness and some mild antiseptic wash — permanganate of potassium being one of the best. The ear is prone to discharge after meas if so, it is at once to be taken in hand and treated carefully and regularly on antiseptic principles. It is to be gently syringed with a weak spirit lotion, a teaspoonful of spirits of wine to the half-tumbler of water, and carbolic oil (1 + 40), glycerine and borax, or the solution of boracic acid in gly- cerine, dropped in afterwards, and a little salicylic wool placed in the orifice. This is to be done three times a day, and every effort made to keep the part sweet. The great danger of aural discharge is its liability to decomposition, and decomposition of the discharge leads to extension of the inflammation to the bone which limits the tympanic ca and so to necrosis and its consequent evils. For some weeks after measles the health demands extra watchfulness. A salt-water bath should be given in the morning, and the clothing be always warm. Anaemia must be treated by iron and cod-liver oil. Any capriciousness of MEASLES. 171 appetite should be guided, if possible, back to normal by the same means, or by the judicious administration of stimu- lants, and above all by change of air — a dry, bracing air — whether it be sea or inland, and plenty of it, is one of the best restoratives. If there be any tendency to enlargement of the glands, no doubt sea air is the better ; otherwise I am inclined to think that a farm-house life, with its freedom from restraint, its good milk and bread, its rough-and-tumble exercise on a farm-pony, is the best restorative in existence. 172 THE DISEASES OF CHILDREN. CHAPTER XL SCARLATINA. Of all the diseases of childhood there is none which pre- sents greater varieties of aspect than scarlatina — none which so often brings, with very short notice, unexpected deaths into a healthy household, or which more often selects for its victims the robust and healthy. Thus writes the late Dr. Hillier; and it would be difficult to put more shortly and more graphically the terrors of this .scourge. Some years ago, when taking charge of a practice in the country, I was called to a village some miles away to see a child who was very ill. I found a well-nourished girl of about five years old. She was pulseless, livid, and comatose, with an almost petechial scarlatinal eruption covering the skin. I was told that she had been quite well till the preceding afternoon. She had suddenly vomited while at the Sunday-school, and came home ill. I saw her about eight p.m. the next day, and she died within three or four hours ; so that the duration of the disqase from its outbreak to the death of the child was under thirty-six hours. Scarlatina is in great measure a disease of childhood, sixty-three per cent, of the deaths, according to Dr. Murchi- son, being under five years of age ; ninety per cent, under ten ; and ninety-five under fifteen years. The disease is not prone to attack children in the first year of life, and this is more markedly the case even than with measles ; but it may occur at any age, and cases are on record where infants have been born with the eruption upon them, and in which des- quamation has occurred in due course. Meigs and Pepper SCARLATINA. 1 73 have seen it perfectly well-marked in an infant twenty-one days old. It is a disease which occurs in epidemics, though no large town is ever quite free, and it varies much in severity. Epidemics differ from each other in this respect, and case from case. To be infected from a mild form is no guarantee of an equally mild attack, etc. It is a disease which spreads by infection, though it is often difficult to fix the source of contagion. Incubation. — This is somewhat variable. It may be only a few hours — in many cases it is stated not to exceed forty- eight hours, and it rarely exceeds seven days. Conse- quently any one who has been exposed to the poison of scarlet fever, and who does not sicken within a week of quarantine, maybe pronounced safe. The disease is gener- ally latent at this stage, and the child retains its ordinary health. Prodromal Stage is short ; so much so that it is common to find a child quite well, or apparently so, till it suddenly turns pale and vomits ; and from that time onwards it is seriously ill, its extremities perhaps cold, fever high, and its whole aspect one of dulness and exhaustion. The disease may set in with convulsions or bad headache, but this is not common. More often there is some soreness of throat for a day or two before the child regularly sickens. Eruptive Stage. — Within a very few hours of the initial symptoms, during which the child will be more or less heavy and prostrate, and in high fever — perhaps vomiting fre- quently, perhaps with bad headache, perhaps convulsed — the eruption appears. It is seldom delayed beyond twenty- four hours. The rash consists of a general rosy blush upon which are set darker red points, the surface being smooth unless, as often happens, it is accompanied by miliaria. Some authors state that the dark red points in the eruption are sometimes distinctly raised. In case the roseola is not 15 174 THE DISEASES OF CHILDREN. too diffuse, the healthy colored skin peeps out here and there. The puncta may be even petechial in places. The rash appears first about the neck and shoulders, and rapidly spreads over the trunk and extremities. It is not always evenly diffused ; on the contrary, it is sometines so patchy as to create a doubt about the diagnosis. For instance, I have seen it almost confined to the buttocks, the back or the ankles. The face is said by some authors not to be often affected, but this is not strictly correct. There is not the punctate rash seen in other parts, but a diffused blush is by no means uncommon. The rash is accompanied by some swelling of the skin. The outbreak of the eruption is attended with a still rising temperature, with increased sore- ness of throat, and with a very rapid pulse. The extreme rapidity of pulse is indeed one of the characteristics of scarlatina, and it goes for little as an indication of the gravity of the case. A pulse of 160 is no uncommon feature. The sore throat is due to some swelling of the tonsils, but more especially to a general swelling and vivid redness of the whole mucous membrane. The tonsils, uvula, and palate generally are highly injected and swollen. The tonsils are covered with secretion of puriform appearance, and are more or less ulcerated after the third or fourth day. The tongue at the same time is thickly furred with a white or creamy fur, through which peep brightly red swollen papillae. The edges of the tongue are often free from fur, and are brightly red, the papillae being bulbous-looking from swelling. This constitutes the " strawberry tongue." The fur gradually cleans away as the disease subsides, and leaves an unnatu- rally raw red-looking tongue. In severe cases the throat is badly ulcerated, or shows patches of membrane upon it. The lymphatic glands in the submaxillary region are en- larged — in mild cases moderately, in bad cases much. At this stage the urine should be free from albumen. It is SCARLATINA. 175 usually somewhat scanty with diminished chlorides, and later with diminished phosphates. It may give evidence of a trace of blood by the guaiacum test, and there may even be albumen or casts. The temperature may rise to any height between 102 and 105 °, and it remains high for three or four days. It gradually subsides as the rash disappears, and if no compli- cations arise, becomes normal in seven or eight days. It is often hindered in its descent, however, by a disproportionate severity of the disease of the fauces — ulceration of the mucous membrane, or swelling of the lymphatic glands — and many young children pass into a condition not easily described, in which the temperature remains high, with a raw, red condition of the mucous membrane of the mouth, a dry skin and general debility lasting for many days. At the end of a few days, desquamation begins. In nine- teen cases noted by Hillier, its commencement varied from the sixth to the twenty-fifth day. The skin, having remained harsh and dry meanwhile, now becomes covered with small branny scales, while about the palms of the hands and soles of the feet larger scales are detected. Occasionally in these parts the entire epidermis is shed en masse as a glove, the nails, perchance, coming off also. The natural duration of the desquamating stage is well-nigh unlimited — the scales being like the dead leaf or blade of grass which depends upon external forces for its removal — but it is advisable to determine it as quickly as possible, and this may be easily done by the frequent repetition of warm baths, scrubbing, and frequent oiling. Modifications. — Such, shortly stated, is typical scarlatina. But this is hardly sufficient — it is necessary again to remind the student that there is no disease which deviates more from a type than this does. The time-honored description of three forms — the simple, anginal, and malignant — testifies to 1/6 THE DISEASES OF CHILDREN. this. I shall adopt no such' subdivision, for the simple reason that there are so many varieties or degrees of severity which pass as such, that it is less perplexing to the student to follow existing authors in stating, generally, that some- times it is so mild that the illness is hardly appreciable, and there is either no eruption or it is of the very slightest amount; sometimes the eruption fades in a day or two in place of lasting five or six days. Again, the intensity of the disease in the throat varies much. It may be very little ; it may, on the other hand, be attended with extensive ulcer- ation and even the formation of membrane.. At another time the fauces may at the most not indicate any severe affection, while yet ulceration is insidious, progressive, and ultimately extensive. As regards the disease in the throat, it is the most regular in its appearance of all the symptoms ; it is certainly often present when scarlatina is rife without any other symptom, and patients thus lightly affected are for the most part protected from subsequent infection. And as regards young children, it is well to remember that it may be present to a considerable extent and pass unnoticed, the refusal to take food which indicates its existence being at- tributed to the anorexia of the febrile state. The enlarge- ment of the lymphatic glands at the angle of the jaw is the best evidence of its presence and its extent, and whenever there is any swelling at the angle of the jaw, a careful exam- ination of the fauces should be made. With reference to the question of malignancy, scarlatina is a disease which, like small-pox, is sometimes so destructive that its entrance into the system is sufficient to put a stop to all the natural processes, and to bring about coma, col- lapse, and death within a few hours. In cases such as this, as already narrated, the child vomits, the temperature runs up to perhaps 105 °, the pulse becomes very rapid and feeble; SCARLATINA. \JJ the extremities become cold, the face lividly pale, and there is often profuse sweating. In a less rapidly fatal and more prevalent form, the fever runs on for four or five days with delirium, perhaps vomiting, and the child succumbs, exhausted, with dry tongue, pos- sibly stupor, convulsions and coma, towards the end of the first week. Complications. — Strictly speaking there are not many. The ulceration of the fauces may be extensive and lead to hemorrhage, or to the rapid formation of glandular ab- scesses, or even to sloughing of the skin. The inflammation of the fauces sometimes extends to the larynx, as in diph- theria. Then again convulsions may suddenly set in, generally in association with the sudden onset of albumi- nuria, but sometimes they may be associated with the onset of meningitis, which is, however, a rare complication, or with the commencement of some intercurrent inflammation. Sometimes in severe cases, as already noticed, there ensues a condition' of coma and rapidly fatal collapse. Diarrhoea is sometimes troublesome ; occasionally, too, the joint affec- tion known as scarlatinal rheumatism may set in early, and may be associated with endo- and more rarely with peri- carditis, and it may be that in severe cases the synovitis may be of a destructive form, and the joint rapidly fill with pus, or thin purulent fluid. Scarlatina may be associated with other exanthems and fevers. I have seen the eruptions of varicella and scarlatina both out at the same time. Dr. Gee has seen the same. Diphtheria or typhoid fever may either of them run concurrently with it — it has usually been that scarlatina has occurred in the course of typhoid fever — and both measles and small-pox are occasionally superadded to scarlet fever. The supervention of diphtheria is very likely to be fatal, but measles and varicella neither alter their 1/8 THE DISEASES OF CHILDREN. course, nor that of the scarlatina, nor do they necessarily increase the gravity of the prognosis. And here may be mentioned what has been called surgi- cal scarlatina. It has been noticed by many observers that a red scarlatina-like rash sometimes appears after operations, the nature of which has seemed doubtful from its quick ap- pearance within a day or two of the operation, and the modi- fied course which it often runs — chiefly in the direction of mildness and rapid subsidence. From what has already been said on the incubation of scarlatina, these w r ill seem but hazardous distinctions with which to combat the scarlatinal nature of this affection; and there is now no longer any doubt that it is true scarlatina for the following reasons, which are admirably stated by Dr. Gee : That it occurs in epidemics ; that a severe case (with bad sore throat and even albuminuria) occasionally relieves the monotony of the mild form ; that the disease is not exclusively confined to patients who have been subjected to operation ; and lastly, that how- ever freely these patients are subject to scarlet fever con- tagion afterwards, they do not contract the disease. It might be thought that an operation or open sore would naturally render its subject more liable to develop a disease which is propagated by fomites, since erysipelas is known to attack such cases with peculiar readiness, and probably enters by the wound. But from some observations made by Dr. Paley and myself at the Evelina Hospital, it appears probable that the poison does not gain an entrance by this means ; for the antiseptic treatment of wounds, a most effective bar to the occurrence of erysipelas, is none to the advent of scarlatina. Several interesting hypotheses have been advanced to ex- plain the readiness with which operation cases develop scarlatina. Sir James Paget attributes it to the lessened resistance induced by the surgical operation. It appears to me, however, that being by no means confined to the sub- SCARLATINA. 1/9 jects of recent operations, the more probable explanation is that some modified process of incubation takes place in any- inflammatory focus that may be existent. This, however, is not the place to discuss a question of such a kind — the important point for the student to lay hold of is, that surgi- cal scarlatina is true scarlatina, however modified, and must be dealt with as such. Relapses are not very rare. Hillier mentions the case of a student who had had three attacks of scarlatina, and a week after his third attack he had a distinct relapse. Thomas de- scribes pseudo-relapses in which a roseolous eruption breaks out after the fever has run its course. They generally ter- minate favorably. A second attack of scarlatina in the same individual is much more common. Indeed, of all the exanthemata, scar- latina is the one which is least protective against its recur- rence. The large majority of persons are exempt, however, from any typical recurrence, but when scarlatina is prevalent, sore throats are common even in those who have suffered from the disease at some former time. Sequel88 are numerous. They are — nephritis, leading to albuminuria and dropsy; dropsy without albuminuria, con- vulsions, serous inflammations, glandular abscesses, diph- theria, otorrhoea, rheumatism, etc. Scarlatinal dropsy, always understood to mean nephritis and albuminuria, may occur at any time, and should always be watched for throughout the attack. It most usually begins during the desquamative stage, but it may begin in the eruptive. If the urine be carefully tested, a transient al- buminuria, or the presence of blood, is probably not uncom- mon in the first week of scarlatina, and I have seen, as probably most of us have, a severe nephritis begin suddenly as early as the fifth day. As a rule, however, the stage of desquamation is the time for albuminuria, and the urine ISO THE DISEASES OF CHILDREN. should be carefully tested day by day until this stage is com- pleted. The frequency of albuminuria appears to vary in different epidemics. Some practitioners may be found who have but seldom come across it, and who indulge in the be- lief that it results from neglect or bad treatment. This is not correct. There can be no doubt whatever that the ma- teries morbi of scarlatina is particularly obnoxious to the kidneys. In the early days of the fever the urine will often reveal by excess of mucus, epithelium, hyaline casts, and occasionally by blood and transient albuminuria, distinct evidence of renal disturbance; children, too, become dropsi- cal and albuminuric while yet in their beds, and with the eruption still out upon them. Nevertheless, this is a whole- some belief, as it makes for what is a powerful prophylactic treatment, and there can be no doubt that much less would be heard of scarlatinal dropsy were children dieted more strictly, and confined during convalescence more rigorously to bed, or to their room, than has often been the custom hitherto. The albuminuria varies so much in duration, ac- cording to the severity of the nephritis that occasions it, that it is impossible to speak in any precise way of its course. In mild cases it may last only a few days, the albumen never being in large quantity. If there be much albumen and blood, then there is severe disease of the kidney, and its course will be such as an acute nephritis is known to take — a lingering one, lasting perhaps a month or six weeks, and often much longer. Nevertheless, it does occasionally hap- pen that a considerable quantity of blood or albumen appears quite suddenly, and disappears in the course of a day or two, almost as suddenly. It is said most commonly to set in towards the end of the second week ; but so long as desqua- mation lasts, an uncertain period of some weeks, there is a chance of its recurrence. In thirty-four of my own cases, of which I have notes, it set in — in the first week in two, in SCARLATINA. I 8 1 the second in eight, in the third in seven, in the fourth in nine, at some later period in four, and in four the relation to the eruption was uncertain. It usually sets in with fever, perhaps with vomiting, and the pallor which comes over the child's face is often most striking. In the cases which I have seen the pulse has not presented those characters of resist- ance or hardness which are recognized so quickly in adults. It is stated to become preternaturally slow, fifty to sixty. It is more common to find it irregular. The evidence of car- diac disturbance is indeed often striking. The impulse is displaced outwards, and may be felt sometimes at one spot, sometimes at another. The beats are irregular in their force, and halting in time; the first sound may be thick and mur- murous, or accompanied by a distinct systolic apex bruit, and the second sound is accentuated. Twelve cases out of thirty-four gave evidence of heart disturbance such as this, and in six of the twelve there was a distinct bruit. The urine quickly presents characteristic appearances; it becomes scanty, is passed frequently in small quantities, and is either smoky or deposits a dirty-brown sediment, or may be port- wine colored from the presence of pure blood in quantity. It is usually highly albuminous, and shows blood, large epi- thelial and hyaline casts, and much granular detritus under the microscope ; but there is much variation in this respect. In the less acute cases the albumen may be in moderate quantity, the color but little removed from a normal standard, and urates present in considerable quantity. The dropsy of the face, and in severe cases of the subcutaneous tissue generally, is prone to follow quickly, and seemingly often suddenly. When the disease runs a favorable course, the albumen may remain in the urine in good quantity for four or five days ; but it quickly diminishes, the blood disappears, the urine increases in quantity, urates begin to be passed in quantity, and gradually all the symptoms disappear. 16 1 82 THE DISEASES OF CHILDREN Unfortunately there are many other less favorable results. The disease may set in with convulsions, or the urine may become gradually more scanty, the dropsy more extreme, and convulsions supervene after four or five days or more. Convulsions are necessarily serious, and are often fatal ; but in many cases they subside, the child remains drowsy for a few days, and gradually comes round again. At another time a child will seem to be doing well, with but a moderate amount of dropsy and albuminuria, when somewhat suddenly its breath becomes short, coarse rales appear in all the bronchial tubes, and death follows quite rapidly, and even, not uncommonly, suddenly and unexpec- tedly. These are they who are said to die by acute oedema of the lung, but in some of whom at any rate acute dilata- tion of the ventricles of the heart takes place, and with this oedema of the lungs and sudden death. In other cases the serous cavities become full, in conjunction with extreme anasarca — a state of things more usually present in the more chronic cases. Ascites may be present at any time, and is not necessarily of serious omen in acute cases, pro- vided that the pleura and pericardium remain free. On the other hand, the nephritis may commence insidi- ously, without any of the symptoms indicative of acute disease, and of course therefore without anasarca. Such cases are, however, rare in comparison with scarlatinal dropsy. In hospital practice, yet another condition must be men- tioned as the most largely prevailing of all — viz., where children are brought for dropsy, many weeks after some indefinite attack of illness which we can only suppose has been scarlatina. In these cases also the onset of the renal affection is probably insidious. No history can be given of any striking alterations in the character of the urine at any time, and with considerable albuminuria there is usually SCARLATINA. 183 free diuresis and little alteration of the color of the urine. In these cases the prognosis must be cautious. [A retrospective diagnosis is often possible in these cases from the peculiar appearance of the fingers and toes. Des- quamation continues here long after it has ceased in other parts of the body, and they present a smooth and shiny surface, as if smeared with oil.] Dropsy without Albuminuria, — Meigs and Pepper state that they have never met with dropsy after scarlatina in which they did not find albuminuria. Most writers, how- ever, allude to a condition of what, for the sake of dis- tinguishing it, we may call simple anasarca, and it is not uncommon. The first case that came under my own notice was in the Evelina Hospital in 1869 — a boy of four, under Dr. Hilton Fagge. There was no history of scarlatina, but he had been suddenly attacked when in good health a fortnight before with frequently recurring vomiting. He had been dropsical for four days, and when admitted was suffering from general anasarca, ascites and some fluid in one pleura. The urine was 1007, and contained no albumen. The anasarca gradually disappeared without any albuminuria. Since then I have seen several less pronounced cases, mostly in the out-patient room, and within the last few weeks another extreme case has been under my care in the Evelina Hos- pital, of which the following are the notes : A girl, aged three and a half years; scarlatina two months ago ; ill a fortnight, but not kept in bed. Dropsy of the legs began a month ago. When admitted, the child was remarkably dropsical, the whole of the subcutaneous tissues being affected. The feet were blue and greatly swollen. She was in a collapsed condition. There was no desquamation. A small quantity of urine obtained con- tained no albumen. She was at once put into a wet pack. 184 THE DISEASES OF CHILDRE . This produced no perspiration, and she passed very little urine. The first sound of the heart was reduplicated, and there was a slight apex murmur. The oedema rapidly sub- sided, and at the end of three weeks had entirely disap- peared. The urine was repeatedly examined, and, though scanty for the first two days, it never contained any albumen, nor any abnormal microscopical elements. The tempera- ture was normal throughout. The treatment consisted of a milk diet, the wet pack, and an occasional jalap purge. Subsequently perchloride of iron was given for the anaemia. Steiner* writes of this affection thus : " Frerichs has de- scribed a rare form of dropsy, without any disease of the kidneys, occurring after scarlatina, which he believes to be due to paralysis of the cutaneous nerves by exposure to cold during desquamation, and I have lately seen one such case where repeated examination of the urine revealed no change, whilst there was very acute dropsy of the skin without any effusion into the cavities, which lasted twelve days." Thomasf alludes to epidemics in which all the dropsical patients were free from albuminuria. HillerJ sug- gests that the slight oedema, with which he alone has met, may be due to anaemia, which is often very great, and in- duced with great rapidity. Latterly, Dr. Duckworth has published a well-marked instance of this affection, and it seems not unlikely from this and other cases that the dropsy is related to suppression of the urine, which was a very marked feature of my own case and also in that published by Dr. Duckworth.- [I have never met with this condition, although two cases of scarlatinal dropsy have occurred in my practice in which the urine though non-albuminous contained casts, and it * " Diseases of Children," Eng. ed., p. 341. f Ziemssen's " Cycl.," American ed., vol. ii., p. 259. J " Diseases of Children, p. 305. SCARLATINA. I8 5 seems but just to insist that the absence of these elements should be proved by careful microscopic examination before declaring a dropsy following scarlatina to be independent of renal disease. At the same time, as suggested by Hillier, it is quite pos- sible to conceive that oedema may be due to anaemia in- duced by the fever. My cases presented the following histories : The first, a boy three and a half years old, had scarlet fever and died subsequently of meningitis. During the five months of his illness he had two attacks of desquamative nephritis. The first occurred, in spite of every precaution in regard to diet and exposure, three weeks after the onset of the fever, and subsided a month later. The other began one month afterwards, the urine being scanty and smoky with a specific gravity of 1030, on acid reaction, and con- taining a large quantity of albumen, numerous epithelial and blood-casts and many free blood-corpuscles. In two weeks the urine became more copious and commenced to clear up, and by the end of another fortnight it was passed in abundance, was perfectly clear and contained no albumen, but a few granular and hyaline casts. Subsequently on four separate occasions, at intervals of several days, the urine, which was normal in quantity, color, reaction and specific gravity, was carefully examined and found to be absolutely free from albumen, though the microscope revealed many hyaline and slightly granular casts. The second case, a boy five years of age, had scarlatina in February. The attack was so light that the child was not considered ill enough to be put in bed or to require a phy- sician. When first seen in March the hands and feet were still desquamating, there was considerable anasarca and a clear history of a precedent scarlet rash and fever. The urine was diminished in quantity, acid, dark-colored, de- 1 86 THE DISEASES OF CHILDREN. posited a soot-like material on standing, and contained a quantity of albumen and numerous epithelial, granular and hyaline casts. He improved rapidly under treatment, and three weeks later the dropsy had nearly disappeared. The urine con- tained a few hyaline-casts but no albumen. Then there was a slight return of renal congestion indicated by the reap- pearance of the soot-like deposit and a small amount of albumen. After four days the urine was again clear and free from albumen, but a few hyaline casts were discovered. During the next four weeks, as the feet were occasionally cedematous, the urine was examined repeatedly and found to contain hyaline casts though it was non-albuminous.] Serous inflammations are not uncommon after scarlatina, and they are liable to be of a suppurative form. Empyema is the most common, but suppurative pericarditis and peri- tonitis have both been known to occur. Endocarditis, meningitis, and inflammation of the joints must also be mentioned ; the two latter, however, cannot be dissociated from the rheumatic affection, which will be considered immediately. An acute empyema may possibly prove fatal ; the pus being often thin, rapidly formed, and attended with severe constitutional disturbance ; but as a general rule purulent effusions* do well. Glandular abscesses in the neck are very common. In young children they are apt to be associated with a diffuse inflammation of the cellular tissue of the neck, and some- times with extensive sloughing of the skin. In other cases there is a diffuse brawny infiltration of the tissues of the neck, rather than any definite glandular affection. In either case the complication is a serious one. When the abscess is circumscribed and confined to one gland or so, there is not necessarily any ground for alarm. * When large and obstinate thoracocentesis is necessary. — Ed. SCARLATINA. 187 Diphtheria has already been mentioned as a complication ; it is usually fatal as such, but it occasionally occurs later^ with equally disastrous issue, either by extending to the larynx or by the exhaustion of the recurrent fever. Otitis is very common. The inflammation may be lim- ited to the external passage, or spread up to the middle ear by the Eustachian tube from the disease in the pharynx. In the latter case particularly — and in any case, if the dis- charge is of long continuance — disease of the bone is apt to arise, and either permanent deafness or worse happens. Of late years scarlatinal rheumatism has been much talked about. It is a common sequela ; occurring some- times during the eruptive stage, it is more common to- wards the end of the second week or later. It is quite like acute rheumatism, as we know it in childhood, from other causes, and shows itself, sometimes by pains only, more or less manifest, sometimes by swelling of the larger joints. Steiner states that it affects the knee and elbow by preference, but I have more often seen the wrists and ankles affected. It is attended by pericarditis rarely ; by endocar- ditis commonly ; or rather it is frequently associated with a systolic murmur at the apex of the heart, but in many cases this bruit disappears. Probably about five per cent, of the cases of scarlatina develop a murmur, but the majority of such bruits disappear within a short time. The relation of this affection to acute rheumatism is still uncertain. Henoch discards the term rheumatism, and proposes that the affec- tion shall be called scarlatinal synovitis ; but I have seen several cases in which there was a strong family history of acute rheumatism — so often so that I have come to think that it may be a constitutional trait, appearing under circum- stances of deteriorated nutrition, rather than a special feature of the scarlatinal poison. It occasionally happens that this scarlatinal synovitis runs 1 88 THE DISEASES OF CHILDREN. on to suppuration and destruction of the joint, with symp- toms of pyaemia. Such cases have, no doubt, tended to throw doubt upon other affections of the joints, it having been thought that the pyaemia of the one might be present in milder form in the serous inflammation of the other. But the suppurative inflammation is so rare that the two forms of joint disease may well be due to distinct causes. There are other sequelae which occur less often — such are pneumonia and bronchitis, chronic enlargement of the tonsils, wry neck (of which I have notes of two cases), chronic diarrhoea, etc. ; and, lastly, may be mentioned as not uncom- mon, a chronic inflammatory condition of the mucous mem- brane of the nose and mouth, in which the surface of the nose becomes excoriated, incrusted with dry crusts, and exudes a thin discharge, whilst the mouth is superficially ulcerated and dotted with thin membranous patches, as in other forms of stomatitis. Etiology. — It is a disease which spreads by infection, and is communicated by means of the exhalations and secretions, and also by the scurf from the desquamating skin. But little infectious, perhaps not at all so, during the stage of incubation, the risk rises during the eruptive, and reaches its height in the desquamative stage. Doubts have been expressed by many whether it may not arise de novo ; but, as it is endemic and widely spread, and is even not unknown in domesticated animals, such as horses, dogs, and cats, in no case can it be said that infection is impossible, and con- sequently there is but little use in discussing a question upon which doubt is dangerous. Further, the germs of scarlatina appear to retain their vitality for long periods, and cases are on record where a fresh outbreak of the disease has occurred months and even so long as a year after a former one, owing to the housing and subsequent use of improperly disinfected clothes, The poison can in this way be carried for long SCARLATINA. 189 distances by such things as letters or books, and in this respect it differs from measles and other exanthems ; but in direct contagion it appears to be less intense than that of either whooping-cough or measles. It can also be conveyed by articles of diet. Of late years outbreaks have been traced unmistakably to the contamination of milk. The poison has been shown to be effectually destroyed by exposure to a heat of 212 , from which it follows that all clothes, woollen or linen stuffs — everything, in fact, that can be so treated, that has been in contact with scarlatinal patients — must be subjected to a dry heat of at least 212 for some hours be- fore they can be considered to be disinfected. The poison is further possessed of extreme tenacity, and for this reason there is often great difficulty in efficiently disinfecting houses or rooms, and the fever breaks out again and again after what has seemed to be the most thorough disinfection. Upon these considerations depends the answer to the question, when may a child who has had scarlatina mix with other children? Not until desquamation is over, and six weeks is about the necessary quarantine, provided that the child has been carefully tended with reference to this matter. Desquamation will linger for two or three months, if not hastened by proper attention to the cleansing of the skin. I must confess, however, to thinking it advisable to act with perhaps exaggerated caution in such matters. It is often a question of sending a child back to school, where it comes into close contact with perhaps a large number of healthy children, and where contagion, if conveyed, will be most disastrous. It is much better in such a case, that the one child should suffer the, after all, but slight loss entailed by an extended holiday, than that any risk should be run by the many ; and I do not hesitate to extend such par- tial quarantine to two, yea, even in some cases, three months. The medical man has to certify to the clean bill, and upon I9O THE DISEASES OF CHILDREN. him lies all the responsibility. He need indeed be cautious, considering the facts which have been proved against it, when dealing with scarlatina. Ten days is sufficient iso- lation for a child who has been in contact with scarlatina, provided he and his clothes have been disinfected. Morbid Anatomy. — Of morbid changes there are none sufficiently constant to make them pathognomonic. Micro- cocci have been discovered in the blood, and it is probable that we are on the eve of more positive information in this direction. All the known facts point to a particulate con- tagium, although we cannot yet identify it. Of macroscopic changes we may expect to find, during the height of the fever, perhaps some mottling of the skin, oedema of the fauces, with livid congestion or ulceration ; perhaps suppuration of the tonsils. The lymphatic glands in the neck are swollen, as also may be the mesenteric glands and other glands of the body. The cervical glands may be suppurating, or in severe cases are imbedded in a diffuse oedema. Thomas alludes even to extravasation of blood around them as a result of intense inflammation. There is really nothing to note elsewhere. The bronchial tubes have been found injected, and the spleen is at times swollen, but this organ is by no means so frequently affected as in typhoid fever. Microscopically various changes have been found. Fen- wick has noted an infiltration of the rete mucosum with leucocytes ; and to some active processes of cell growth of this kind set up by the fever must be attributed the later symptom of desquamation. Klein has found that minute changes go on in the viscera, particularly in the kidney, spleen, liver, and lymphatic glands. Some of these — for example, the hyaline degeneration of the intima of the small arteries, and the parenchyma of the liver and kidney — may be no more than the conditions dependent upon the febrile SCARLATINA. I 9 I state, for they have been found by several observers in other pyrexial states than scarlatina ; but it is important to note that, in addition to these, Dr. Klein has found in the early days of scarlatina (within the first week), that there is a hyaline change in the Malpighian tufts ; that the epithelium of the capsule shows signs of disturbed function by prolifer- ation ; and that the muscle nuclei of the small arteries un- dergo similar changes. Further, w r hen the disease extends on to the tenth day, there then appears an extensive accu- mulation of leucocytes in the connective tissue around the vessels and tubes. Thus we have anatomical evidence, within the first week, of the action of the scarlatinal poison upon the kidney. The changes, indeed, are very similar in kind, to those that have been detected in the skin. The risk of nephritis is thus clearly indicated, and the warning given to take care of the kidney. In this stage there will be little or nothing morbid in the general appearances of this organ ; it may perhaps be over-full of blood, but no conclusion can be drawn from that. The later stages of scarlatinal nephritis show to the naked eye enlargement or swelling of the kidney, and with this increased resistance when handled or cut. The surface becomes mottled from the admixture of the natural color with patches of opaque yellow or buff, and, more closely examined, the surface is seen to be speckled with minute yellow dots, and the section is muddled from loss of the natural streaky arrangement of the alternating vascular and tubal areas. The amount of this yellow or buff material varies much, and with it the appearances of the kidney. When extreme the aspect will be that of the large white kidney, but, so far as I have seen, it is not often that such is the case. In children there may be very advanced changes in the kidney, with but little pro- nounced departure from the natural appearances. The kid- ney may be rather paler than natural ; perhaps a more buff 192 THE DISEASES OF CHILDREN. tint, but as to which there would be a doubt had we no clin- ical evidence to go upon, and no microscopic examination to further us. Microscopically, however, the changes are fairly constant. There are the appearances of glomerular nephritis. These are such as have been enumerated above, but in addition, we find extravasation of blood or fibrinous material into the capsule, with mpre marked epithelial pro- liferation of the lining of the capsule and of the tuft itself; the tuft is either turgid with blood, or pressed back to one side of the capsule by the extravasation ; and there are hy- aline thickenings of the capsule, and peri-glomerular collec- tions of leucocytes. In addition to all these the renal tubules are choked with cloudy or fatty epithelium ; there are peri-vascular aggregations of inflammatory products in parts other than the capsules ; local patches of congestion with the vessels crowded with blood ; and casts in some or other of the tubes, composed sometimes of blood, sometimes of fibrinous material. It is the more or less of this change and of that, at one time or another, which makes up the variety of pattern and gives perplexity to the student, so that it is necessary to insist upon the fact that a very bad kidney may not reveal itself decisively to the naked eye. The morbid changes in the viscera associated with renal disease are not special to childhood, and need but a passing mention, with perhaps one exception — viz., dilatation of the heart. It is usual to find in death from scarlatinal dropsy that there is both ascites and hydrothorax, whilst the lungs are small, of a dull leaden hue — their bases being solid from an oedematous pneumonia, and the upper part also deficient in air — and with a copious frothy fluid exuding on pressure. This is the condition called acute oedema, a well-recognized condition towards the end of a case of chronic parenchym- atous nephritis. There is very likely to be double pleurisy in addition, perhaps pericarditis or endocarditis. But it has SCARLATINA. 1 93 not been very generally recognized that the ventricles are liable to be dilated. Dilatation of the heart is recognized as an occasional result of the scarlatinal poison or of the fever engendered by it, but it is not this to which I am now alluding. It is more important to impress upon the student that ventricular dilatation is not uncommon as the result of scarlatinal nephritis. It is indeed, a common result of chronic nephritis in adults ; but, whilst adults probably but seldom die from acute dilatation of the heart in acute renal disease, children are liable to die quite suddenly. In this, perhaps, may be found the explanation of a difference which, as I believe, exists in renal disease between the pulse of children and adults. The hard pulse of chronic renal dis- ease in adults is well recognized, and obviously it is the combined result of two factors — obstruction in the capillaries or small arteries, and compensatory muscular action on the part of the heart. The power of cardiac compensation is most striking in adults ; as it is less evident in childhood ; and therefore acute dilatation of the heart must be watched for and guarded against. I have once seen diffuse suppu- ration in the wall of the heart in scarlatinal nephritis. It occurred in a girl of three and a-half years, thirty-one days after the onset of the fever.* Such a case is perhaps of more value in emphasizing the tendency that exists in scar- latina and its sequelae to changes in the muscular wall of the heart, than in itself it would otherwise be. A rare occur- rence of this kind can be the experience of but few. To dilatation of the heart must also be attributed some of the cases of hemiplegia which occur after scarlatina ; but, these being common, most writers mention their occur- rence ; and, whilst some cases are due, no doubt, to dis- lodgement of clots from the inflamed valves, some may be * " Path. Soc. Trans.," vol. xxxL, p. 70. 194 THE DISEASES OF CHILDREN. due to the formation of thrombi in the trabecular pouches of a dilated ventricle. Of other morbid changes which are more or less prone to associate themselves with the post-scarlatinal state, there must be mentioned empyema, suppurative peritonitis, sup- puration in one or other of the joints, suppuration in the middle ear with disease of the petrous portion of the tem- poral bone, periostitis and necrosis of the long bones, sloughing of the glands of the neck and the superficial skin, cancrum oris and broncho-pneumonia. Even this list might be extended, but without any great advantage, for all these are but occasional occurrences, although, when scar- latina claims so many victims during the year, they can hardly be said to be uncommon. Diagnosis. — When in doubt, admit it, and act on the as- sumption that the disease is scarlatina. Rotheln, roseola, bastard measles, German measles, and all such terms are of bad reputation, and are only to be admitted when the evi- dence is indisputable that the attack is not scarlatina. There may often be a doubt, but the public is to have the benefit, not the eruption. Scarlatina may be mistaken for measles when the latter is more diffused and less raised than usual, or when the scarlatina is less diffused and more livid than usual ; a scarlatina-like rash sometimes precedes the erup- tions both of measles and variola — the latter by no means uncommonly, but variola is hardly one of the diseases of children. The lividity and elevation of the spots are to be attended to in addition to the coryza which is so character- istic. Rotheln is characterized by the rash which is sometimes more like scarlatina, at another like that of measles. At one time there is much coryza and angina, at another none ; and of individual cases it may be impossible to speak de- cidedly. But it occurs in epidemics, runs a short, sharp SCARLATINA. 195 course, without much illness, without desquamation, and without sequelae. Tonsillitis is usually one-sided, and limited to the tonsil. The glands at the angle of the jaw are all but quiescent. There is no preceding vomiting, the attack is sporadic, acute upon some chronic enlargement, and is not very com- mon in childhood. Roseola, if it can be distinguished, is of a lighter tint ; less papular-looking, may be traced to food or drink, etc. Dr. Gee mentions that the swelling of the joints which sometimes occurs in scarlatina before the out- break of the eruption had been mistaken for rheumatism. Prognosis. — An attack ushered in by convulsions is nearly always fatal, and severe delirium is also a symptom of great gravity. Other symptoms of bad omen are excessive py- rexia, nasal discharge, evidences of failing circulation — lividity of the surface, excessive rapidity and feebleness of the pulse — diarrhoea, and any tendency to exhaustion, such as sordes in the mouth, membrane on the fauces, severe sweating, etc. Treatment. — Uncomplicated and mild scarlatina requires no treatment during the eruptive stage except to confine- ment to bed, the substitution of fluid diet for that of ordinary health, and a mild aperient every other day or so. The room is to be well ventilated, kept at a uniform temperature of 65 °, and the bed and body-linen changed frequently. Nevertheless, it is with mild cases that there is so much trouble. Perhaps, a child is hardly ill, and the parents do not see the necessity of, and the doctor does not insist upon, three weeks in bed. It is allowed to get up, perhaps to go out of its room, and then dropsy supervenes. Dropsy, no doubt, varies in its frequency in different epidemics, but this does not alter the fact that it may be averted in many a case by timely care. Three weeks, at least, in bed and a further I96 THE DISEASES OF CHILDREN. fortnight or three weeks in one room make the proper pre- ventive treatment for this complication. If the eruption is full out and the fever high, a warm bath night and morning will give much relief. When the fever is excessive, tepid sponging, the cool bath as described un- der the head of measles, or the wet pack, must be resorted to. For the soreness of throat, an electuary of equal parts of the glycerinum boracis and honey may be given in small quantities at frequent intervals. Inunction is advisable in most cases as soon as the erup- tion appears. It relieves the stiffness and itching of the skin, it stimulates the circulation, is agreeable to the patient) and promotes sleep, and thus indirectly tends to better the disease. Carbolic oil 1 X 40 is a very good preparation, possessing as it does disinfecting properties. Meigs and Pepper recommend cold cream, to which a drachm of glycerine per ounce has been added — a very nice prepara- tion, which may easily be made disinfectant by substituting the glycerinum boracis for the pure glycerine. The inunc- tion may be applied as often as necessary — two, or three, or more times a day. If not resorted to before, a daily warm bath should be commenced as soon as desquamation begins. Plenty of soap and water and friction hasten the completion of this stage. Care must, of course, be exercised to avoid any chill, but this can readily be done by having a bath at ioo°, and a large, warm towel or sheet to envelop the body during the process of drying, and in which the child may be carried back to bed. In the more severe cases the temperature will probably be higher, and the cooling processes a more im- portant element in the treatment. Cold sponging, the tepid bath, or the ice-pack must be resorted to more freely ; and, in cases where there is much delirium, an ice-cap may be applied to the head with advantage. These are cases where SCARLATINA. 1 97 much depends on feeding. The throat is sore, and the child refuses food in any shape. It must be coaxed with all the variety the nurse or physician can suggest. Barley-water, with uncooked white of egg added to it; simple water and albumen ; nutrient jellies, blanc-manges, chicken-broth, veal-broth, Brand's essence, milk, whey, all readily suggest themselves as valuable in turn. To these must be added stimulants, either brandy, champagne, or port wine. When food by the mouth fails, nutrient enemata must be tried ; but, as I have already said, they are not well borne by chil- dren. I am disposed to think more highly of the catheter passed through the nose into the stomach, and of regular feeding conducted through it. As regards local treatment, when the faucial inflammation is severe, there is much dif- ference of opinion. Meigs and Pepper think that the good that might accrue is often nullified by the exhaustion pro- duced in the struggles of resistance. I am, however, of opinion that, when it can be applied, some glycerine prepa- ration gives such relief that children will often submit readily to the re-application. I am not prepared to say dogmati- cally that one preparation is better than another. Per- sonally, I am in favor of boracic acid and glycerine, or that in combination with bicarbonate of sodium — at any rate whenever there is any tendency to the closing of the fauces by viscid mucus or the formation of membrane ; but others are equally fond of perchloride of iron and glycerine, or chlorate of potassium, etc. The inhalation of steam, im- pregnated with carbolic acid or eucalyptol, is always ad- visable. And a spray of liquor calcis and the sucking of ice are both well worth a trial in suitable cases. Internally perchloride of iron, chlorate of potassium, carbonate of ammonium, and quinine are the most serviceable drugs when drugs are needed. The chlorate of potassium may be given in three- or four-grain doses with five or six 17 I98 THE DISEASES OF CHILDREN. drops of hydrochloric acid and a little syrup of Tolu, etc. This is useful in adynamic cases, or when the throat is much affected. Carbonate of ammonium is also a valuable stimu- lant in severe cases, two or three grains being given in milk every three or four hours. Quinine should be given if the temperature keep up beyond four or five days. Of drugs for cutting short the exanthem, none have as yet any claim to trust. Belladonna has been tried and abandoned. Hyposulphite of sodium in five-grain doses, and sulpho-carbolate of sodium are thought well of by some, and salicin is a good remedy when there is much fever. The complications and sequelae of scarlatina, excepting the nephritis, must be treated each of them on its own merits ; but this general rule will apply, that, resulting from fever, they are generally an indication of the need for stim- ulants an.d tonics. In scarlatinal dropsy, the child — if not already in bed — must be at once sent there. The diet is to be fluid, the bowels are to be regularly opened by jalapin (gr. j) or scam- mony (grs. v to vij) or seidlitz powder once a day, and the skin is to be acted upon by a warm bath night and morning. The bath should be 98 to ioo°. The child should be im- mersed up to its chin and allowed to remain in it for fifteen or twenty minutes, care being taken to keep up the tem- perature of the water the while. It is then to be wrapped in a dry warm sheet and put to bed again. Should these measures not be successful, dry cupping to the lumbar region may be added, and frequent hot applications by means of spongio-piline. Digitalis should be given inter- nally for two purposes — first, to keep up the flow of urine, and secondly to guard against the occurrence of dilatation of the heart. The tincture may be given with the liq. ammonii acetatis and spt. setheris nit. (F. 37) or by itself, in SCARLATINA. 1 99 two, four or five minim doses every two or three hours. Ten or fifteen minims of the infusion every three hours is sometimes more successful than the tincture. Should there be any tendency to suppression of urine and should convulsions threaten, immediate and repeated resort must be had to all these means. Purgation must be free, and bromide and iodide of potassium should be given internally. Diuretics are recommended by many, but I prefer to trust to the action of bowels and skin rather than run the risk of further blocking an organ already at a standstill from hypersemic conditions. In this condition a warm wet pack — by means of a blanket wrung out of hot water — for two or three hours at a time, is very useful, and in bad cases I have used subcutaneous injections of pilocar- pi, though not with any striking success. [Infusion or fluid extract of jaborandi administered by the mouth acts very efficiently, especially if combined with hot packs. For the latter purpose the child, stripped of its clothing, is placed between blankets and surrounded by bottles containing hot water and covered with flannel cloths wrung out of hot water. The pack should last from ten minutes to half an hour, according to the amount of sweat- ing and feebleness induced. It may be repeated when there is little prostration twice daily, and should the child com- plain of faintness whilst undergoing this treatment the bottles must be removed at once and a dose of whiskey given. Hot-air baths are useful in producing diaphoresis, but are more apt than the packs to produce faintness and a sensa- tion of difficulty in breathing. Heated air may be intro- duced, the child being blanketed as before, by a tube leading from an inverted funnel held over a gas jet or spirit lamp.] When the acute symptoms subside — the dropsy diminish- 200 THE DISEASES OF CHILDREN. ing and diuresis becoming established — then is the time for iron. Tincture of the perchloride is useful ; under its use the albumen will decrease, the blood disappear, and the anaemia become much less manifest. Sometimes milder preparations are required. If so then reduced iron, or car- bonate of iron, or Parrish's food may be resorted to. [The following formula, which differs somewhat from " Basham's Mixture," is perhaps the best way of adminis- tering iron in these cases. R. Tr. Ferri Chloridi, Addi Acetici DiL, Liq. Arnrnonii Acetat., Elix. Aurantii, . Syrupi, f3J * .~J iS - f 3 x. Aquse, . . . . . . . q. s. ad 15 vi. M. S. — One tablespoonful three or four times a day, for a child of four years.] The kidney is not an organ that repairs quickly. Con- sequently if the albuminuria is of any duration the child must be kept in bed for some weeks. When the albumen has disappeared there is still need for much caution. The clothing must be very warm — flannel next to the skin — and the diet must be of the most assimilable possible. It should consist largely of milk for a long time. Open-air exercise is to be resorted to gradually, and only at first on the warmest days. And if the parents are in a position to allow of it, a temporary sojourn at some mild watering-place, such as Torquay or Penzance, is very desirable. Scarlatinal rheumatism is to be treated by salicin or salicylate of sodium in the same way that acute rheumatism is treated ; eight or ten grains of the salicylate, or more according to age, ma}- be given even' three or four hours in acetate of ammonium and syrup till the pain is relieved; SCARLATINA. 201 then it may be continued at less frequent intervals, and sub- sequently combined with quinine. For the otorrhoea a Gilbertson's syringe should be pro- cured and the ear gently syringed with warm spirit lotion (5j to ox) three or four times a day. After syringing, a little oil (F. 38) should be dropped into the ear, and some salicylic wool kept in the meatus. When there is a discharge from the nose it is advisable to pass up the affected nostril a brush which has been immersed in glycerinum boracis, or in an ointment com- posed of fifteen grains of iodoform, half an ounce of the oil of eucalyptus and vaseline to an ounce and a half. Preventive Treatment. — No doubt in the future we shall have adequate hospital accommodation for fever patients, and homes for those who are convalescent; at present, when out of reach of these means, we must come as near as may be to the sanitary requirements of the day. The child must be kept in the one room, its nurse or nurses occupying another on the same floor. All unnecessary stuffs and linen, carpets, etc., are to be removed from that floor. Sheets steeped in carbolic acid are to be hung from the doors of the rooms, and a similar material is to be sprinkled freely oyer the floor. No actual contact is to be allowed with the rest of the household, and all linen from the sick-room is to be steeped in some disinfectant before removal. This quarantine must be rigidly enforced and maintained throughout the illness — that is to say, until des- quamation is completed — an irksome and difficult task enough. When the term of quarantine has expired, the child should have a final bath, leave all his cloths behind him and don a clean outfit outside his room ; after this he may be considered to be clean. When a case of scarlatina breaks out in a school it is a good plan when possible to have the temperature of all the 202 THE DISEASES OF CHILDREN. children taken night and morning. By this means very early isolation can be effected, and there is every chance in this way of arresting the spread of the disease. After the exit of the patient and his nurses, the rooms occupied by them must undergo a thorough disinfection. Sulphur should be burned in them for some hours. The papers stripped, the ceiling rewhitened, the floors scrubbed with carbolic soap and all bedding and linen which cannot be subjected to prolonged boiling must be sent to some disinfecting oven and subjected to prolonged heating over 212°. Clothing in like manner and, where expense is no object, everything in the way of cloth or wool that has been contaminated, should be burnt. ROTHELN — ROSEOLA. 203 CHAPTER XII. ROTHELN— ROSEOLA. Rotheln (Epidemic Roseola ; Bastard Measles ; German Measles ; Rubella) — is an affection which appears to have been noticed at various times in the last hundred years ; but many, even yet, have seen little or nothing of it, and doubt its existence. There is not, however, any longer room for doubt that an exanthem is occasionally present with us which in some things resembles scarlatina, but, in more, measles. Originally it was thought by many to be a hybrid between scarlatina and measles, now it is commonly supposed to be a distinct species. But the one opinion does not exclude the other ; there are, e.g., some who think that diphtheria — from certain peculiarities in its history and associations — is a disease in which the germ of what will be, but is not yet, a distinct species is in process of evolving ; that it is in fact an illustration of the tendency which plants exhibit of vary- ing under domestication — and, indeed, what can be more likely ? We know that in the cultivation of plants variations occur, and that hybrids are grown which can occasionally be propagated so as to constitute them distinct species. Why should exanthem germs be — is it probable that they are — altogether exempt from such tendencies to variation ? Thus, when we have to do with a disease which is at one time more like scarlatina, at another like measles, but always to some extent like both, and always wanting some of the features of both, I see not only no difficulty in considering the disease a hybrid, or a derivative of one disease or the other, but also none in regarding it as a distinct, though 204 THE DISEASES OF CHILDREN. perhaps as yet but an imperfectly stable, species, and one which, regarding its probable source, is of the greatest pos- sible etiological value. Naturally we must be very cautious in accepting any conclusions upon such a point. Eruptions very like scarlatina, very like measles, are undoubtedly pro- duced by various articles of food, drugs, and so on. It will not do, therefore, to conclude, because of the existence of a nondescript rash, that some new exanthem has started into existence. I only wish to maintain that there is no inherent objection to this derivative view, and that until we know more of the nature of the " germ/' it will be as well to keep our minds open. But in thus stating dogmatically that the existence of a distinct exanthem which resembles two others, but is neither, is proved to demonstration ; let me say, as I shall again do with regard to Roseola, that the affection is an uncommon one, and that the diagnosis is to be arrived at with the greatest possible circumspection. " German measles " is a term which is terribly abused. A doubtful rash makes its appearance, and the medical man, instead of saying he is not certain of its nature, calls it German measles. " Then it is not scarlatina ?" ask the parents. " No," says the doctor ; and the parents, thinking nothing of measles, take no precautions. Any hospital physician sees many such cases, and knows also very well — considering the rarity of the actual disease — that when he has to do with what is called German measles, it is more probable than not that the nature of the malady is scarlatinal, and that in this direction he must look for the explanation of whatever sequelae he may meet with. As regards its specific entity it may be pointed out, that it occurs in epidemics ; that one attack appears to be pro- tective against a recurrence ; and that it is no protection to have suffered previously from scarlatina and measles. Of sixty-three cases seen by Dr. Dukes, thirty-nine had ROTHELN ROSEOLA. 205 had measles, twenty-three had not. If anything, it appears to be more common in adults, at any rate in young adults or adolescents — a class of whom a larger number are pro- tected by previous attacks of scarlatina and measles than in younger children. Conversely, those who have suffered from rotheln procure no immunity from scarlatina or measles. I should add to this that Thomas states that it is especially a disease of childhood, attacking indiscriminately older and younger children down to sucklings, suscepti- bility being essentially weakened at puberty, and nearly lost after forty. It is very contagious, though less so than measles. The infective power is said to exist for a month, so that strictly a child should be isolated for that time. But the disease is one of so little severity, that, except in the case of weakly children, it can hardly be necessary to keep up any strict quarantine after ten or fourteen days. As a matter of prac- tice, provided one is sure of the nature of the disease, there can be but little objection to allowing a child to return to school at the end of a fortnight, if thorough disinfection has been carried out. Definition. — Dr. Squire thus writes of it: "A specific eruptive fever, the rash appearing during the first day of the illness, beginning on the face in rose-red spots, extending next day to the body and limbs, subsiding with the fever on the third day, and not preceded by catarrh, nor followed by desquamation." Incubation. — A fortnight or more during which the child is quite free from symptoms. Dr. Dukes records thirty-six cases, in twenty-five of which the incubation is given; in one or two only was it twelve days, in the remainder four- teen up to twenty-two days. The Eruptive Stage may be well illustrated by a case : a lady who always enjoyed good health, was quite well till 18 206 THE DISEASES OF CHILDREN. May 20th ; she felt out of sorts and depressed all day, with lumps in her neck, and on May 21th, in the early morning-, an eruption appeared and I saw her immediately. The tem- perature was then 98. 6°, the pulse 80. The face and neck were covered with a red raised eruption, consisting of clus- tered papules rather thickly set, but the intervening skin being white and healthy-looking. There was no soreness of throat, but well-marked, rather hard, and not tender, en- largement of glands on both sides of the neck. She felt perfectly well. The next day the rash had become much more diffused ; the face now presenting a livid appearance, with a general red ground and lumpy raised elevations upon it. Over the chest there was a roseola not unlike scarlatina, but less punctate. The temperature still remained normal. The next day she was well, and no desquamation followed. Here we have all the characteristics well marked : twenty- four hours of the most moderate indisposition ; the outbreak of an eruption like measles, though attended by a roseola not unlike scarlatina; the absence of catarrh, such as is characteristic of measles ; the absence of desquamation, characteristic of scarlatina ; considerable temporary swelling of the glands of the neck, but no sore throat, no fever at any time; and the affection running its entire course in four days. Some latitude must be allowed both to the definition here given and to the type which is illustrated by the case. For instance, the eruption, though usually raised in coalescing points like measles, is occasionally diffused, and unquestion- ably more like scarlatina ; pyrexia may, or may not, be present : it is always moderate when present ; there may also be some slight catarrh, and occasionally there is some slight branny desquamation. But these features are present in only the minority of cases, and will then necessarily tend ROTH ELN ROSEOLA. 207 to obscure the diagnosis. Dr. Dukes describes a mild and a severe form. In the latter the eruption is profuse and the temperature up to 103 . Complications and sequelae there are none, so that if after an attack of German measles a child remains thin and feeble or has any discharge from its ears, these things indicate, to my mind, that some error in diag- nosis has been made, and the disease was either scarlatina or measles. Diagnosis. — I have already alluded to the liability that there appears to be to mistake rotheln for scarlatina and measles. I have only to add that the possibility of eruptions produced by drugs and food must be borne in mind when forming an opinion, and Dr. Dukes mentions also the fre- quent occurrence of a measly rash which is caused by hand- ling some species of caterpillar — a very common hobby with boys at school. Treatment. — The child must be kept warm in one room, and in bed, if possible, for a day or two, but this is not ab- solutely necessary ; some saline diaphoretic may be given, and any mild aperient that may be necessary. Here, as in any other exanthem, the clothing must be attended to after the attack, the child being kept warm and guarded from chills, and, should any debility show itself, an iron tonic should be given. The room inhabited by the child during the attack must be fumigated as for other exanthems. Roseola, or rose rash, has no strict right to be considered in association with the specific exanthemata ; but the chief point of the affection is the difficulty of the diagnosis — a question of such moment as quite to justify the departure from any mere scientific arrangement. Rose rash is an irregular mottling or blush upon the skin, dependent appa- rently upon gastric disturbances. It wants the minute bright red punctiform appearence of scarlatina, and is _ ; 8 THE DISEASES OF CHILDREN. sometimes more like measles in mottling the skin. It is dally diagnosed by the absence of any definite symp- toms of scarlatina, and, experimentally, by the fact that it has not in any given case spread by contagion. But let it be indelibly impressed upon the student that it is often very difficult to distinguish this complaint from scarlatina, and that a mistake may be followed by the gravest consequences. Many a case :: rose rash has proved itself in the result to have been scarlatina. There- fore, unless there is no doubt, it is safer to take precautions as if the more serious disease were present. Rose rash stands in this respect with surgical scarlatina or membra- nous croup. It is probable that there are scarlatina-like eruptions which are not scarlatina, and membranous inflam- mations of the larynx which are not diphtheritic, but they can seldom be distinguished. Many such cases prove indisputably to be of the graver sort, and for the safety of others, in default of conclusive evidence to the ; ntr :.:y, all should be so regarded. So too should it be with roseola, for scarlatina now stalks about as often as not in the garb of innocence, and does incalculable harm both to the pa'tient and to those with whom he comes in contact. For instance, two children suffer from a red rash, called rose rash by the doctor, who commits himself positively to the non-scarla- tinal nature of the affection. But subsequent observation shows that they have sore throat int in the house has a bad throat ; and the aunt also has a bad throat, and is unwell for some weeks. Of the patients the: 30th subsequently have enlarged cervical glands and desquama- tion, and one has discharge from the ears and albuminuria. Another child has what is called rose rash ; but it remains and has discharge from its ears, and does not regain strength foi >3me weeks. Now, inasmuch as roseola is a ent and trifling matter, and is fol- ROTHELN ROSEOLA. 209 lowed by no sequelae, when a child remains weak and thin, with a red raw tongue, dry skin, and has discharge from the ears after such an attack, it is probable that a mistake has been made in the diagnosis, and that scarlatina has been the disease. The above are both cases that actually oc- curred, and every one of us must know of many more of a similar kind. A more careful examination of such cases, with this in mind, will often lead to the detection of a gen- eral fine branny desquamation, or some flakiness of the cuticle on the hands and feet. Such children, I say, are abroad in numbers, wholesale purveyors of scarlatina; and they will continue to be so, so long as roseola or rose rash is of common occurrence. Our attitude is not to ignore its possible existence, but to accept it only upon the strongest evidence ; and the usually accepted evidence — viz., absence of pronounced symptoms of scarlatina — is not strong enough, for there is no disease which is more variable both in the intensity of single symptoms, and in the grouping of those which may be considered typical. Treatment, — When we are sure that we are dealing with roseola, very little treatment will be required. Some simple saline, such as citrate of potassium with acetate of ammo- nium, and warmth in bed for twenty-four hours, with lighter diet for a day or two, will probably be all that is necessary. 2 I : THE DISEASES OF CHILDREN. CHAPTER XIII. DIFHTHEBI*. Diphtheria is a disease very frequent amongst children; it is most common between the ages of two and ten. It is usually considered to be due to a specific poison, because it is often epidemic and it is certainly contagious. But there are points in its natural history which differ much from many other specific fevers, and of these it may be mentioned that its contagious power is not a very high one. It is com- municated by one patient to others hy means of inoculation from a materies derived from the diseased parts, and thus doctors and nurses are chief sufferers ; an imperfectly disin- fected tracheotomy tube may impart it ; and a healthy child put into a bed or a particular corner of a room recently occupied by a diphtheritic child may thus u catch " the disease; but it is not communicated to other children or patients in a building, or carried about in clothing like measles or scarlatina.* It has also a curious tendency much more frequent with it than with other specific fevers, though not unknown in them, of tacking itself on to some other fever. Thus measles followed by diphtheria, scarla- tina followed by diphtheria, typhoid fever followed by or going with diphtheria, are all well known and not uncom- mon. Epidemics of all these three — measles, scarlatina, and typhoid — occur in which diphtheria attacks man}-, so that some have thought it wanting in specificity and capable of being bred out of these diseases. Irs relationship to * Many authorities hold that diphtheria is contagious in the ordinal} ::" :r.i :-:... — E~ . DIPHTHERIA. 21 I scarlatina appears to be unusually close. Again, if mem- branous croup and diphtheria are one disease, as very many now hold, diphtheria is endemic, for sporadic cases are common and appear to keep company in a large number of - with no other known source of contagion than bad- smelling drains. There is indeed much to be said in favor of a pythogenic origin denoi'c cases. It From other n having no proper eruptions attaching to it, being often without any at all ; it one of scarlatinal character, sometimes one like that of measles, more often perhaps an anomalous patchy roseola — in virulent cases the rash may be petechial. Las specific affections, diphtheria has no powerful protective infi ust anrther attack at some fut time. Incubation. — This stage appears to be somewhat uncer- tain. It ranges from two tc tight cays — three days being a usual time :: elapse between the reception of the germ and the first symptom. The Eruptive Stage is characterized by the formation of tough yellowish or grayish membrane upon a mucous sur- face, generally of pharynx or larynx, combined with hocal inflammation. The local symptoms are associated with certain so-called constitutional symptoms — viz., fever and uminous urine. Different cases vary in many respe The type is pharyngeal diphth- sometimes the mem- brane forms not up : n the fauces, but on the cc va or the labia pudendi, oftentimes in the larynx. Sometimes it in great measi ir :- confines itself to the nasal mucous mem- brane; sometiir.es it may be found upon the lips, sometimes on some sore up?:: the skin; sometimes e nbrane is present, yet the remainder oi the symptoms make the c indistinguishable from one of diphtheritic nature. Sc the albuminuria. In some cases it is much and persistent; 212 THE DISEASES OF CHILDREN. in others it is moderate in quantity throughout ; in others the albumen quickly disappears. The pyrexia too may be of all grades of intensity : sometimes so little that the child is able to sit up in its bed and play with its toys ; sometimes the constitutional disturbance is so severe that the condition is desperate even from the commencement. Pharyngeal Diphtheria. — The onset is usually some- what leisurely, the child is out of sorts, heavy-eyed, languid and pale, for four or five days, by which time the tempera- ture reaches perhaps ioi°. The throat is now seen to be red and swollen, and predominance of redness or lividity over swelling is of evil omen. The appearance of the throat in a simple tonsillitis is, usually speaking, a more juicy or cedematous one than the perhaps less swollen, but firmer-looking, thickening of the parts in diphtheria, and the swelling is more often unilateral. The membrane begins as small patches of yellowish material, not in themselves dis- tinguishable, or at any rate certainly so, unless perhaps occasionally by their dirty color, from the plugs of welded epithelium and secretion which issue from the mouths of the follicles of the tonsils in the course of tonsillitis, both acute and chronic. Their nature has to be decided by their position — if they are on the soft palate, provided of course that we are not dealing with thrush, they are of membra- nous nature — by their roughness, by the general appearance of the throat, by the constitutional symptoms, pain in swal- lowing, fever, and glandular swelling. At this time the glands beneath the angle of the lower jaw on one or both sides should be hard, tender and slightly enlarged, but the swelling need not be much. In cases of severity it is often considerable. The diphtheritic plaques tend to increase in area, and to coalesce ; they adhere rather stoutly to the surface of the palate or tonsil, and when removed a shallow ulcer is seen, with numerous bleeding points upon it. The DIPHTHERIA. 213 urine is usually of good color, good specific gravity, and a moderate cloud of albumen is precipitated if cold nitric acid be added. It but seldom contains blood. Hyaline and occasionally epithelial casts may be found by examination of the urinary sediment microscopically. [In addition to the symptoms above mentioned there are early in the attack : chilliness, pain in the back and limbs, headache, thirst and fever. Prostration, in proportion to the length of time the patient has been ill, is very marked. The pulse is frequent, weak and easily compressed. Opening the jaws produces considerable pain, and the neck is fre- quently much swollen. The breath is very fetid, and at times membrane tinged with blood is coughed up. The voice is altered, and the cough, should the larynx be in- volved, is croupy.] In a case of this kind terminating favorably, the mem- brane perhaps remains in situ for some three or four days, and then slowly disintegrates, disappearing in perhaps ten days from its first appearance, and the child slowly regains its former state of health. When the membrane clears away, a somewhat indolent, though shallow, ulcer is usually left behind, which is often slow in healing up, and is fol- lowed, or not, as the case may be, by paralysis of the soft palate. And this may be so even when the evidence of real illness has been but slight. In favorable cases the albu- minuria disappears, sometimes with peculiar suddenness, in a few days, but it may last even in considerable quan- tity for some time after the subsidence of the throat symp- toms. Modifications. — (1) There may be much membrane about the soft palate and fauces, and very little constitutional dis- turbance, and no albuminuria — e.g., a girl, aged ten years, had been ill for twelve days with sore throat. . The urine contained no albumen at any time, the temperature only 2T4 THE DISEASES OF CHILDREN. reached 99 , and she hardly seemed ill, yet the sides of the fauces were covered with membrane, her cough was croupy, and there was decided dyspnoea. She was treated with chlo- rate of potassium, perchloride of iron internally, and a local application of bicarbonate of sodium, and recovered. (2) The membrane may be considerable, the constitutional symp- toms slight, but albuminuria considerable, and after a few days the child may die almost suddenly, either from collapse or sudden syncope. (3) The throat affection maybe severe, the fauces, soft palate, and uvula being covered by thick leathery lymph, and some parts perhaps sloughing, in which case the constitutional symptoms will almost certainly cor- respond in severity. In such cases the nasal mucous mem- brane is liable to suffer, and a thick offensive discharge issues from the nostrils and crusts and about the anterior nares. In these cases the fever is high, the pulse rapid, the albu- minuria copious, and the prostration and somnolence pro- found. [These cases if seen early usually present the livid appearance about the mouth and the anxious facial expression so indicative of obstructed respiration. At the same time there is a foul, acrid, serous and sometimes bloody discharge from the nostrils which produces excoriation and swelling of the upper lip.] (4) The throat symptoms may be slight, the fever severe, and the general symptoms those of bad blood-poisoning, death occurring within a day or two, or even less. (5) The fauces may show no membrane, but the tonsils and parts around are in a condition of acute phleg- monous inflammation. I have seen cases of this kind where the tonsils have been sloughing out en masse, and in which death has occurred by sudden failure of the heart. (6) The laryngeal symptoms may be paramount, or the disease may be entirely confined to the larynx, but there can be no doubt that in many of these cases (called " croup") the DIPHTHERIA. 215 early faucial inflammation has been overlooked from the insidious manner of onset peculiar to the disease. Causes of Death. — No case of diphtheria, however mild, is free from danger. The risks are chiefly four : 1. Of blood-poisoning. 2. Of some inhibitory action upon the heart, causing slow pulse and syncope. 3. Of asthenia. 4. Of extension of the membranous inflammation to the larynx, with all the consequences which this involves. The last mentioned is, in hospital experience, much the more frequent, but perhaps this is only due to the fact that as such cases require operative treatment and very special nursing, they are therefore more likely to be sent into a hospital. But to take the various risks in order. I. Blood-poisoning carries off some. Cases of this kind are usually severe from the commencement — probably the throat symptoms are excessive; the nostrils involved; the membrane is plentiful, tough, and dark-colored ; the breath fetid ; the albumen copious ; the temperature high ; and the pulse rapid and feeble. Four or five days sees the termina- tion of such a case as this, and death comes either by som- nolence, gradually deepening into coma ; or more suddenly by a rapidly falling temperature, coldness of the extremi- ties — perhaps profuse sweating — and a general lividity of the surface ; a condition, in short, of septic collapse. 2 and 3. All acute inflammation about the fauces show a tendency to cause slowing and irregularity of the pulse ; this is specially the case with diphtheria and constitutes one of the great dangers of the disease. Moreover, the symptom is by no means confined to cases of severity, and the risk appears to attach not only to the acme of the disease, but to the period of convalescence afterwards. Cases are on record 2VZ THE DISEASES 17 IHILZZZN. in which sudden syncope has ensued after all membrane had disappeared from the fauces, and the ulcers, remaining were healing satisfactorily. The pulse will sink to 50, 40 or even .ess — Hillier says even so low as 20 — per minute, and be- : : . e : r e g a r ; this condition being associated perhaps with vomiting, and the child is said to die quite suddenly. I have lately made an inspection of the body of a boy of four, under the care of my colleague, Dr.-Wilks, who had been ill six weeks, and had had paralytic symptoms for a fortnight. He was a thin s.~?z~ : .c b : y. and appeared to die from exhaus- tion. The left ventricle of the heart was widely dilated, although the muscular tissue looked healthy. It may also be added that, in addition to this disordered innervation, the action of the heart may be exceedingly feeble from fatty degeneration of the muscular fibres of its wall. 4. The greater proportion of deaths are due to suffocation caused by the extension of the membrane from the fauces into the larynx and trachea, or by a more or less general broncho-pneumonia due to this, or to this and the operation of tracheotomy resorted to for the relief of the asphyxia. This also is a complication which is more likely to ensue in the cases of moderate severity than in those which run a more rapid course, and, as I have already said, it appears ofttimes to be the primary affection. But careful inquiry generally serves to show a period of four or five days' ma- laise, and I have known laryngitis to foHow pharyngeal diphtheria so late as the twelfth day. Some still doubt whether there is such a thing as an uncomplicated laryngeal diphtheria — that is to say, whether there is not in all cases some, even if it be but slight, faucial disease as well. Others, on the contrary, go so far as to say that whenever a mem- branous laryngitis is met with it is due to diphtheria ; in other words, that membranous croup is always diphtheritic. If this be correct, the other opinion cannot be ; as it is quite DIPHTHERIA. 217 certain that a membranous laryngitis is met with in which the fauces are free. In these cases there is slight malaise for three or four days ; then a noisy reedy cough is noticed, and slight inspiratory stridor. The temperature of the body is as yet hardly in excess, although even already the urine may be albuminous. The noisy hissing respiration increases, the temperature rises, the child becomes more and more restless, the features become livid and then leaden, and un- less the windpipe be opened, death ensues shortly from suf- focation. The best guage of laryngeal obstruction is the recession of the weaker parts of the chest walls during in- spiration ; that of a pressing deficiency of aeration is rest- lessness. A diminution of restlessness accompanied by the onset of a leaden pallor of the features, betokens impending dissolution and the immediate necessity of tracheotomy. Complications and Sequelae. — These are not numerous, albuminuria and paralysis are the chief of them. Moreover, it may perhaps be mentioned that at times a somewhat deep ulceration may be met with about the tonsils, which is slow in healing ; and at times though far less commonly than in scarlatina, a diffused brawny swelling of the connective tis- sue of the neck, such as has of late years received the name of Angina Ludovici. The albuminuria of diphtheria requires mention for many reasons. It is remarkably constant, though the quantity of albumen passed varies much ; should it be persistent, and the quantity of albumen be large, although in other respects the child may seem to be doing well, the prognosis is of considerable gravity. One may notice further that it is a symptom of the disease — being present at an early period of the attack, generally by the third or fourth day ; that the urine is not as a rule characterized by scantiness, or the presence of blood, and that casts, if present, are hyaline and not epithelial ; that it leads to no after-symptoms, such as 2l8 THE DISEASES OF CHILDREN. dropsy ; and that the kidney does not usually show any defi- nitely marked change. Thus essential differences are estab- lished between the albuminuria of diphtheria and that of scarlatina : in the one it is an early symptom, in the other a late one; in the one the urine is not characteristic, in the other it contains blood and epithelial casts ; in the one it has no after-effects, in the other dropsy is the rule ; in the one the kidney shows no definite structural change, in the other there is a recognized form of nephritis. Gerhardt has found peptones in the urine of diphtheria. Diphtheritic Paralysis, unlike the albuminuria, is an affection of the convalescent, and declares itself usually after two or three weeks by a paralysis of the soft palate. This is known by the peculiar alteration of the voice, and oftentimes by food coming through the nose in swallowing. But the paralysis is often much more extensive than this. It may extend to the external ocular muscles and cause squint; to the ciliary muscle and cause dimness of vision from erratic accommodation; and to the muscles of the trunk and extremities producing a general paralysis, in which the child is unable to hold anything or to feed himself, or he staggers about in a tipsy way, such as is very liable to be mistaken for the symptoms of cerebral tumor if the practitioner be not on his guard. I have seen more than one instance of this in out-patient prac- tice, where the history of diphtheria has been, as it may be, very unobtrusive. It is further not uninteresting to note that in diphtheritic paralysis the patella tendon reflex is often absent, and this fact, together with the occurrence of disturbances of vision, has in adults led to a mistaken diag- nosis of ataxie locomotrice. Deafness, loss of taste, and disturbance of common sensation are quite occasional. Paralysis is to diphtheria what dropsy is to scarlatina, a symptom which often leads to the detection of a hitherto DIPHTHERIA. 219 unsuspected ailment. But in calling diphtheritic paralysis an affection of the convalescent, we must not forget that in the active stages of the disease we have also a paralysis which constitutes one of the gravest dangers of diphtheria — viz., paralysis of the heart ; one can but suppose, indeed, that this is only a part of the same tendency to the implica- tion of the nervous centres as is seen in the stage of con- valescence, and that in those terrible cases of sudden death, which are by no means uncommon both during the disease and convalescence, we have some sudden disturbance of the vagus, brought about by means of its cardiac branches. Morbid Anatomy and Pathology. — The fauces are more or less swollen, and covered with lymph ; but the extent of the swelling and the amount of lymph may alike be small. In the most severe cases the uvula and surface of the pharynx generally are sloughy-looking, or the tonsils and adjacent mucous membrane are boggy or much thickened from a diffuse inflammation. In later stages the parts may be much defaced by deep ulcers — I have myself seen all these conditions. But the majority of cases which prove fatal, at all events of those in hospital practice, do so from laryngitis and extension of inflammation down the trachea. The mucous membrane of the epiglottis is thickened and crinkled, and a tough adherent membrane lines the laryngeal surface of the epiglottis and the interior of the larynx above the true vocal cords ; it often extends from these parts over the edge of the epiglottis to the base of the tongue, and over the ary-epiglottic folds to the mucous membrane of the pharynx; and the reflection of mucous membrane from the pharyngeal aspect of the larynx to the pharynx proper is a favorite seat for membrane, and one too from which it is not easily detached or reached by local applications. As soon as the trachea is reached, the character of the membrane alters — it loses its toughness, all firm adhesion to the tra- 220 THE DISEASES OF CHILDREN. cheal mucous membrane ceases, and it is only in exceptional cases that any tough cast of the respiratory passages is ob- tained ; by careful manipulation with water a flimsy cast may frequently be separated from the trachea and larger bronchial tubes ; but it is more common to find the passages full of a thick puriform mucus with shreds or granules of membrane, the mucous membrane beneath being mottled and thickened from a diffuse inflammation of the submu- cous tissue similar to that found in the pharynx. The mucous membrane often fails to show any intensity of inflammation, as judged by injection. The extent of disease is apparent more by superficial ulceration, minute points of suppuration or early membranous formation, and a general pink and yellow mottling of the whole surface. The smaller bronchial tubes are usually full of thick pus, and the lungs in a state of more or less diffused broncho-pneumonia com- bined with atelectasis. It must be remembered that in nearly all these cases tracheotomy has been performed some hours, if not days, before death, and therefore that the mor- bid appearances below the larynx ought perhaps to be con- sidered as a combined result of the disease, and of the operation rendered necessary by it to avert impending suffocation. But little more need be said — membrane is very occa- sionally found in other parts of the body, the gastroin- testinal tract, the genital passages, and the intestine should be examined; and throat affections are sometimes asso- ciated with anomalous appearances, such as swelling and injection of the glandular patches and solitary glands, or perhaps some more diffused enteritis, although no actual membrane may be present. But all such things are rare. Certain negative facts, however, are probably not unimpor- tant — first, that the spleen, which in most conditions of blood-poisoning is large, soft, or pulpy, in diphtheria is not DIPHTHERIA. 221 of abnormal size, and is usually firm ; secondly, the kidneys show no change whatever to the naked eye, nor is anything very decisive found by microscopical examination. Small foci of micrococci with some associated disseminated ne- phritis are said to be present. Lastly, I would note, as a point which is perhaps not without value in reference to the pathology of the neuro-paralytic symptoms of this disease, that in some cases, in particular epidemics of diphtheria, meningitis has been found. I have myself once seen such an association of morbid changes, but it is a very rare con- dition in my experience, and apparently in that of other English pathologists. The diphtheritic paralysis appears to be due to a species of anterior polio-myelitis of somewhat irregular distribution. There are now some sixteen cases published by Dejerine, Abercrombie, Kidd, and others, and in all much the same changes have been found. It is, how- ever, worth remark that no after-results, such as infantile paralysis, have ever yet been recorded ; it would appear that most cases get perfectly well, though some die, but that between these two extremes there is no mean of permanent paralysis. Pathology. — This has been already trenched upon in the opening remarks, but repetition will not be out of place in a matter of so much importance. Diphtheria is a contagious blood disorder — some would say a specific blood disorder, meaning thereby a disease due to some definite and constant germ ; but I avoid the term specific, because there are pecu- liarities about the disease which must to some extent raise a doubt whether it may not result from varied causes. For instance, it is associated with or comes on after so many different specific diseases. It is a frequent accompaniment of measles, of typhoid fever, of scarlatina. Exposure to the effluvia of bad drainage notoriously often precedes its occurrence, and catarrh and chronic inflammation of mucous 19 222 THE DISEASES OF CHILDREN. surfaces predispose to it. Secondly, it is not protective against subsequent attacks. Per contra and in favor of spe- cificity, we have the fact that it occurs in epidemics ; that the period of incubation is fairly constant ; that the symp- toms are also uniform ; and that there is abundant proof, both by cases and experiment upon animals, that the disease is transmitted by contagion. In bygone years, not yet far removed, it has been much discussed whether the disease is a local or a general one ; but in view of the now prevailing doctrine, that all specific fevers are due to the introduction into the blood and tissues of germs from without, that question loses much of its point. All such affections must now be held to be more or less local at first. The difference lies in this — that while some germs gain entrance by several doors, or diffuse themselves with great rapidity by many means, others proceed by more isolated routes, and generate themselves only after some process of maturation in the seat of infection. To the latter kind belongs diphtheria. This is well shown in the case recorded by the late Dr. Hillier, of an eminent surgeon who pricked his finger in the operation of tracheotomy upon a child for croup. The next day the puncture became painful. The following day a pustule formed, and a day or two later the cutis sloughed. This was followed in six days by diphtheritic deposit on the tonsils ; and, a month later, there was paralysis of the soft palate, partial paralysis of the fingers and legs, and some impairment of sensibility. To this case many others could be added, where medical men have been inoculated by ejecta from the throat and fauces, while en- gaged in painting the throat, in operating, or in clearing the trachea of membrane. Others could be cited where kissing has conveyed the contagion. Diphtheria, then, is the result of a germ introduced from without by direct contact. It, generally speaking, fixes itself upon the fauces or throat, and DIPHTHERIA. 223 becomes generalized from thence ; but supposing it to gain an entrance by some other channel, such as the conjunctiva or skin, it still is liable to show a partiality for the fauces, and to appear, sooner or later, as a membranous exudation on that part. The contagion is not one which readily dif- fuses itself, and therefore direct contact is the chief source of its propagation ; but in this way it is possessed of consid- erable vitality, which evinces itself by the persistent way in which it clings to a particular room, a bedstead, or articles of furniture once contaminated by the sick child. I have more than once seen a patient infected by means of a bed- stead which had undergone what was supposed to be thor- ough disinfection. The infecting germ is supposed to be the micrococcus, or the bacterium termo. These bodies, fixing themselves upon the bed they choose, be it the catarrhal throat, the hyper- trophied tonsils, the cutaneous sore, or otherwise, form a membrane by their own growth and the exudation of a fibrinous material from the affected tissue. At the same time they gradually work themselves into the tissues, into lymphatics and the bloodvessels, and thus are carried to all parts of the body. Taking the kidney and the brain par- ticularly as the parts from which definite symptoms of the disease emanate, we -may pursue the life-history of these bodies further, and we shall find that in the kidneys they grow in foci about the organ, blocking up branches of the smaller bloodvessels and branches of the capillary tufts. Thus is brought about a cause of thrombosis, of ecchymosis, and therefore of albuminuria ; while in the brain the same blockage of the small vessels may lead also to capillary hemorrhages and softenings, and thus may be explained the paralytic conditions which exist so often. [In a paper on the Nature of Diphtheria, published in 1882, Drs. H. C Wood and H. F. Formad arrive at the con- 224 THE DISEASES OF CHILDREN. elusion that diphtheria is " a putrid sore throat with or without a secondary constitutional septicaemia, " and assume that the cause of diphtheria " is not a specific organism dif- ferent from that common to healthy and inflamed throats but is an active state of that organism." I prefer, however, to look upon diphtheria as a constitutional affection, and am supported in this view by many authorities, among whom may be mentioned Meigs and Pepper, W. H. Day, and J. Lewis Smith. The latter states the following facts in this connection : 1. It is a law in pathology, that those diseases that have or may have a long incubative period — say of a week or more — are constitutional. 2. Another fact which indicates primary blood-poisoning in diphtheria, is observed in certain cases, namely, the occurrence of severe constitutional symptoms for a longer or shorter time, perhaps for half a day, before the appear- ance of the usual inflammation. 3. The quick succumbing of the system in certain malig- nant cases is evidently due to diphtheritic toxaemia. 4. Important evidence of the constitutional nature of diph- theria is afforded also by the state of the kidneys.] Diagnosis — Croup and Diphtheria. — The student must be prepared with some ideas on a question of such impor- tance as this. I have already mentioned incidentally that there are many who think nowadays that all cases of mem- branous croup are diphtheritic — that membranous croup is that form of diphtheria which attacks the larynx. The points of distinction usually drawn are these : Croup is a sthenic disease, diphtheria is a disease attended by prostration ; in croup the urine is not albuminous, in diphtheria it is ; croup is not followed by paralysis, diphtheria is ; croup is not an epidemic disease nor is it contagious, diphtheria is both. But none of these distinctions suffice for their purpose, be- DIPHTHERIA. 225 cause cases of croup are of frequent occurrence, in which holding perhaps at first, they fail afterwards ; perhaps by the appearance of albumen in the urine, as is most common; perhaps by some evidence of the possession of contagious properties, as the attack of two children in one house; or it may be by its appearance in an epidemic form. Moreover, it cannot now be contended that diphtheria is always at- tended by prostration — laryngeal diphtheria need not be at- tended by any such evidence of debility from its beginning to its end. Such cases frequently terminate purely by broncho-pneumonia and asphyxia. The question of conta- gion, again, depends much upon the existence of epidemic disease — all sporadic disease is less prone to exhibit conta- gious properties. Thus, of symptoms, those of disordered innervation alone remain as distinguishing between one dis- ease and the other, and these are not available for the pur- poses of diagnosis at the time when it is all-important to form an opinion. Some have taken up other ground, and have appealed to the local lesion to help them ; and Oertel, admitting the ex- istence of two forms of membranous laryngitis, maintains that the presence of a profusion of micrococci and of bacterium termo in a membranous exudation is sufficient to determine against a simple fibrinous inflammation, sufficient to allow one to predicate the speedy formation of membrane upon a part hitherto free. But I hesitate to indorse such a state- ment, although it be backed by such a competent authority. I prefer to teach, what I believe, that there are no certain histological differences which will allow us to distinguish by microscopic aid between a diphtheritic and a non-diph- theritic membranous laryngitis. My own opinion is, that there are grounds sufficient for a belief in the existence of a non-diphtheritic as well as of a diphtheritic membranous laryngitis ; but, inasmuch as it is admittedly impossible to dis- 226 THE DISEASES OF CHILDREN. tinguish readily and certainly in doubtful cases between the two, and the question of contagion is involved in the decision, it is best to consider all cases as diphtheritic, and to take precautionary measures in accordance with that assumption. [Meigs and Pepper confess that, apart from sporadic cases, they are unable to detect any difference between pseudo- membranous croup and cases of so-called primary laryngeal diphtheria, when the angina is trifling, and is rapidly fol- lowed by the formation of pseudo-membrane in the larynx. J. Lewis Smith states that the diagnosis of diphtheria from membranous croup, though possible in typical cases, in localities where diphtheria is not endemic or epidemic, is difficult, if not impossible, at the bedside, in localities where diphtheria prevails, especially when there is little or no exu- dation in the fauces. Ellis remarks that, " despite the high authorities who urge the identity of these diseases, I confess to remaining uncon- vinced."] Scarlatina may be mistaken for diphtheria, but the points of distinction are numerous, and in well-marked cases should be decisive. The attack is sudden in onset, the pyrexia in like manner quickly attains a persistent altitude, the fauces are more generally reddened, and the strawberry tongue is present. There is none of the characteristic membrane. Albuminuria is a sequela, not an early symptom, and it is associated with dropsy and haematuria. Lastly, endocardi- tis and rheumatism may follow up scarlatina. [Endocarditis is not an infrequent occurrence in diph- theria. Its presence should influence the prognosis or the attack, and put us on guard against the development of chronic endocardial lesions and their accompaniments. Heart-clot also sometimes occurs. It is most often de- veloped about the time that the patient enters upon con- valescence.] DIPHTHERIA. 227 In tonsillitis the onset is sudden ; the swelling great and oedematous ; often unilateral, without glandular enlarge- ment. It is not a very common disease in childhood, except in mild form, as part of the history of a chronic condition. Treatment. — Our present knowledge, which is derived in part from experiment, in part from the experience of the records of cases, teaches, as has been already said, that diph- theria is due to a germ, which effects a lodgement usually in the fauces or respiratory passages, undergoes a process of incubation, and subsequently becomes generalized. This is the central point from which much of our treatment must be directed. Diphtheria is in great part a local disease, and is to be treated in great part by local measures. Unfortu- nately, the poison in some cases becomes very rapidly gen- eralized, and the child then suffers from a bad form of blood- poisoning, which deprives the local affection of its primary importance ; and it must also be added, that hitherto local treatment has not been very successful. Thus, internal treatment being by no means unimportant, has, perhaps, in its more easy applicability, hindered the thorough persever- ance in local measures. But neither is the local treatment of ringworm very successful — certain!}' not if anything short of the most thorough measures be adopted ; neither is the local treatment of cancer very successful. But in neither case are local measures discarded ; the whole tendency of modern teaching is to make our local treatment of these diseases more searching; and so it must be with diphtheria. The parallel I would draw between diphtheria and ringworm of the scalp is a particularly apt one ; for both, according to present knowledge, are parasitic, and ringworm is acknowl- edged to be readily curable, so long as it is superficial, and does not dip into the hair follicles. I believe a similar inva- sion of the follicles, and even deeper structures, is a leading feature of the resistance of diphtheria to local measures. 228 THE DISEASES OF CHILDREN. When superficial, it is easily kept at bay; but when the whole surface, follicles and all, are stuffed with micrococci, the local treatment fails to arrest the growth, and the failure of what is — let us acknowledge it at once — a troublesome treatment, paralyzes our energies, and the growth of mem- brane conquers. I say local treatment is troublesome. It is easy enough to order the application of a spray to the throat; it is easy enough to order the fauces to be swabbed with this or that gargle or lotion ; but orders of this kind usually result in some utterly ineffectual application. To keep diphtheritic membrane at bay, the application must be thorough, and, it may be, frequently repeated. This means a frequent disturbance of a child whose only want, perhaps, is to be let alone ; and a thorough application of anything to the fauces means generally that the strong resistance of a struggling child has to be encountered — perhaps taking two people to hold it whilst a third attends to the throat — perhaps necessitating a gag ; and all this with an amount of sputtering, gasping, and choking from the irritation of the epiglottis and larynx, such as makes the parents recoil from it with dread, so that only the strongest determination and belief in the value of the means will enable the physician to persevere. No one who accepts the bacterial nature of the diphtheritic process, who clearly realizes the nooks and crannies of the throat and fauces in which membrane de- lights to grow, and the difficulties of management of unrea- soning childhood, will have any difficulty in understanding why local treatment has often failed — why local treatment will often fail again. But this will not deter him from re- turning to the attack with all possible additional aids and suggestions. And whatever we may think of the nature of the disease, that treatment will, I believe, be, in the long run, the most successful, which, while doing everything pos- DIPHTHERIA. 239 siblc to support the child, is ever on the alert to combat the formation of membrane. For treatment, then, first and foremost, I place local ap- plications, undeterred by the fact that they have often proved ineffectual. And of local measures, I prefer the applica- tion of antiseptics rather than escharotics. They must be re- peated as often as membrane begins to form on the surface ; and since prevention is more easy than cure, whatever local ap- plications be adopted should be applied at regular intervals, until the chance of fresh formation of membrane be altogether past. The plan that seems to me best to adopt is to detach and remove any membrane that can be reached, and then to apply the local application. This plan is held by many most experienced men to be useless, or worse. It is harmful upon the ground that any injury to the mucous surfaces encourages the fresh formation of membrane. It is useless because the noxious germs composing the membrane have already passed beyond the reach of local applications to the lymphatics and bloodvessels beneath. Such reasoning does not convey conviction to my mind, and the want of success upon which it is founded is, as I have shown, not altogether surprising. It is advisable to apply our local applications as gently as possible. The healthy mucous membrane should be in all cases respected. But the little bleeding that ensues upon detaching a thick flake of perhaps fetid membrane can surely be of but little importance ; and supposing that the membrane forms again, things are not worse than they were before. Of local applications many have been recommended. I prefer a saturated solution of borax with soda, or boracic acid in glycerine, the solution being made by the aid of a water bath ; or a solution of permanganate of potassium, twenty grains to the ounce ; or a ten-grain to the ounce solution of quinine, made by the aid of hydrochloric acid, in equal parts of glycerine and water. These are not un- 20 23O THE DISEASES OF CHILDREN. pleasant, the borax or boracic acid least of all so, and are best applied by painting with a bent laryngeal camel-hair brush. I prefer this method, as I believe it to be more thorough than any other. But the af n can, if it be preferred, be made by means 01 the hand spray — the nozzle being placed upon the tongue between the teeth, or p. : , through Mr. East's ingenious funnelled tongue depressor, and the pumping continued for a few seconds. The appli- cation must be repeated at least every two or three hours, often every hour. Other things have been recommended, such as perchloride of iron in glycerine, sulphurous acid in glvcerine, solution of liq. sodae chlorinatae or chlorine water, carbolic acid, etc. These are all antiseptics or germicides, and are radical in their intention ; others are useful for dis- solving the membrane, and of these lime-water and bicar- bonate of sodium solution (20 grains to the ounce, used as spray, are at once effective and harmless. For the same object Dr. Hale White has proposed a solution of pepsin in glycerine, and this solution also has active solvent power. For internal administration a c ot potassium or iacum lozenge may be given every three or four hours, or the citrate of iron and quinia may be given in glycerine, or chlorate of potassium and perchloride of iron in equal parts of glycerine and water. [The following prescription, acting both locally and gene- rally, frequently produces excellent results : R. Quiniae Sulphatis, lloratis, . Tine. Fern Chloridi, Syrupi Zingiberis, r. . gr. xij. gr. xlviij. . . . . t-.-. .... rg. q. s. ad fjfiij. M. S. — - nful, dilut : h juts, for a child from ye its. Should the stomach revolt against quinine, either the sul- phate or bisulphate, in two to three grain doses, may be DIPHTHERIA. 23 I given in suppositories, every four or six hours, at the age of six years. In the preparation of these care must be taken to reduce the drug to an impalpable powder, lest local irri- tation be produced. Stimulants in free doses — as one teaspoonful of whiskey every hour — are called for in some instances.] Cases of this kind should have plenty of fresh air, but be kept warm in bed, and the air should be kept charged with a moist disinfectant vapor. One of the best is, I think, the following: creasqte. 5j, pulv. acaciae, oij. The gum and creasote are rubbed up together, and added to two ounces of lotio acidi carbolici (1 and 20). The whole is then put into a bronchitis kettle with a pint of water. A not un- pleasant vapor is given off, distinctly different from either creasote or carbolic acid. The food given must be of the strongest: milk, eggs, strong beef-tea, Brand's essence. If children refuse liquids, there is no particular objection to the administration of solids ; and for those who are difficult to tempt it may be advisable to try artificially digested foods, which are most temptingly administered in the form of jelly or blancmange. Wine also must in many cases be administered, and in large quantities; two or three ounces of brandy in the course of the twenty-four hours. In the worst cases it may be ad- visable to try enemata; but they are not borne long in chil- dren, as the rectum becomes irritable and expels them after one or two have been retained. Indeed, as I have elsewhere remarked, the failure of enemata has induced me to resort to the passage of a soft catheter along the nares into the oesophagus, and food has been introduced by this means into the stomach very satisfactorily. Tracheotomy. — If a child is choking, it is obviously right to give it the further chance which opening the windpipe offers : no one will dispute this. The chance appears to :x. vary in the experience of different physicians, but probably Trousseau's original estimate of his own cases — one recov- ery in five — is about the average all round. Still there is no little difficulty in deciding this question, for there is prob- ably no operation in surgery, if I may venture to say so, which requires so much the personal supervision of the sur- geon as tracheotomy, and I believe there can be few in which - the degree of hope which may be indulged depends so much upon the after treatment. But it is the custom of the advo- cates of operation to argue that the mortality after trache- otomy is so great because the operation is postponed till too late ; that the operation itself is not a serious one, but that it cannot be expected to succeed if performed when the dis- ease has extended down the trachea, and that if performed early more success would attend it. Now first of all let us clearly understand what this means. It means that the trachea is to be opened before there is any immediate risk to life, and this ; /different thing to an operation h is the only chance left of life. But there can be no objection to an early operation if no extra risks are entailed by it, or if any extra risk is compensated by advantage gained, such as, e.g., if by operating early the formation of membrane can be arrested. I would venture to dwell upon these alternatives, is I do not think they have been always well considered. Early operation has been defended chiefly upon the ground that the operation is not a serious one. Now I say that in diphtheria it is a serious operation. It is prima facie unreasonable to contend otherwise, if it be true, as many think, that even the membrane on the fauces should not be disturbed for fear of provoking fresh inflammation and formation of membrane ; and as a matter of fact, the operation of tracheotomy, when performed upon the diph- theritic child, is frequently followed by diffuse inflammation eilular tissue of the neck — the edges gape, and a DIPHTHERIA. 233 large sloughy wound is formed, which becomes dry and fetid, and not unfrequently covered with membrane. But further, is it supposed that the mucous membrane of the trachea itself suffers no injury from the introduction of the tube ? The richness of the glandular and blood supply, and the sensitiveness of the mucous membrane to changes of temperature, make such a thing highly improbable, whilst it would be easy to show, in the clearest manner, by the evidence of the post-mortem room, that the operation itself, and the presence of a tube afterwards, are, in one way and another, fraught with danger. It is, in fact, my belief that the broncho-pneumonia, the purulent bronchitis, the excessive tracheitis, so often seen in fatal cases of diphtheria, are chargeable quite as much to the operation as to the original disease. The state of the trachea in fatal cases is not calculated to impress one favorably with the harmless- ness of tracheotomy ; but let that pass, for it may well be said that these are the hopeless cases, qua diphtheria. But even in others that do well the amount of mucus and muco- purulent discharge ejected from the tube, and the slowness with which this ceases, are sufficient to show that the mu- cous membrane of the trachea must in any case undergo grave alterations. . For these reasons, amongst others, early tracheotomy in diphtheria must be advocated, not from its harmlessness, but upon other grounds. But hitherto these other grounds have been little appealed to in practice. The operation has been performed ; if happily the membrane failed to spread — well, but no thanks to treatment; the operation relieved a symptom and temporized while the disease spent itself. If death resulted it was only to be ex- pected of the disease ; the operation has taken no share of the responsibility. But if, on the other hand, we resort to an operation not immediately necessary, in the hope that by so doing, some local measures may be adopted which will 234 THE DISEASES OF CHILDREN. help to combat the formation of membrane, the operation has another basis upon which it may stand of a less assail- able nature. Upon this ground alone — that of the more thorough application of local remedies to the larynx — does an early operation admit of advocacy. Possibly on this ground the operation will yet justify itself and the additional risk which it necessitates be more than counterbalanced. It cannot be said that this is so at present ; and, although I would urge perseverance in local measures, I still think that the operation of opening the windpipe should be deferred to the latest possible limit. [Tracheotomy should not be too long delayed. It should be performed as soon as there are urgent symptoms, and every preparation for the operation should be made beforehand, that no valuable time may be lost during it. The symptoms demanding operation are increasing dyspnoea, supra-sternal depression, well-marked retraction of the scrobiculus cordis, and lividity about the face and finger tips.] When tracheotomy has been determined upon, the prin- ciple upon which success depends is to tamper with the tra- cheal mucous membrane as little as possible. To put a tube into the trachea and to leave it there, save for changing it occasionally, is but to exchange the risk of choking for the more deadly one of diffuse and ulcerative tracheitis. No doubt a certain sense of security is felt by the surgeon when a tube is safely in the throat, but it is dearly purchased for him by his patient, and the largest percentage of suc- cesses will certainly be procured by dispensing with the tube as much as possible. But this treatment cannot be carried out without a trained nurse who is equal to remov- ing and re-inserting the tube, and who is also possessed of sufficient self-command to meet the still greater emergency of not being able to re-introduce the tube, when it will be- come necessary to keep the wound open by forceps until DIPHTHERIA. 235 assistance can be procured. With a nurse of this kind, and the frequent supervision of the surgeon, one cannot doubt for a moment that the stated mortality can be, and has been in the hands of individual operators, largely reduced. The operation itself is a surgical procedure, and it may perhaps be thought that I have no necessity and no right to speak upon that subject. Nevertheless, upon the principle that lookers-on see most of the game, I shall venture to add what seem to me hints of importance for its due perform- ance. The rules which I would lay down for the conduct of opening the windpipe, are these : The operation should be as high as possible (i) because it may be necessary to deal locally with the formation of membrane in the larynx by means of the aperture, and this can be more effectively done when the operation is high than when it is low; (2) because it is advisable to interfere as little as possible with the tra- cheal mucous membrane, and the connective tissue of the neck is less encroached upon in the incision. When the trachea is opened, the incision should be well separated by a dilator, and the parts thoroughly examined. This done, any membrane discovered either above or below it is to be removed gently by a soft feather, and if necessary, an appli- cation may then be made to the larynx of a solution of boracic acid or borax in glycerine, either by a feather or the spray. The opening must be kept as free as possible, and the interior of the windpipe tampered with as little as pos- sible. The expulsion* of membrane is thus favored, and the risk of extension of inflammation down the trachea is re- duced to its minimum. To accomplish these objects some instrument, such as Golding-Bird's dilator, or Parker's auto- matic retractor, seems to me best in principle, although per- haps a metal tube as large as possible is more available for practice . This must be inserted for the first twenty-four hours . 236 THE DISEASES OF CHILDREN. After this our aim is to do without any dilator or tube as much as possible. By this time any inequalites upon the sides of the incision which would be likely to hinder the easy re- introduction of the tube will have become sealed by lymph. Whatever the instrument employed it should be removed, the child being closely watched, so that it may be re-in- serted when necessary. The time for which the dilator can be removed will vary much. Sometimes not more than ten minutes can be allowed — sometimes half an hour, or an hour, or more : the more the better. Some cases have been treated successfully throughout without any tube, and I sus- pect this could be done more often and with much advantage to the patient. The tube is to be taken out several times daily, and kept out as long as possible, and after a day or two the metal tube is to be replaced by one of Mr. Morrant Baker's soft india-rubber tubes as short as possible. When the edges of the wound have consolidated, the curve of the tube may be removed, leaving a straight stump long enough to reach from the surface through the cedematous tissues to the trachea, but not longer. So far as the nature of the material is concerned, I believe it would be better to insert a soft rubber tube at once, but the objection to this is that the bore of these is smaller than that of the metal tubes, and for the first day or two it is of paramount importance that the aperture should be as free as possible. When the tube is removed or replaced, the opportunity must be taken, if it be judged necessary, for applying the boracic solution to the larynx. This should be done regularly ; the trachea should only be treated in similar fashion if there be evidence that the membrane is extending downwards. The applica- tion may be made by a feather or a laryngeal brush, or by a piece of sponge or cotton wool twisted into a loop of wire. If necessary a spray can be applied to larynx or trachea through the opening. I have no great affection for feather- DIPHTHERIA. 237 ing the trachea for the removal of membrane, and probably a free aperture best effects its expulsion ; but one of the risks attaching to the operation is the loss of expiratory power, which results from opening the trachea below the larynx, and this makes it necessary to be ever on the alert to re- move membrane either in this way or by the tracheal forceps, which must always be ready to hand. I must further add as regards the final removal of the tube, that those only who have had experience of such cases know how difficult this often is. What the exact conditions in the trachea or larynx may be that render it so are difficult to state, but it is often many days, and sometimes weeks, before the tube can be altogether dispensed with. Perhaps the child will breathe well by day and badly by night, or will go without the tube completely for three or four hours and then have dyspnoea. In all these cases the short tube should, if possible, be worn, and the external aperture should be kept plugged as much as possible so as to compel breath- ing by the natural passages. The creasote vapor has already been advised, and plenty of fresh warm air. Many recommend a steam tent, but, provided the cot is well fumigated by the moist vapor, this is hardly necessary, and it often makes the child hot and restless. There is yet the treatment of diphtheritic paralysis to be considered, and this may be both preventive and curative. It is of the utmost importance to remember that diphtheria is a disease which leads to great anaemia — great exhaustion; and it is the opinion of many that if after diphtheria the child be confined to bed, kept quite free from excitement, and fed frequently, and so treated until the nutrition has been in some measure restored, and the anaemia curtailed, paraly- sis will but seldom occur. There can be no doubt that to be up and about in the early days of convalescence, feeling 238 THE DISEASES OF CHILDREN. ill, but without anything definite the matter, is one of the surest incentives to its onset, and it is also to be remembered that, like the albuminuria of scarlatina, the paralysis after diphtheria may follow such cases of indefinite disease, as the malaise and slight sore throats which so often run through a household when one of its members is attacked with the pronounced disease. When paralysis has come about, the same rules apply ; perfect rest in bed is the first necessity, together with the most nourishing food. This must be given at frequent inter- vals, and it is well to remember that in the paralysis of the throat solids are often better swallowed than liquids. It may be necessary to feed by means of a tube passed into the stomach, and probably the nasal tube will be more easy of application than the oral. Enemata may be also given and, in addition to the food, stimulants are valuable, and maltine and cream are good additions to the food. The greatest care and patience is requisite in feeding these cases lest they choke, or food passes into the larynx and trachea and sets up a broncho-pneumonia. Most of the cases of localized faucial paralysis recover but slowly, and a great deal of inconvenience may be experienced for months — sometimes in swallowing, sometimes by difficulties in pho- nation — but those where the affection is general are always tedious and often dangerous. The heart suffers and the respiratory muscles also ; the one becoming dilated, the others, by their sluggish and imperfect action, leading to collections of mucus in the bronchial tubes and so to bron- cho-pneumonia. These cases must be fed as others; iron and arsenic must be administered, and the muscular system must be renovated by the movements of shampooing and by electricity. In paralysis of the heart in its worst forms the sudden fatal issue precludes all treatment; but a careful watch upon the heart should be kept in all these cases for DIPHTHERIA. 239 the earliest indications of dilatation of the ventricles. A careful administration of digitalis, or belladonna and iron, and stimulants may, in these cases, sometimes be attended with successful results. [Strychnia in properly proportioned doses, either alone or combined with iron, should be employed in cases of pa- ralysis.] 24O THE DISEASES OF CHILDREN. CHAPTER XIV. VARICELLA. Varicella. — The chief interest of chicken-pox lies in its resemblance to small-pox, and in the suggestions which come out of this resemblance. The relation of vaccina to variola and the different behavior of the latter when intro- duced by inoculation to that which it shows when operating upon virgin soil, under conditions of introduction, so to speak, of its own choosing, show how liable is variola to undergo modification. And when further we bear in mind the many points of resemblance which modified variola bears to varicella, the question irresistibly presents itself, is vari- cella modified small-pox ? To this the answer must be — No. For many reasons, but for this one above others — conclusive as it is considered for all exanthems — that varicella and va- riola may both occur within a short time of one another in the same person, and pursue an unmodified course. One of the most striking cases of this kind is recorded by Dr. Sharkey in the Lancet, vol. ii., 1877, p. 47. A boy, aged five, under Dr. Bristow, was admitted with varicella out upon him. Variola was rife at that time, and existed in the block where the child was warded ; he was on this account vacci- nated the third day after his admissioii, and took very well. Ten days after admission, the eighth day from vaccination, he became very ill, and the next day the variolous eruption appeared. Varicella does not therefore protect from variola, nor does vaccina protect from varicella, and the germs are distinct. Incubation. — This is variously stated to last from eight VARICELLA. 241 to sixteen days. Dr. Dukes, from some careful observa- tions made at Rugby, makes it as long as fourteen to nine- teen days, the shortest incubation in fifteen cases being thirteen to fourteen days in one case, fourteen in two, four- teen or fifteen in one, fourteen to sixteen in two, fifteen in three, and the remainder more. It is attended by no defi- nite symptoms ; but there may be slight malaise for a day or two before the outbreak of the eruption. Eruptive Stage is generally associated with more or less pyrexia, loss of appetite and langor ; but the amount of constitutional disturbance may be, and usually is, very slight indeed. In unhealthy children the eruption may be copious and the resulting sores lingering in their course, and in such the illness may be considerable, and even followed by per- sistent anaemia, discharge from the ear, or some enlargement of glands ; but this is rather an outcome reserved for the squalid and forlorn than for the child of the well-to-do. It is also stated, and this is interesting when we remember the mortality which attends measles in native races, that the mortality is sometimes high in India amongst the ill-fed and badly clothed children of the native population. The eruption cosists of oval or globular vesicles containing opalescent contents situated upon a slightly inflamed base. The vesicles commence as a small red papule, the vesicle forming within a very few hours, whilst the amount of inflammation around it constitutes a measure of the severity of the disease and of the condition of the patient. In many cases there is no areola round the vesicle ; a small pearly bleb rises from an almost natural skin, and the appearance of the child suggests that it has been exposed to a shower of boiling water. In severe cases the zone of injection around is vivid and considerable. The eruption comes out in crops, one crop quickly succeeding another, mostly on the back and abdomen, but -also found on the face, scalp, 242 THE DISEASES OF CHILDREN. and other parts, more rarely in the mouth. The vesicles form rapidly; they contain alkaline serum, which becomes a little turbid, in some cases purulent. In ordinary cases the vesicles shrivel within a day or two and leave a small dry scab. This falls off in another day or so and leaves behind a small pigmented stain, and occasionally a slight scar. Mr. Hutchinson thinks that scars are not uncommon if carefully looked for ; but this depends much upon the extent of local change. If the vesicles are rubbed or ex- coriated in any way — or if the vesicle ulcerates, as it may sometimes do, these scars will be found, but not otherwise. The vesicles come out in crops, occasionally lasting for six or eight days, but usually exhausting the disease within three or four days, or even sooner. The disease occurs in quite young infants. Gee gives a table of 727 cases from the Ormond Street Hospital, with this result : Under I month, 2 Under 4 years, 100 tt 2 months, 8 <( 5 " • 96 " 3 " 13 " 6 " . . 58 " 6 " 57 tt 7 " . 30 a 12 " 97 tt 8 " . . 29 " 18 " 62 tt 9 " • 10 " 2 years, 75 " 10 " . . 5 " 3 " 78 (( 12 " . . 7 It is not known to recur, and has no complications and almost no sequelae. It may, however, be stated that the vesicles are attended with a good deal of irritation, and in the unhealthy children of the hospital out-patient room, it is not uncommon to find somewhat persistent superficial ulcers, perhaps beneath scabs, for some time after the out- break of the varicella. But when this is the case, the stu- dent should have it in mind that the original malady may have been pemphigus and not varicella at all. VARICELLA. 243 Diagnosis. — Modified variola causes the most difficulty. It will be well to bear in mind that varicella has no prodro- mal fever, that the vesicles are not umbilicated, and collapse at once when pricked — in other words, they are simple, not multilocular ; and that the eruption comes out in crops, and therefore exhibits stages upon the skin ; while variola appears at once. [With variola, varicella stands contrasted by its brief in- vasion period, the short duration of its initial fever, the absence of secondary pyrexia, the difference in the position at which the surface lesion first appears, the larger size and softness of the papules and the rapid transition of the phases of the eruption. There are several features of small-pox, usually considered to be important distinctions between it and chicken-pox, that are of little diagnostic value, because, practically, they are common to both diseases. These are the appearance of the eruption on the scalp, its presence on the visible mucous membranes, umbilication of the vesicles, and pitting* I have often seen the eruption of varicella on the scalp, and in the majority of my cases a varying number of pseudo- membranous points were present on the mucous membrane of the cheeks and palate, differing from those of variola only by being larger and more yellow in color. Again, the vesicles are frequently umbilicated; this occurs only in those that begin to desiccate in the centre, and on close inspection minute crusts can be detected in this position. Both the cause and appearance differ, therefore, from the variolous umbilication, but the likeness is close enough to confuse a superficial observer. Pitting, too, occurs where large vesicles are accidentally broken by scratching. It is usually seen on the face, and the scars which rarely number more than three or four are broader, shallower and smoother than those of variola.] 244 THE DISEASES OF CHILDREN. Pemphigus can hardly cause any difficulties, if the case be thoroughly inquired into, unless, indeed, we have to do with cases such as have been described: (i) by Mr. Hutchinson as persistent or relapsing varicella — where the disease may last as long as a month ; (2) by Trousseau, in which biebs like those of pemphigus come during fifteen to forty days, causing ulcerations like those of pemphigus, and which continue for six or eight weeks. Varicella has also occasionally to be distinguished from vesicular or pustular rashes following upon vaccination. Hebra says of them, that they resemble varicella. They are not very common. Sequelae. — Most writers would be inclined to say that there are no sequelae of varicella ; but superficial ecthyma- tous-looking sores are by no means uncommon in the hospital out-patient room. Mr. Hutchinson alludes fully to this condition, and how it may resemble pemphigus. Under the term varricella prurigo, adopted by him, are included not only the clearly vesicular rashes, which con- tinue after varicella, but also many of those papular prurigos which have hitherto been called lichen urticatus, lichen strophulus, etc. Mr. Hutchinson points out that many of these cases called lichen show abortive vesicles ; that they occur on the palms and soles, where no lichen can — seeing that it is a disease of the hair-follicles ; and that there is, in some cases at all events, a history, if not of origination in a recognized varicella, yet at any rate of definite onset at some particular date. Mr. Hutchinson seems, however, to adopt a view which I have long believed, that in these cases it is hardly so much the disease which is at fault as the child ; it is the fact of the occurrence of varicella — a disease which is apt to start a chronic itching — in a pruriginous skin (not uncommonly an inherited weakness), which entails such dis- agreeable results upon the child. VARICELLA. 245 Treatment. — Varicella very seldom requires any — at the most some simple saline, a mild aperient, and a little vase- line or ung. metallorum to relieve the local irritation of par- ticular spots, are all that can be necessary. Vaccina. — Of this as a disease it is hardly necessary to speak, so little in the majority of cases does it affect the child's health. But this much may be said, that amongst the lower orders a large number of cutaneous affections are attributed to vaccination. If assertions of this kind are traced to their source, many have no foundation in fact. Yet some have — and it is well not to discredit such tales too readily. It can hardly be that the introduction of a material such as vaccine into the system never proves detrimental, and unquestionably, from time to time, vaccination is fol- lowed by various forms of cutaneous eruption. The risk of such an occurrence is as little to the individual as the gain to the community is great from the practice; but the occa- sional occurrence of such a result is an incentive to the exercise of the most scrupulous care in vaccinating only such infants as appear healthy, and in selecting only such lymph as is absolutely pure. Much has been heard of late of the introduction of the syphilitic virus by means of vaccine, and I cannot doubt that such a thing may occasionally happen, but its exceeding rarity, while it should serve to ensure the strictest precau- tions, may very well be used as an argument in favor of vaccination rather than one against it. [A short synopsis of the symptoms of the typical vaccine disease seems proper. Local Symptoms and Course of the Sore, — Usually on the third day a small hardened nodule of faint-red color appears at the seat of introduction of the virus. A serous exudation now raises the cuticle, and a vesicle is formed which by the sixth day begins to be depressed in the centre, or umbili- 246 THE DISEASES OF CHILDREN. cated, and at the same time is surrounded by a narrow ring of inflammation. The vesicle increases in size, and reaches perfection by the eighth or ninth day ; it then projects above the surrounding surface, has a dull white color, and is about one-third of an inch in diameter. The narrow inflamma- tory zone has now extended so as to become a broad areola as much as two inches in breadth, of a scarlet, rose or dark- red hue, the color gradually fading from the centre to the periphery where it shades into that of the normal skin. Coincident with the surface inflammation the subjacent con- nective tissue becomes infiltrated, hard, tender and painful. By the tenth day the inflammatory symptoms have reached their height. The areola now rapidly fades and the vesicle loses the pearly appearance — pus taking the place of lymph and giving its characteristic color to the sore. By the four- teenth day the inflammation has subsided, the pus has become inspissated and the crust begins to form. This be- comes harder and darker in color, and falls by the end of the third week. The resultant scar is of a deep red or purple color, but in the course of from three months to a year should become smaller in diameter and present a smooth shining surface marked by pin-point depressions or radiating lines. General Symptoms are seldom present before the eighth day, when the child may become fretful, with fever, disturbed sleep, restlessness and partial anorexia. Vaccination, — The introduction of vaccine virus into the system is effected in several ways — by incisions or scarifi- cation, puncture and abrasion. The virus employed may be contained either in lymph directly from the vesicle, the dried vaccine crust powdered and suspended in water, or the lymph from cow-pox. Scarification consists in making four or five parallel inci- sions about a line apart and intersecting these with the same VARICELLA. 247 number at right angles. Should blood flow one must wait till this stops and there is but an oozing of serum, before the virus is rubbed in. The puncture method consists in making a horizontal pocket in the true derm with the point of a lancet, in the groove of which is the virus. The puncture is then closed with isinglass plaster. Abrasion is the preferable method. The skin is made tense between the thumb and forefinger of the left hand, while with a gum lancet, which has no points to catch or cut the skin, the epidermis is quickly removed by a rapid but gentle scraping movement until serum slightly tinged with blood exudes from the true derm. The virus is then applied. Whatever form may be used must be well rubbed in and the part left exposed until the exuded serum, which contains the bulk of the virus, dries. Vaccinating from arm to arm, taking the lymph directly from the vesicle, is not very frequently done now, and is not to be recommended, though convenient in public institutions, where there are many individuals to be vaccinated at once. Care should be taken that no blood is mixed with the lymph. The crust is still frequently employed. The central part only should be made use of, as the margin is apt to contain blood and may be the means of conveying disease. The part employed should be rubbed into an impalpable powder and dissolved in water. It is claimed by some that humanized virus takes a day sooner than bovine virus. This may be of importance in epidemics and should be remembered. Fresh bovine lymph on quills or ivory points can be ob- tained at any time in almost all large cities, and is much to be preferred as it does away with the possibility of the patient becoming inoculated with any foreign poison. When applied the points or quills are moistened with clean water and the virus is well rubbed into the abrasion. 248 THE DISEASES OF CHILDREN. The age considered most suitable to perform the operation in infants is from the fourth to the twelfth month, though it is very common to vaccinate about the fourth week before the monthly nurse is discharged. It seems important that the operation be performed early, as statistics show that in England nearly one-fourth of the mortality from small-pox occurs during the first year of life. Should an epidemic be prevalent the child should be vaccinated within the first twenty-four hours. The point selected for inoculation is usually the left arm, over the insertion of the deltoid muscle, but the leg is to be preferred, the choice position being beneath the knee and on the outside of the limb, just below the junction of the tibia and fibula. In this site the sore is less apt to be irritated than at any other part of the body; there is no tight-fitting garment as there is about the arm, the diaper does not come within two inches of it, and besides the lymphatics are less apt to sympathize. The part, too, is easy to get at, and where the abrasion method is employed the operation can frequently be completed on a sleeping child without its being aroused. The number of points of insertion do not seem important so that the system be thoroughly impressed. Of this we can feel pretty sure from the character of the sore and the resultant scar. If later in life revaccination is performed, almost a positive immunity from small-pox can be as- sured.] ^ MUMPS. 249 CHAPTER XV. MUMPS, Parotitis (Mumps). — Inflammation of the parotid gland occurs under two sets of circumstances. In the one, it is secondary to typhoid fever, scarlatina, measles, etc., when it usually ends in suppuration ; in the other, it is a primary, acute, epidemic and contagious disorder. With the latter we have alone to do now. Mumps appears to be looked at askance by writers on specific fevers. Like whooping- cough it has such definite local symptoms that there is reason for treating of it as a disease of the part which is specially concerned. But, inasmuch as it occurs in epidemics, is very contagious, whilst a second attack is exceedingly rare, there seems very little ground for excluding it from specific diseases. Incubation. — Fourteen to twenty-five days, according to Dr. Dukes' observations, which are the most complete that I know of. He gives fifty-seven cases of mumps ; fifteen of these were not available for the purpose of drawing conclu- sions. In the other forty-two the incubating period was from sixteen to twenty days in thirty, and possibly in thirty- four. Like most other specific fevers, the period of incuba- tion certainly varies. In a family which I observed myself, a little girl incubated for fourteen days after coming in con- tact with a child with mumps. The next child took it twenty-one days later, and the third twenty-one days later still. Henoch gives the stage of incubation as about four- teen days ; but I think this is too short. Ringer says eight to twenty-two days. 25O . THE DISEASES OF CHILDREN. Symptoms of Attack. — The disease is attended with con- siderable malaise rather than with downright illness. The child looks very pale, ancj — on one side or the other, per- haps on both, often commencing on one side (the left, so it is said, more commonly), and extending to the other — there is a tender swelling which occupies the parotid region be- hind the angle of the jaw, and spreads over the side of the face in the situation of the socia parotidis. Generally, the color of the skin is not altered; but occasionally there may be some redness over the parotid. There is a dull, aching pain when the masticatory muscles are moved. The tem- perature may be a little raised, but in many cases it remains normal. The swelling lasts for four or five days, and then gradually subsides. As regards the constitutional disturb- ance, there is some variety. The fever may be considerable (103 ) for a short time; Dr. Gee has recorded one case of onset with convulsions, and there may be some delirium at night. As regards the swelling, it is not always by any means confined to the parotid ; it extends to the submaxillary gland, and also to the cervical lymphatic glands, and may sometimes even be confined to the latter, in which case the disease is likely to be mistaken. Occasionally the swelling is so great as to extend from one side to the other in a huge continuous double chin. When the disease is severe, the difficulty of deglutition is considerable, and, the child breath- ing with its mouth open, the tongue may thus become brown and dry. This is a point which it is important to remember for the symptom is one which might otherwise lead us to regard the case with greater anxiety than need be. The duration of the disease is very variable; five or six days appears to be about the usual limit ; its course, how- ever, maybe protracted, for it sometimes happens that when the swelling has subsided on one side, it recommences on MUMPS. 251 the other, and in this manner ten or fourteen days may be occupied. Complications. — Chief of these is the tendency, a rare one, in males to the occurrence of orchitis. It is often spoken of as a metastasis ; and I do not know that there is any ob- jection to the term, inasmuch as the testis usually becomes affected as the parotid swelling subsides, although the two regions may be affected concurrently. Dr. Dukes gives twelve cases in boys ; in six the orchitis began on the seventh day; in four on the eighth; with one on the ninth; and one on the first. The body of the testis becomes suddenly swollen and intensely painful, and fluid often collects in the tunica vaginalis. The accompanying constitutional disturb- ance is generally severe, there being high fever and perhaps considerable delirium. All writers record the occasional occurrence also of an homologous affection of ovaries and mammae ; but I suspect that this is one of the statements which is copied from book to book, and is far more imagi- nary than real. I cannot find any notes of such cases. The occurrence of orchitis in mumps is rare ; indeed, it is a dis- ease of adolescents rather than of children. Dr. West has no personal experience of it, and Dr. Dukes considers that it comes only to those who have arrived at or beyond the age of puberty. I have, however, seen a very severe case in a boy of about twelve. He came under my own care some years ago. The orchitis usually subsides within a few days; but it may, on the other hand, lead to persistent hydrocele and atrophy of the testis. [The appearance of orchitis at the date on which the par- otitis naturally begins to disappear, tends to support Nie- meyer's view, that the two affections are in reality due to the same cause, and that there is no true transference of inflammation from the parotid to the testicle. The right 252 THE DISEASES OF CHILDREN. testicle is more frequently affected. The inflammation and swelling increase for from three to six days, after which resolution is rapid and generally complete by the end of the second week. The general symptoms are somewhat more intense than during the mumps, and, if the orchitis be bi- lateral, they are still more severe, and the course of the dis- ease is slightly prolonged.] Meningitis is another complication described as occurring but which must be very rare. Possibly a similar remark applies to this as to the ovaritis and mastitis ; and it is not unlikely, I think, that the severe delirium which occasionally presents itself in the course of the testicular — and even some- times of the parotid — inflammation may by some have been considered evidence of meningeal inflammation. Sequelae. — A chronic induration of the gland is sometimes left behind after the attack ; but it is of little consequence, and usually cures itself in the lapse of time. Suppuration of the gland is an occasional but rare sequela. iEtiology. — Although there are some who doubt it, the infectious nature of mumps seems to me indisputable. Why I think so, I have already stated. It is now only necessary to add that, although the disease is communicated by germs, it is not necessary to take any special precautions for the isolation of the affected children. The disease is so mild and so free from sequelae, that it can seldom be worth while to enforce any strict quarantine. Delicate chil- dren should naturally be protected as far as may be, and possibly boys when they are attaining to the age of puberty. It is certainly advisable to avoid all risk of orchitis. Morbid Anatomy. — Practically none. Virchow has con- tended that the disease is a catarrhal affection of the ducts of the parotid gland, and Bamberger states the whole gland to be enlarged, red, and oedematous from interstitial exuda- MUMPS. 253 tion. This is, indeed, highly probable, but facts to corrobo- rate it are very few. [The exact pathological lesion is obscure, on account of the rarity of opportunity for post-mortem examination. Foerster states that the affected gland first becomes hyper- aemic, and is then the seat of serous exudation. It is red- dened, swollen, and on section presents a uniform, flesh-like, moist appearance, in place of the ordinary granular surface. The tumor is often greatly increased in size by a simultaneous serous infiltration of the periglandular connective tissue ; occasionally, this tissue alone is involved. The rapid and complete disappearance of the glandular swelling by the process of resolution favors this view.] Diagnosis. — I can imagine that in young children the sudden and rapid swelling of the cervical glands from scar- latinal or diphtheritic poison might cause some doubt. But the extreme illness in the one and the less serious state in the other will ere long settle the doubt. On the other hand, the fact that mumps may show itself as an affection of the submaxillary gland or even of the cervical lymphatic glands, and leave the parotid untouched, though such cases are rare, is worth remembering. Lastly, the occurrence of sup- puration should make one suspect and examine for some septic state other than that which hypothetically we sup- pose to be present in an attack of uncomplicated mumps. Treatment. — It often happens that no medicinal treatment is required. The child is kept warm in one room, and its diet is made to conform to its inability to masticate — to con- sist, that is to say, of milk, broth, jellies and blanc-mange. Should there be much fever, a drink maybe made of barley- water, to which fifteen or twenty grains of nitrate of potas- sium, and the same quantity of bitartrate, have been added to the pint. The local pain may be relieved by warm moist applica- 254 THE DISEASES OF CHILDREN. tions, such as spongio-piline wrung out of hot water, or by lint soaked in warm water and covered with oil-silk. Chlo- roform or belladonna may be sprinkled on these, if neces- sary. Small doses of Dover's powder are also sometimes necessary. If the fever is severe, a drop of tincture of aco- nite may be given every hour for a few hours. The child is to be kept indoors for nine or ten days, and some tonic, such as Parrish's food, may be given afterwards. In older children of the male sex and adolescents, particu- larly the latter — for the older the boy the more likely is there to be orchitis — the child must be kept in bed for eight or nine days, and the temperature carefully watched. 9 Dr. Dukes has found that a rise of temperature is a good warning of the occurrence of this complication, and that the early application of poultices to the part mitigates the pain and lessens the severity of the affection. It has been asserted of late that jaborandi and its alkaloid pilocarpine have the power of arresting mumps if given suf- ficiently early. I have not had any personal experience of this ; but it is worth a trial, always remembering that pilocar- pine in children has sometimes acted as a powerful depres- sant, and should therefore be given with caution in the case of young children. I have given it in acute nephritis to the extent of one-fifteenth up to one-tenth of a grain as a subcu- taneous injection in children of ten and twelve years of age, and from the slight effect produced by the lesser dose this might safely be given to children of eight or six years. In the violent delirium which occasionally happens, I should be disposed to trust to saline aperients and warm baths. The orchitis requires plenty of warmth in the way of fo- mentations and baths, while the fever is treated either by aconite or saline diaphoretics. The urgent symptoms are not usually of any duration. WHOOPING-COUGH. 255 CHAPTER XVI. WHOOPING-COUGH. Pertussis. — I shall complete the specific diseases inci- dental to childhood with an account of pertussis. ' Like mumps, it is always a question with writers whether this disease shall be placed with specific diseases or with those affecting the parts or organs with which the symptoms more particularly concern themselves ; but surely, if the disease is specific and possesses infective properties, the most impor- tant feature of the disease as regards the community is its specific nature — as regards the individual only, can the local symptoms claim priority. Since, therefore, the well-being of the community is of the first importance, pertussis, I think, most properly groups with those other diseases having con- tagious properties ; and, indeed, more fitly does it take this place than some others, for next to scarlatina it has the highest mortality of all the diseases of children. Incubation. — I have but few data of my own from which to fix the period of incubation — in a family of two sisters it appeared to be eight days, the one being exposed to infection, and a cough beginning eight days after, the other following suit eight days later — it is stated to be from four days to a fortnight. Dr. Murchison quotes three cases upon the au- thority of Dr. Bristowe, which are almost free from the possibility of error, and which give a period of incubation of fourteen days.* These cases are so well told, and the infor- mation is so precise, that I quote them as they are reported : * Observations on the Period of Incubation of Scarlet Fever, and of some other Diseases : " Trans. Clin. Soc," vol. xi., p. 238, etc. 256 THE DISEASES OF CHILDREN. u In the winter of 1874-5, Dr. B.'s three youngest chil- dren, owing to having suffered from severe ' colds ' in the previous autumn, were kept in the house in London from the early part of December until May, when the following occurrence took place : They were then in perfectly good health, and for several months had seen no children nor visitors of any sort. But at that time some nephews and nieces of Dr. B. were ill at Sydenham with whooping-cough. On Saturday Dr. and Mrs. B. went to dine with his mother, who also resided at Sydenham Hill; and, on arriving, they found the eldest boy of the family referred to living with her. He had hitherto escaped the disease, and was living with his grandmother in the hope that he might escape it altogether; but on this very Saturday he had, for the first time, a con- stant troublesome cough. Mrs. B., being afraid on account of her own children, and believing that the boy was in the early stage of whooping-cough, did all she could to avoid him ; but he clung to her the whole evening, climbing on her knee, and coughing and sneezing over her. When she got home at night she took off her dress and laid it over an ottoman under a window in the dressing-room, intending next morning to have it hung out in the open air. Unfor- tunately, however, the eldest of the three children referred to came into the dressing-room early next morning, and began playing at the window over the dress. As soon as this was noticed she was sent away, and the dress was car- ried out of doors. Exactly thirteen days afterwards, on the Saturday, this little girl appeared to have caught a bad cold, and ten days later she began to whoop. The two youngest children caught the disease from her, and both sickened about a fortnight after she first showed signs of illness. The seven other children in the family escaped, but they had had whooping-cough before. " Probably here, as in other infective diseases, the incubative WHOOPING-COUGH. 257 stage is a variable one, depending upon the conditions, both atmospheric and individual, under which the poison or germ is cultivated. Symptoms. — The disease has almost always been de- scribed as one of three stages, but there is no true third stage. There is a primary stage of catarrh and fever, and a second of the paroxysmal cough ; but for a third, it is neces- sary to fix an arbitrary limit where the disease does not define any. The distinction between the two stages is of importance, not only because of its clear definition, but because the remedies applicable in the second stage are harmful in the first. In the first stage, which lasts a week or ten days, the child is poorly, with moderate pyrexia and a hoarse, dry cough, sometimes with a peculiarity of timbre which has been called ringing. As with other febrile conditions, the child maybe pretty well during the day, with good appetite, or have its . fits of fretfulness and cough, with loss of appetite. Probably the more or less of these symptoms depends upon the extent to which the fever runs. Auscultation at this stage usually reveals more or less bronchitis of the larger tubes, indicated by moist and dry bronchial rales, but there is little or no visible secretion from the bronchial tubes. As the catarrhal stage proceeds, the cough becomes more noisy and parox- ysmal, with nocturnal exacerbations, and the face a little full-looking with the eyes suffused, an appearance which to a careful observer may suggest what is coming. The whoop, the characteristic of the second stage, appears towards the end of the second week. As I have watched it mostly in severe cases, and with the child in bed, the onset of a par- oxysm has been quite sudden, a short series of rapid expi- ratory coughs ; but, should the child be up and about, it often becomes restless for some few seconds or minutes before, and may even run to its nurse or mother for support. 258 THE DISEASES OF CHILDREN. But, from some observations which Dr. Newnham was kind enough to make for me in the whooping-cough ward of the Evelina Hospital, it appears that in some it begins thus, and in others with a deep inspiration. In either case the first expiratory part is short, and followed by a short whoop, to be quickly succeeded by a longer series of similar short expiratory efforts to those at the onset, and a second and longer whoop, when the paroxysms may be over, or a third and a fourth may succeed, until the child is fairly exhausted. The paroxysm, short or long, terminates by a flatulent eruc- tation and vomiting — a quantity of stringy mucus and food being ejected, often mixed with a little bright blood. The frequent repetition of the cough produces, in many cases, a characteristic appearance of face, which cannot be mistaken; the features are swollen or puffy, and dusky in color, not unlike, so far as the tinge is concerned, the aspect of a case of typhus. The eyes are watery-looking, and dusky in like manner, an appearance due, as is the color of the skin, to numerous minute ecchymoses or congestions of the smaller capillaries. In many cases there are extravasations of blood beneath the conjunctiva, which, of course, hardly admit of mistake. If examined during this stage, the chest has little to tell, provided there is no broncho-pneumonia — a few rales, dry or moist, may be heard here and there, nothing more. The spasmodic stage of whooping-cough has no definite duration, and varies much in intensity. In severe cases there may be twenty to thirty paroxysms in the course of the twenty-four hours, or even more. At the Evelina Hospital, where all cases are recorded upon a chart, it is found that some paroxysms are accompanied by a whoop ; some are not ; and that sometimes one, sometimes the other, kind predominate. A typical case, one would suppose, should show an onset of the paroxysms without whoop, gradually lessening in number; paroxysms with whoop to WHOOPING-COUGH. 259 replace them ; these again gradually declining and being replaced by a gradually lessening paroxysmal cough without whoop. But, as a matter of fact, it can hardly be said that this is so, the varieties are so many. Very young children often do not whoop. It is sufficient to know that they have fits of coughing, followed by sickness, and usually with some puffiness under the eyes. Children who are very ill with broncho-pneumonia often do not whoop ; and, in the de- clining stage, there is much of habit in the paroxysmal nature of the cough, so much so that, as is well known, it is constantly happening, months after the cessation of the cough, it returns again, perhaps more than once, with nearly characteristic features, under the stimulus of some perfectly neutral catarrh. As regards the nature of the whoop there has, at one time or another, been much discussion, but it appears to me that too much attention has been paid to it. The whoop is the natural consequence of the paroxysmal cough, and is probably facilitated by the flexibility of the laryngeal carti-. lages in young life. The nearest approach to the cough of whooping-cough is the sudden paroxysm induced by food (usually fluid) getting into the rima glottidis. We have there the remarkably sudden onset of a number of rapidly succeeding expiratory efforts, till the face becomes turgid, the eyeballs almost starting, and the eyes run with tears. In some cases a mild whoop is not uncommon, and is clearly then the sound produced by the influx of air through parts which are not ready to allow it to pass easily. Whether they are actually in a state of spasm seems to me to be doubtful — all that seems requisite appears to be some want of harmony in the laryngeal muscles such as would produce at any rate a relative incapacity in the size of the conduit to the thoracic cavity, which needs, having been emptied to an extraordinary degree, to be filled with more than usual 26o THE DISEASES OF CHILDREN. rapidity. There is also another class of cases which bear upon the whoop — viz., such as frequently make an inspira- tory crow. There are some babies who, under the stimulus of any sudden excitement, such as waking from sleep, or sud- denly being carried from a warm room to cold air, have a well-marked inspiratory crow, not so noisy as in pertussis, but still surely of like nature. I have long held that this condition is one incidental to the infant larynx in a certain proportion of cases, for it occurs in perfectly healthy chil- dren, goes on for many months, and then disappears. I had supposed it to be due to an unusual flexibility of the carti- lage, by which, under the call of sudden and deep inspiration, the membranes covering them were allowed to close in and partially to restrict the entrance of air. But Dr. Lees has lately shown the state of the parts in such a case after death, and though practically the explanation holds good, for the mechanism is the same, the actual condition demonstrated is an excessively incurved epiglottis by which the ary-epi- glottic folds are so approximated as to form a mere chink. Spasm may well aid in accentuating the relative incapacity of the rima for the demand which is made upon it to admit an excessive supply of air in a given time, but I doubt if the existence of spasm is a necessity for the production of the whoop. From this it follows that the essential of the disease is not the whoop, but the rapid series of expiratory coughs, or the stimulus by which this discharging force is set going. [The expulsion of a quantity of ropy, tenacious mucus at the end of the paroxysm of coughing is also an essential feature of the paroxysm.] As regards other symptoms, I will only allude to the statements that have been made concerning ulceration of the fraenum linguae, and increase of dulness over the root of the lungs and behind the sternum, as indicative of enlarge- ment of the bronchial glands. Neither are of any real help, WHOOPING-COUGH. 26l the ulceration of the fraenum occurring chiefly in cases where the character of the cough leaves no doubt, and the exist- ence of abnormal dulness in the regions indicated being, according to my experience, and I have made a frequent practice of testing the statement, exceedingly rare and equiv- ocal. Whooping-cough, if of any ordinary severity, is usually accompanied by wasting, and in bad cases the emaciation is sometimes excessive. The duration of the disease is very variable, six to eight weeks is said to be the usual time. Of 126 cases of my own, those lasting three weeks number 7; four weeks, 15 ; five, 6; six, 13; seven, 12; eight, 16; nine, 8; ten, 13; eleven, 4; twelve, 12; and those over twelve weeks up to twenty numbered twenty in all. The age at which it most often occurs is between two and six years, the exact figures in 314 cases being — 3 months and under, . 9 6 years and under, . • 27 6 a 23 7 a it ■ 7 1 year li 30 8 a a 2 2 years a 60 9 a a 1 3 3 " a 60 10 a a 1 4 " a 54 5 " a • 38 Total, . • 3H The mortality amounted to t*venty-four males and six- teen females, a total of forty of the 314, or about 12 per cent. ; but this is really too high, because it includes all cases, whether in-patients or out-patients, and of the in- patients naturally the larger proportion are severe cases with much broncho-pneumonia. If the two classes of cases be separated the mortality amongst the in-patients rises to 40 per cent., that amongst the out-patients falls to 9 per cent. The ages of the fatal cases well illustrate the rule that the younger the child the greater the risk. Ten were under six months old, four others under a year, twelve be- 262 THE DISEASES OF CHILDREN. tween one and two years, seven from two to three, four from three to four, two from four to five, one child died at nine and a half of a very lingering broncho-pneumonia, probably of destructive nature. Thus in thirty-three out of forty deaths the children were under three years of age. As regards the causes of death, five-and-tw T enty died of broncho-pneumonia; in three of the cases convulsions were superadded ; six others had convulsions ; the remaining nine died under various conditions, of which I may note a drowsy state, probably associated with atelectasis and wast- ing, which I suspect is not uncommon. Henoch gives an accurate account of cases such as this : They occur in young children under a year with apncea, cyanosis, occasional evi- dence of bronchitis and broncho-pneumonia, contraction of the fingers and toes, and occasionally convulsions. He mentions also that occasionally in the complexity of symp- toms they simulate very closely cases of tubercular menin- gitis. While upon the subject of the mortality from whoop- ing-cough, I may add that in so far as the estimate drawn from the immediate cause of death, the rate falls no doubt far short of the reality — for, though it is difficult to prove the fact, whooping-cough is a fertile source of caseous dis- ease of the bronchial glands and tuberculosis, and of dilated bronchial tubes with all th& chronic ills of lungs and heart which are associated therewith. Modifications. — Pertussis is not a disease which shows much variety — it may be very mild so as hardly to be recognizable, or it may be very severe. Either stage may vary ; the febrile onset being excessive or prolonged and obscuring the paroxysmal, or the initial stage maybe hardly noticeable and the whoop the first thing to attract attention. There may be much pneumonia or none at all ; and as re- gards other symptoms, there may be much or little haemop- tysis — much or little vomiting — much or little wasting. WHOOPING-COUGH. 263 The haemoptysis and vomiting are in proportion to the vio- lence of the cough, and the wasting is in proportion to the vomiting. In very severe cases the whoop disappears alto- gether, and the cough is associated with an amount of laryn- geal obstruction so as to resemble laryngismus. Such cases are liable to general convulsions, and are very dangerous. Complications. — I shall only mention epistaxis, haemop- tysis, ulceration of the fraenum linguae, convulsions, and broncho-pneumonia ; pleurisy, pericarditis, and laryngitis. Of these, convulsions and broncho-pneumonia alone are of importance. Hemorrhage from the nose, mouth, or lungs, and a fortiori from the ear — which is mentioned by writers as an occasional occurrence — is never so profuse as to cause any anxiety; and ulceration of the fraenum linguae is hardly worth a note. It occurs occasionally. I have noted its presence four times in twenty-two cases. It is an indication of a violent cough, and is probably due to the fretting of the fraenum against the lower incisor teeth. Epistaxis of some severity I have noted as occurring thirteen times in the 314 cases, though doubtless, in minor degree, it is present far more commonly than that. Haemoptysis is excessively common, and convulsions constitute an element of great gravity; they are mostly present in young children, or are associated with severe broncho-pneumonia. Of nine cases, five were children of a few months only — one nine weeks, one of twenty months, one of eighteen months, one of five months, one of seven months, one a "baby." The other three were cases of broncho-pneumonia with convulsions supervening, and probably causing death. In some chil- dren a profound stupor takes the place of convulsions, and if possible is of even graver significance. Broncho-pneumonia is met with in every variety as re- gards its degree and the position which the disease occu- pies in the lungs. As a rule, it is characterized by being 264 THE DTSEASES OF CHILDREN. wide-spread. There may be patches of disease about the front of the lungs, along the anterior edges, or round the nipple more particularly. The root of the lung is a favorite spot for all the pneumonias of children, that of pertussis not excepted ; and not very uncommonly the disease may be excessive and occupy the greater part of one, or even both, bases. Moreover, it sometimes happens that a some- what extensive pneumonia rapidly clears up. I have quite recently had a child aged two under my care in the hospital. There was extensive consolidation at both bases, indicated by loud tubular breathing and other signs, and the greater part had cleared in five days. On the other hand, broncho- pneumonia is also exceedingly likely to become chronic in pertussis, and in young children the middle lobe of the right lung appears, for some reason or other, to be particu- larly prone to slowness of repair. This lobe is very liable to pass into a solid condensed state of leaden color, and on section to be studded over with crenated patches of caseous pneumonia, each with a dilated bronchial tube in the centre full of thick pus, or actually softening into cavities. Pleurisy is naturally not infrequently associated with whooping- cough, mostly by extension from patches of pneumonic consolidation; and pericarditis when it occurs (I think but seldom) probably originates in a similar manner by direct extension. Laryngitis I have noticed as occurring in five cases, but in none has it been of any severity. Results and Sequelae. — Emaciation may very properly be considered as a result of pertussis, for several reasons. In itself it is no unimportant condition that a child should be little more than a skin covered skeleton. The viscera under such circumstances must risk various forms of degen- eration, and it might naturally be supposed that so bad nutrition would dispose towards cheesy change in the WHOOPING-COUGH. 265 glands and a secondary tuberculosis ; and that such is actually the case many have very little doubt. Atelectasis, or collapse of the lung, is another important consequence, important in itself, as being in young children extensive, and causing death ; important in the further con- sequences it entails, of broncho-pneumonia, emphysema, and dilatation of the bronchial tubes, all which results come about very naturally as the consequences of collapse. The whooping-cough is associated with more or less bronchitis, and this with more or less secretion in the smaller bronchial tubes. The expiratory efforts drive the air from the pulmo- nary parenchyma, and, unable to return by reason of the plugs in the tubes, the lung becomes collapsed in various parts. The collapse leads to inflammatory processes in the lung, and the tubes of the part become dilated — very often a little pleurisy forms on the surface of these patches, and perhaps also some adhesion follows, which tends to increase the bronchial dilatation. Thus it is that after a bad attack of whooping-cough the child often remains delicate, with a small and laterally flat- tened chest, the lower ribs being expanded over the ab- dominal viscera, and thus causing the disproportion between the abdomen and thorax which is so common as a result of old atelectasis. The relation of cheesy bronchial glands and phthisis to pertussis is no doubt a question of much difficulty, for it is not only difficult to obtain the direct proof when one dis- ease succeeds another at some considerable interval of time, but it is also impossible in many cases to free this question from others, such as the effect of intercurrent or concurrent measles, of hereditary taint, constitutional predisposition, etc. Nevertheless, I feel sure, and there are many who think likewise, that both on the ground of probability and the ground of fact, pertussis is a frequent source of cheesy 266 THE DISEASES OF CHILDREN. glands and tuberculosis. That such occurrences are prob- able, is only too evident when we remember the bronchitis, the broncho-pneumonia, the swelling of the bronchial glands, that characterize so many cases of the disease, and on the ground of fact we are all unfortunately too familiar with so many cases where cheesy bronchial glands, cheesy pneu- monia, and disseminated tubercle in the lungs and viscera have succeeded pertussis, to have less than an almost posi- tive conviction. And I believe it will be worth while to remember that when after pertussis the child remains wasted for a long time, and the cough still preserves its paroxysmal character even months after the attack, the case should be very carefully scrutinized from all points with reference to settling the question of the existence of glandular disease. [The wasting spoken of may be due to mucous disease, a frequent accompaniment and not infrequent sequel of per- tussis. The bulk of the mucus ejected at the end of the paroxysms of cough comes from the stomach, and the intes- tines, as shown by the stools, also secrete large quantities of tough stringy mucus.] iEtiology and Pathology. — It is a disease which is said to be more common in females than in males ; but my own figures make this doubtful — 136 out of 282 cases being males, or very nearly half. It is said also to be more fre- quent in the spring months ; but neither does this appear very decidedly in this series, although the statement is prob- ably correct : Cases, .... Deaths, Jan. Feb. Mar. April. May. June 29 30 29 32 37 26 2 3 1 3 7 July. Aug. Sept. Oct. Nov. Dec. 22 10 6 14 33 16 O 2 2 Cases, . . • . . .22 Deaths, The excess of mortality in the winter months is undoubted. It is a disease which occurs in epidemics and which is un- WHOOPING-COUGH. 267 questionably contagious, whilst the contagion is capable of -ion from one child to another by articles of clothing >ut any actual contact of the diseased with the healthy. It is also protective against any recurrence. Thus it has all the characteristics of a germ disease, although what may be the nature of the virus we, as yet, know not. It is usually supposed that the germs, which some have thought they have discovered in the shape of micrococci in the respired air and in tlie bronchial mucus, act locally upon the mucous membrane of the respiratory tract, and thus lead to the pul- monary phenomena which have been described. But this view fails to account satisfactorily for the neurotic element of the disease, and, on the whole, I think it best to say that diphtheria is the disease with which it has most analogies. Diphtheria is unquestionably a blood disease, yet it tends to fasten itself upon the throat, and it is also followed by a nerve lesion which must be definitely localized, if we are to judge from the uniform character of the paralytic symptoms. Whooping-cough behaves in much th manner. In the first place, it would seem to be a blood disease, as evi- denced by the onset and catarrhal stage of the fever; and, in the next place, the virus localizes itself in part in the res- piratory centre — and thus brings about a nerve discte which ends in the expiratory cough — and in part upon the pulmonary surface, leading tc the swelling of the mucous membrane, the bronchitis, the pneumonia, and the of the bronchial glands. Given these two sets of condit: no doubt the one tends to intensify the other; the over-sensi- bronchial surface will provoke nerve discharge, and the e discharge will tend to increase the peripheral disturb- ance. The difficulty in the way of acknowledging the specific nature of pertussis — and that there is a difficulty is shown the fact that some even yet call it a neurosis, and refuse to it any specific nature, while others feel there is something 268 THE DISEASES OF CHILDREN. peculiar in its behavior which makes its presence incongruous in any group of diseases — seems to me to be in the impossi- bility of fixing what is the limit of the vitality of the conta- gion. In most of the specific fevers we have been able to fix some limit from the behavior of the disease; but to pertussis there is none. It lasts mostly six weeks to two months, but the whoop may continue long after that. All that can be said of it in this respect is that it is most contagious in the early stages, but the virus appears to want any definiteness of course. One cannot argue against the specific nature of the disease from the absence of fever, and the tendency to recurrence of a non-contagious cough ; diphtheria is sometimes so mild as to have but little fever, and its nerve lesion is quite distinct from contagion. The cough is started by the disease, but soon tends to become a habit, and thus to return again and again, until the habit dies out in the oblivion engendered by more healthy and regulated discharges of nervous energy. And it will be quite impossible to arrive at any conclusion upon the natural history of pertussis germs until we leave the whoop out of our calculations altogether, and pay more at- tention to the catarrhal stage. Morbid Anatomy. — The actual lesions found in whoop- ing-cough are not many. Of chief importance, at any rate as a cause of death, is broncho-pneumonia. This shows itself in children by more or less wedge-shaped patches of solid, perhaps tough, leaden-colored material, in which the vessels and tubes stand out prominently, and the latter are often dilated. If the diseased area is large, there will be seen, in addition, ill-defined areas of redder or paler color, dotting it over, perhaps, with a rather sandy or granular appearance. It is common to find the greater part of one or both lower lobes affected in this way, or the parts about the roots of the lungs, and spreading outwards in the middle WHOOPING-COUGH. 269 zone quite to the surface. The parts of the lungs corre- sponding to the mammary region are particularly liable to be affected, and thus to lead the unwary to conclude that he is dealing with a secondary phthisis. The bronchial tubes contain a thick glairy muco-pus, and the mucous membrane of the trachea and larynx are often injected or even minutely ecchymosed. The margins of the lungs are usually cedema- tous. As regards the bronchial glands, there can be no doubt that they are liable to acute swelling ; but the number of children dying of a perfectly uncomplicated pertussis is not large, and in many cases the swelling that is found is the natural result of broncho-pneumonia. Various cerebral conditions have been described, such as congestion, oedema, serous effusion, and the like ; but they are all of very doubtful significance ; ecchymosis, or, in some cases, larger extravasations of blood, such as to have de- served the name of meningeal apoplexy, can alone be said with certainty to have been due to this disease. In chronic cases other lesions are found ; the broncho- pneumonia undergoes 'degenerative changes which convert it either into solid cheesy masses or isolated nodules with softening centres. The bronchial tubes become more di- lated, and, in many cases, a disseminated tuberculosis of the lungs takes place. The bronchial glands also are liable to lose their red, swollen, fleshy appearance, and to become converted into masses of firmer yellow cheesy substance like those in the lung. The explanation of these further changes is not hard to discover. The catarrhal pneumonia is well known to present under many circumstances a tendency to such changes, and the chronic disturbance of the respiratory tract, which we recognize as chronic bronchitis, is only too likely to perpetuate the initial hyperplasia of the bronchial glands and to lead to their caseation and to the development 23 27O THE DISEASES OF CHILDREN. of acute tuberculosis of the lungs and viscera, or to an acute tubercular meningitis. Diagnosis. — There can be very little difficulty as regards the whooping stage ; but it may be as well to insist specifi- cally, although it, to a certain extent, follows from the re- marks already made upon the nature of the whoop, that the peculiar cough may return again and again upon trivial ex- citement. Further than this, it is allowed by all writers that chronic diseases of the bronchial glands sometimes produce a noisy paroxysmal cough very like pertussis. The distinc- tion will be in the absence of any definite stages ; the absence of any evidence of infection — such cases occurring sporadi- cally and not in epidemics; the absence of whoop; the evi- dence of associated lung disease ; possibly symptoms of spasmodic asthma; and a history of wasting long before the occurrence of the cough. [In enlarged bronchial glands there is dulness over the first bone of the sternum, stridor on inspiration and weakened respiratory sound over the lung provided a bronchus be pressed upon, and if the return of blood in a large vein is interfered with, besides lividity of the part and turgescence of the vein, there will be a hum heard through the stetho- scope placed over the seat of pressure. Before the swelling has become so large as to produce the symptoms just men- tioned, Eustace Smith's method of examination gives most assistance in making the diagnosis. He writes: "If the child be made to bend back the head, so that his face be- comes almost horizontal, and the eyes look straight upwards at the ceiling above him, a venous hum, varying in intensity according to the size and position of the diseased glands, is heard with the stethoscope placed upon the upper bone of the sternum. As the chin is now slowly depressed, the hum becomes less loudly audible and ceases shortly before the head reaches its ordinary position."] WHOOPING-COUGFI. 2J I In the catarrhal stage, however, there may be considera- ble difficulty. Indeed, in many cases, we can only have our suspicions and act accordingly, watching in individual cases for a confirmation of the diagnosis in the onset of the par- oxysmal cough. Here, as in so many other conditions, to be forewarned and on the look-out is the true preparation against mistake; not a definite memoria technica of phe- nomena, any one of which, or all, may fail us when doubts arise and we come to test them. [If, however, an epidemic be prevailing, if the cough be paroxysmal and worse at night, if the eyelids are puffy and marbled with injected vessels, and the conjunctiva suffused, the onset of whooping-cough may be strongly suspected.] Prognosis. — In very young children (under a year old) the disease is always a cause of anxiety ; but in uncompli- cated whooping-cough at four or five years of age the mor- tality is not large. The gravity of the case will depend upon the complications that may arise. If there should be much broncho-pneumonia, naturally the danger will be great; so also if convulsions are severe. Then, again, if the child is rachitic and its chest depressed, the occurrence of whooping- cough will tend to increase the already existing collapse and bronchitis and to set up pneumonia, and the risk increases in proportion. The frequency with which complications occur must vary no doubt in the practice of individuals ; but it may be as well to state that Meigs and Pepper give, as the result of their practice, 65 cases associated with complications out of 208, or nearly one-third. Of 320 cases of my own, 57 had broncho-pneumonia or bad bronchitis; 16 others, various other complications. Probably, therefore, from a fourth to a third of the cases may be expected to be complicated in some way, varying somewhat with the epidemic influence and the time of year at which the cough occurs. Atmos- 272 THE DISEASES OF CHILDREN. pheric changes have a most important bearing upon pertus- sis. It has been repeatedly noticed in the whooping-cough ward at the Evelina Hospital that the children are worse, even when otherwise doing well, when the wind turns cold or suddenly changes ; and it is notorious that the disease runs a much less determined and persistent course in sum- mer than in the colder seasons of the year. Lastly, I would say again, beware of too hastily assuming the existence of phthisis where the broncho-pneumonia runs a chronic course ; for it is noteworthy that not a few cases with pronounced signs of chronic consolidation of various parts of the lungs and extreme emaciation, ultimately — and sometimes rapidly — mend and become completely restored to health. Treatment. — This is a very important part of the subject if it be true, as is said, that this is the most fatal of all dis- eases of children under one year. Some people think and teach that whooping-cough will run its course and gradually wear itself out, and that no drugs influence it materially. Some deny to it any specific virus, and consider it merely a nervous trick associated with catarrh, and, just as some tricks are easily caught in childhood, so, they say, is the whoop of whooping-cough. It is no doubt a disease in which, until trial has been made, it is difficult to say what drug will act best in any particular case. But that there are drugs which are of decided use I have no doubt whatever; and there are moreover other points in the treatment which it will be well to make oneself acquainted with. In the first place let it be again repeated that whooping-cough is generally a disease of two stages ; there is the primary catarrhal stage — in which the child is feverish and ill ; and there is the after or whooping stage — in which the child may not be ill at all, though this of course will necessarily depend upon the severity of the disease. WHOOPING-COUGH. 273 In the catarrhal stage there are few remedies of more value than simple expectorants. I give the mist, oxymellis co. of the Guy's Pharmacopoeia, which consists of vin. ipecac, tr. camph. co., nitrate of potassium, and oxymel. Sometimes, if the child is four or five years old, tr. camph. co. alone is sufficient, the benzoic acid and opium of which make it a good sedative expectorant. Often a little dilute nitric acid proves useful. Some have suggested this as a specific for whooping-cough; and though it is impossible to indorse this view, some children seem to be relieved by its use, and with syrup, and perhaps a little Tolu, it does not make a bad mixture for a child to take. This is all that we can do for the first ten days or so, so far as the experience of the pres- ent guides us. At the same time I would say if whooping- cough is a disease dependent upon a specific virus or germ, it is as well to be alive to the fact, and to make trial of any new remedies that may be suggested. There is no reason that I know of why we may not some day find a specific for pertussis, as quinine is for ague, and we should certainly try any remedy that may be suggested as likely to prove useful. With this in view I have tried salicylic acid, thinking it might possibly have an antiseptic influence — possibly a ner- vous influence over the disease — but without any success. I have tried carbolic acid both internally and as an inhala- tion, equally without success, and expectorants are upon the whole the most useful drugs. For the whooping stage also many remedies have been suggested, and I think I have tried almost everything that has been suggested. There can be no doubt that all drugs fail to cut the disease short in most cases, but some are of considerable value in con- trolling it. Far before all others I must, as most others have done, place belladonna. This drug has been recommended very strongly by Trousseau, and it is one of which many think highly, though some think it of no value. I cannot 2/4 THE DISEASES OF CHILDREN. doubt that it is often very effective; but chiefly so when it is given in large doses. Trousseau advises the use of the extract of belladonna given in the morning as a single dose, beginning with one-third of a grain and gradually increas- ing it. I confess, however, to having a liking for the tincture or the liq. atropine. * These are more manipulable, whilst the dose of either can be readily increased, and it is essential to the treatment that considerable doses should be adminis- tered if the remedy is to do good. Many advise that the drug should be pushed until it produces some known physi- ological effect. I doubt if this be necessary. Children are very tolerant of belladonna, and the cough is generally con- trolled some time short of any poisonous effects. At any rate, my own experience undoubtedly corroborates that of most other observers as to the good effects of the drug, although I cannot recall to mind more than one or two in- stances, and those of children in hospital, where any physi- ological effect (dilatation of the pupil) has been produced. As regards the actual dose, ten or twelve drops of the tinct- ure may be given to a child three years old to commence with, and the quantity increased up to twenty drops or more it necessary, and this every three or four hours. Even in very young children large doses may be given with advan- tage ; I have given ten drops three times daily to a child of five months old, and no dilatation of the pupils resulted. This child began at fourteen weeks with four minims, the dose was then increased to six, afterwards to eight, and then to ten drops ; and infants of five and six weeks old will take * Liquor Atropine, Br. P., contains : Atropia, ........ 4 grains. Rectified Spirit, ...... I fluid drachm. Distilled Water, ...... 7 fluid drachms. Dissolve the atropia in the spirit, and add this gradually to the water, shaking them together. — Ed. WHOOPING-COUGH. 275 four or five minims easily, and with relief to the violence of the cough.* But as regards the tolerance of the drug which children exhibit, let me say this much, that although it is undoubted, I believe it always wise to feel one's way, and to watch the effects carefully. I am no advocate for giving a thumping dose offhand. It is best to begin with some dose propor- tionate to the age, three or four drops in babies, and five, six, eight, or even ten for older children, and watch its effect. Should it control the cough — well, what need to increase the strength ? If not, let the dose be increased drop by drop till it does so or fails, when something else must be tried. Some prefer to give the drug in small doses at more frequent intervals, and there is much to be said in favor of this plan on the score of scientific therapeutics. But, except in hospitals with trained nurses, it is difficult so to work it as to run no risk, unless the child's attendants be exception- ally furnished with medical intelligence. But, however we give it, it will undoubtedly relieve many cases, and appear to stop some. [Belladonna by inhalation has been employed with very satisfactory results, reducing the frequency of the paroxysms of coughing and overcoming the whoop after from four to eight inhalations. Enough should be inhaled to produce the physiological effects.] There are many other drugs which are useful. Quinine certainly does some cases good, but it requires, like bella- donna, to be given in somewhat large doses. I have given as much as two and three grains to a child three times a day. Some time ago I tried benzol in this stage, and cer- tainly with good results. For some months all, or nearly * The difference in the strengths of the British and American preparations of belladonna must be remembered. The latter are about twice as strong. — Ed. 276 THE DISEASES OF CHILDREN. all, uncomplicated cases of pertussis were given five to ten drops of benzol in syrup and pure water, and in a good many cases they had previously taken other remedies with- out avail. The cough in many became less frequent and less violent. The objections to it are that it is very diffi- cult to make palatable, and it occasionally causes sickness. Carbolic acid has been recommended, and I have tried that also, both as an inhalation and internally. The inhalation is troublesome, and seems to me of very doubtful use ; and this holds good, whether applied locally to the indi- vidual or generally to the atmosphere in which he lives. Nor have I been by any means impressed with its value as an internal remedy (F. 39). Sometimes I have given as much as a grain three or four times a day. Alkalies are also very useful. The carbonate of potas- sium, in doses of a few grains every few hours, is strongly recommended by Meigs and Pepper as useful in their hands and those of others ; and I am convinced that the combina- tion of bicarbonate of sodium and belladonna, a mixture that has long been in vogue at the Evelina Hospital, is a very valuable combination. Alum is a remedy which may perhpas be mentioned next, because, though it is in some cases singularly useful, its action is probably the opposite of the alkaline carbonates. They possibly aid by facilitating expectoration — the use of alum, on the contrary, is said to be indicated, when there is already an excessive secretion from the bronchial tubes ; but having tried it with this special object, I feel free to confess a considerable doubt as to having ever accomplished the end aimed at, though as to the occasional control exer- cised by the drug over the disease I have no doubt what- ever. [I have found the following combination of alum and belladonna very useful : WHOOPING-COUGH. 277 R. Pulv Aluminis, : gr. xxiv. Ext. Belladonnoe, gr. }£. Syrupi Zingiberis, Aquoe, aa f gjss. M. S. — One teaspoonful every two hours, for a child of one year.] Then, again, the bromide of ammonium or of potassium and chloral are highly useful in some cases. The succus hyoscyami, and all and more than these, are useful in their turn, and, indeed, there is much about the treatment of per- tussis which brings out clearly the neurotic element, for, like epilepsy, it would seem that there are many drugs which avail for a time, but in the long run, and when sur- veyed rigidly, one seems to have as much or as little influ- ence as another. I am more particularly impelled to say this, because in practice amongst the out-patients, I was decidedly of opinion that benzol gave better results than any other remedy in pertussis ; but when we came to test the results upon the in-patients with a rigid appeal to facts, the results were much more equivocal. But there are other important points in treatment which are not less worthy of notice. Whooping-cough is a dis- ease which, in most cases, is attended with frequent vomit- ing. The paroxysms of coughing will come on twelve, fifteen, twenty times in the course of the day, and each time very likely will end with vomiting. It is therefore easy to understand that nutrition is in some cases much interfered with, and the child becomes much emaciated — it is, in fact, starved. In these cases the most watchful cafe is required, and the routine must be entirely subservient to this exigency of vomiting ; the food should be entirely fluid and highly nutritious ; in some cases it may with advantage be artifi- cially digested, and it must be given very often, a little at a time. Moreover, food should always be administered di- rectly after an attack, so that as long a time as possible may 24 278 THE DISEASES OF CHILDREN. be obtained for absorption before the contents of the stom- ach are again rejected. By this means a good deal may be done to combat excessive wasting, and in averting this we no doubt do the best that can be done to ward off those degenerative changes of which mention has already been • made. Of other remedies, let me first mention an occasional emetic as very useful in the earlier days of the whooping period. It clears the bronchial tubes of their contained mucus, allows the lungs free play, and in this way by acting at the periphery does what can be done to quiet the central instability. In the later stages, friction to the spine is an old remedy that I believe to be useful ; and in the chronic whooping stage, few things act so satisfactorily as change of air. I have previously insisted that the remedies which are used for the second stage are not suitable to the first, but in saying this let me repeat that one expressly reserves the question of specifics. The remedies now in vogue for the second stage are in no sense specifics ; they control the violence of the paroxysm, but have no destructive action upon the supposed germ which causes them. But if the disease be due to a germ, and the behavior of the disease is certainly in favor of this view, then it may be hoped, as I have already said, that a specific will one day be found, and obviously any drug exhibited with such an object must be applicable at any time during the life of the germ. TYPHOID FEVER. 279 CHAPTER XVII. TYPHOID FEVER. Typhoid Fever. — No period of life is exempt from enteric fever, and cases sometimes occur in infants of but a few months old ; but of thirty-eight cases from my notes, two were under a year old (both being fatal, and the diagnosis verified by an inspection), one under two, two of three and under, two of four, four of five, five of six, six of seven, three of eight, five of nine, six of ten, and two of eleven years, so that thirty-one of the thirty-eight were over four years of age. Symptoms. — As in adults so in children — fever, rose spots, diarrhoea, enlargement of the spleen, and bronchitis. Nor are children by any means exempt from the tendency seen in adult life to a repetition or relapse of all the symp- toms, when the primary fever has completely, or all but, run its course. But the disease is generally milder in children than in young adults ; and its more markedly remittent type is notorious. The fever is, generally speaking, of insidious onset. Headache and loss of appetite are first noticed, ac- companied, perhaps, by occasional vomiting. It is charac- terized often by very few symptoms during the day — except fretfulness — though symptoms of fever, with weak pulse and dry skin, are not wanting to careful observation. Towards evening the face becomes flushed, or a red burning spot surmounts one cheek, the lips become red, and the tongue dry; the child's sleep is restless and disturbed by delirium; towards morning the fever subsides, and hopes are enter- tained of speedy recovery. Day after day the same history 280 THE DISEASES OF CHILDREN. repeats itself, and now the abdomen is tumid, the spleen is large ; there is diarrhoea, and perhaps rose spots appear ; there is considerable cough, and the child rapidly becomes emaciated. Sometimes during the afternoon profuse sweat- ing may set in, though without relief to the symptoms. From these remissions the term u infantile remittent" takes its rise ; they are sometimes very marked and appear to continue throughout the fever, gradually lessening in severity as it runs its course. But this complete picture often fails. The duration of the fever is more variable, diarrhoea may be absent, and the roseola also. Even the splenic enlarge- ment may be wanting, so that the disease is perhaps only established by the temperature chart, with, it may be, the existence of an associated bronchitis. A large number of cases occur with no distinctive feature of any kind. It is noticed that a child is ill, and its temperature is found to be high — 101° to 103 ; a more rigorous observation is then instituted, and it is kept in bed. Then it is found that there is continuous fever with evening exacerbations for some days, accompanied by tumidity of the. abdomen, and a coated or beefy condition of the tongue. At the end often or twelve days there are more marked remissions, or else by some sudden fall the fever ends, and convalescence is established. In default of any definite symptoms, there is a disposition to consider cases such as these as being cases of mild ty- phoid. Some German authorities, however — Lebert for in- stance — adopt the term infective gastritis for febrile attacks of this kind ; supposing, in unison with doctrines now in vogue, that the products of gastric catarrh are capable of infecting the system generally, and thus of keeping up a continued fever. The " gastric fever " of English authors might usefully be made to convey a like suggestion ; but that in common parlance it has come to be synonymous TYPHOID FEVER. 281 with typhoid fever. I do not wish to assert dogmatically that an infective gastritis distinct from typhoid fever has an existence, but I allude to the possibility of such a thing for the purpose of impressing upon the student that in dealing — as he will often be called upon to do — with continued fever in childhood, of indefinite type; whilst treating it, as he is bound to do, with all circumspection, on the chance of the existence of enteric ulceration — he is yet ever to bear in mind that other possible causes than the assumed one have a claim to consideration, and that careful observa- tion and record of all such indefinite types are necessary, in the hope that at some future time some order may be in- troduced into the at present chaotic domain of " simple con- tinued fever." Temperature. — In adults the pyrexia of typhoid fever is characterized by a gradual rise in three or four days to the acme of the fever. Next, by a period of continuous fever (103 to 104 ), the morning temperature being a degree or so lower than that of the evening ; and at the end of the second, or early in the third week, the period of remissions sets in, the morning temperature falling to near the normal line, the evening rise still continuing for some days. In children the same three stages may be noticed, but they are seldom so continuous or so well marked. The remittent nature of the affection is the most prominent feature of in- fantile typhoid, and may characterize more or less the whole course of the disease. Further, the remissions need present no regularity from day to day in time of their occurrence. If the temperature be only noted morning and evening, no doubt in the latter it is often high, in the former low ; but taken every two or three hours, the chart will be remarkable for its irregularity, sometimes running up and down several times in the course of twenty-four hours ; and the highest point reached may be at any hour, often about 6 p.m., but 282 THE DISEASES OF CHILDREN. sometimes 9 p.m., 6 a.m., 12 p.m., midnight, 3 A.M., or, indeed, any hour. All authors appear to have noticed a tendency to the occurrence of two distinct exacerbations about 4 and 9 p.m., with intervening remission and occasional profuse sweating. I also have seen the same thing; the type being malarial or like the hectic of suppuration. The oscillations in these cases are extreme, and if long continued are indi- cative probably of severity of ulceration. The difference between the lowest and highest temperature for the twenty- four hours should not exceed two or, at most, three degrees. Nervous System. — In severe cases there may be a good deal of noisy delirium occasionally showing itself by a fre- quent harsh cry, not unlike that of tubercular meningitis, and very perplexing for diagnosis ; in cases of moderate severity the child lies stupefied and apathetic, with more or less mild delirium at night. Deafness is not uncommon. Rose spots have been present in the majority of cases that have been under observation at the proper time. To de- termine their presence it is necessary to examine the entire trunk day by day. But many children among the poorer classes are only brought to the hospital at the last stage of the disease for continued ailing or emaciation, which is thought by the parents to indicate consumption. In many of such the rose spots are absent. They are absent through- out in perhaps a fourth of all the cases. In a considerable proportion they are but few in number, and may easily be overlooked. As in adults, they appear in crops from the eighth to the twelfth day onwards. Sudamina are often seen late in the second or third week. Bronchitis may be a prominent symptom, and not infre- quently is associated with slight haemoptysis ; sometimes it is very severe, and it may prove fatal. I have seen it so severe as to mask the nature of the disease altogether, the case assuming the aspect of acute bronchitis. TYPHOID FEVER. 283 Splenic enlargement is present in many cases, and should always be looked for as an aid to diagnosis. Henoch states that he found it palpable in thirty out of seventy-five cases ; in others it could be distinguished only by percussion. The enlargement is present sometimes in the primary fever, sometimes in the relapse ; and, I should have said, was in all probability related to the intensity of the fever; but too little is known about the symptom to speak with certainty. The tongue is often characteristic. It may be coated with a white creamy fur on the dorsum, with red edge and tip, or it may be of a beefy red all over, with prominent papillae or unnaturally smooth. Duration is much more variable in children than in adults ; many cases last only ten or twelve days ; seventeen to nineteen days is not by any means an uncommon dura- tion. Then, again, many cases give a preliminary history of three or four weeks of malaise before the onset of any definite symptoms. It is probable, however, that could these be more carefully watched, they would resolve into cases in which a mild primary fever, unrecognized, had led on to a relapse. For instance, a girl, aged seven and a half, had been ill three weeks, had been much worse for seven days, and had suffered from diarrhoea for three days. She was admitted with a steady fever of 104 , diarrhoea, rose spots, and enlargement of the spleen, and the complaint ran a course of fifteen days. The total period was thus divisible into two of fourteen days each. Again, a boy, aged five, said to have been ill three weeks, but worse with diarrhoea three days, was admitted with a temperature of 104 , and the complaint ran a course of nineteen days ; a total, again, well divisible into two attacks of between two and three weeks each. Many such cases could be given. Morbid Anatomy. — The ulceration of Peyer's patches and of the solitary glands is less frequent, less extensive, and less 2 34 THE DISEASES OF CHILDREN. characteristic than in adults, and the younger the child the more is this true. In not a few cases no ulceration of any kind has been present ; in others, one or two small ulcers in parts of the agminated glands ; in others, slight raised fleshy swellings of the entire patch or of parts of it. As in adults, the large intestine may be affected — nay, may even be the chief seat of ulceration ; and I have once seen death from the after-result of hemorrhage from typhoid ulceration of the colon. Perhaps it is in consequence of the mildness or the ulceration that the fever is so variable — that the late of oscillating temperature may sometimes fail — that tympanitis and hemorrhage from the bowels are uncommon — and that death by perforation is one of the rarest modes of termina- tion. Otitis maybe present, and, in rare cases, parotitis ; one of my own cases proved fatal in this way. I have only once seen death from acute peritonitis. It was associated with jaundice, ascites, and plueritic effusion in a child of four and a half years. For the most part, the morbid anatomy of typhoid in children differs from that of adults by wanting all the more characteristic features. Slight ulceration of the solitary glands and of Peyer's patches, or swelling only, combined with a swollen spleen, and more or less sodden solidification of the bases of the lungs, complete the picture in most cases. The following case may be given as an illustration of these points. It is an exceptional one for two reasons: the early age of the child and the fatal result: A male child, four years old, attended as an out-patient at the Evelina Hospital with diarrhoea, a tense abdomen, and some rose spots on its buttocks. It was only seen once. It died in convulsions. I made an inspection three days after death. The spleen was large and rather soft. The mesenteric glands were large and ecchymosed. TYPHOID FEVER. 285 Throughout the small intestines Peyer's patches were in- jected and swollen, so as to be slightly raised above the surrounding level in a flat plaque. The upper patches were mostly ulcerated ;' one lower d©wn had a circumferential line of ulceration as from a slough just commencing to sepa- rate, and others of them had small ulcerated pits in them. The ileo-caecal valve was ulcerated. There can be little doubt that this was a case of typhoid fever. There was the large, soft spleen, the swollen and ecchymosed glands, and the swollen and ulcerating Peyer's patches ; but the swelling of these was very slight as com- pared with that usually seen in adults. Diagnosis. — It is a matter of frequent occurrence that a pale, wasted child is brought to the out-patient room with a history of four or five weeks' illness, with diarrhoea and cough, the expectoration being slightly streaked with blood. These are signs from which the student not unnaturally con- cludes that the disease is of phthisical nature. Moreover, this opinion may be apparently confirmed when the chest is examined and he finds bronchitic rales present; or some roughened respiration at the apices which he considers to be bronchial, and therefore to indicate consolidation. A further examination, however, shows that there is no dulness on percussion, and but slight, if any, difference between the abnormal sounds on the two sides ; and, perhaps, the tongue is red and glazed, and the abdomen full. After a day or two in bed the case turns out to be typhoid fever in the second or third week. So often does this picture present itself in practice, that I believe it to be of importance to insist that w r hen in children prima facie phthisis is indi- cated, the student should have typhoid fever as an asso- ciated idea and proceed to decide between the two. Typhoid fever is one of the wasting diseases of childhood. Sometimes it is quite impossible to decide between acute 286 THE DISEASES OF CHILDREN. tuberculosis and typhoid fever; the insidious onset is the same for both, and the temperature chart of both is one of oscillations, owing to the evening exacerbation of the fever. Vomiting is sometimes a feature of early typhoid fever, and a slow pulse not by any means infrequent. On the other hand, I have several times, noticed diarrhoea in acute tuberculosis, and a tuberculous spleen may often be felt below the ribs ; thus it may happen that a positive opin- ion can only be arrived at after careful observation, at more than one visit, of all the circumstances of the case, and that in some cases — perhaps not very common, but yet suffi- ciently frequent to necessitate insistance on the fact — the two diseases cannot be distinguished. [Meningitis is sometimes extremely difficult to distinguish from typhoid fever. I will illustrate this by three cases : A boy, aged twelve, came home from school ailing, after the mumps. A boy at the school had had typhoid fever there some months previously, but he was thought to have taken it from elsewhere, the drainage and sanitary conditions being perfect. The lad was pale and thin, with a rather beefy tongue, a full and tense abdomen, and a large spleen ; his evacuations loose, but not frequent ; no spots ; temperature, ioi°. For twenty-four days he thus continued, perfectly clear in his intellect, but with slight intolerance of light, a frequent short cough, a high but oscillating temperature, and gradually increasing muscular tremor. He also had rather frequent priapism, the import of which did not strike me till afterwards. Gradually a dry pleuritic rub developed, and some evidence of partial consolidation, in diminished resonance and blowing respiration in the scapular region. Next there came pain on movement, delirium at night, and then almost suddenly he passed into a comatose condition, with rigidity of his extremities and more priapism, and he died after an illness of thirty days. For more than three- TYPHOID FEVER. 287 fourths of that time I was quite unable to decide between typhoid fever and general tuberculosis ; but his mode of death, combined with various slight symptoms which could be read more distinctly after — viz., the intolerance of light, the pria- pism, the muscular tremors, and the pains in his extremities on movement — made the diagnosis without doubt to be cerebro-spinal meningitis." Another case, a boy, aged five, was admitted with a history of three weeks' illness, chiefly of frontal headache, vomiting, and latterly diarrhoea. His temperature was very high (io3°-i04°), the condition of one lung was -question- able, and he had much delirium. For seventeen days he continued in the same condition, without any definite signs of typhoid fever, and with many of severe cerebral disturb- ance and fever. He had, however, an occasional typhoid- looking stool, and the temperature ran high for tubercular meningitis ; therefore, on the whole, I favored the diagnosis of fever, and so it proved to be. From the seventeenth to the twenty-fourth day the temperature fell, and the child got well. The third case is that of a girl, aged twelve. She had been subject to sick-headaches for a long time, but worse since a blow on the head a year before. She had also wasted. For five days the headache (frontal) had been very bad, with frequent vomiting and constipation. She was quite clear in her mind, with temp. ioo°, pulse 72, exceedingly irregular, but with no intolerance ; the fundus of the eye being normal. The disease ran on without declaring itself till pain in the neck developed, then squint, and then coma. Ulcerative endocarditis will sometimes closely simulate typhoid fever, and is all the more difficult to distinguish, in that the physical signs of valvular lesion are apt to become masked by the formation of fungating vegetations about the diseased apertures. Any previous history of rheumatism, 288 THE DISEASES OF CHILDREN. any evidence of valvular disease, and particularly any evi- dence that infective maladies of any kind are prevalent, should suggest a careful consideration of this possibility be- fore coming to any definite opinion. Ostitic pyaemia may simulate typhoid fever, and a case of this kind has recently been in the Evelina Hospital. A child of about eight was admitted, with diarrhoea, much abdominal distension, and the general aspect of severe typhoid. The result showed a very acute pyaemia, with abscesses in parts of the lung. Of the incubation and other points concerning typhoid fever in general, it is hardly within the scope of the present work to treat; but it may be remarked that, as regards the incubation — which is said to vary from two days to three weeks, and to be most commonly about two weeks — children afford virgin soil, undergo changes of body-heat readily, and therefore may be expected to mature a poison rapidly ; an important consideration when tracing the source of infection. Further, it would seem that children are peculiarly sensitive to drain emanations, whilst water and milk, which constitute so large a share of their diet, have been shown to be the more common sources of the introduction of the poison. Treatment. — In the majority of cases the treatment is simple. The child must be kept in bed, its temperature carefully watched, and the diet regulated. The food must be fluid, or pultaceous — such as soaked biscuit, custard, milk, and beef-tea. Should the stomach be inclined to 'reject these, even lighter materials must be given — milk and lime- water, or milk and water, whey and artificially digested milk, or blanc-mange. As regards drugs, a little dilute nitric acid, with syrup, is agreeable and refreshing, and some attach importance to its therapeutic value. Quinine is another remedy much in vogue with some. In cases of moderate duration, no stimulants are necessary ; but when the fever TYPHOID FEVER. 2c°9 extends to or beyond the third week, and the symptoms have been severe, two, three, or four ounces of wine, or one or two of brandy, in the twenty-four hours, are often needed after the second week. Constipation is not uncommon, and, if associated with any distension of the abdomen, is to be treated by simple enemata, or a small dose of castor-oil. The evacuations should in all cases be treated with some disinfectant, and all soiled linen is to be removed at once and treated in like manner. As regards the more severe cases, the noisy delirium may perhaps indicate the need of stimulants; but the relief afforded is not so decided as in adults, and, as a rule, I do nothing, provided the child is taking its nourishment well. Small doses of Dover's powder or bromide of potassium are sometimes beneficial, and a tepid or warm bath sometimes exercises a calmative and soporific effect. If the temperature is persistently over 103 , frequent resort to tepid sponging, cold sponging, an ice pack, or the tepid or even cold bath is indicated. An ice-cap to the head is occasionally useful in the same way. Quinine may be given in one, two, or three grain doses three times a day, and I have also tried salicin, but without much evi- dent effect. For abdominal distension there is nothing so good as turpentine or terebene. Either of these may be mixed with mucilage of tragacanth, syrup, and cinnamon- water ; or mixed with butter and put at the back of the tongue. In this way, five drops of the oil of turpentine or two or three of terebene may often be taken without excit- ing much resistance. Hillier recommends an enema of as- safcetida. For diarrhoea, five drops of tincture of opium with an ounce of starch-water by enema, is the plan of treatment which seems most generally successful ; but two or three grains of Dover's powder, given internally once or twice in the twenty- four hours, will often be equally efficacious. A moderate 29O THE DISEASES OF CHILDREN. diarrhoea, two or three evacuations in the twenty-four hours, is not to be checked. Severe diarrhoea is generally associ- ated with abdominal distension, and indicates severe ulcera- tion ; and although it is the general practice to give o*piates, I prefer to combine them with such other drugs as may have an antiseptic effect upon the surfaces of the ulcers, such as turpentine, borax, etc. It is further advisable in such cases to see to the quantity of food taken. The diarrhoea may be moderated by reducing the quantity of milk, and giving thin broth of chicken, veal, or mutton. Brand's essence of beef gives a large amount of nourishment in a form which one supposes is absorbed from the upper part of the intestines, and cannot leave much behind to worry the ulcerated surface below. Bismuth subnitrate and ipecacuanha wine are also of use, and so also the tincture of krameria, extract of logwood, and chalk mixture. For the bronchitis, a little ipecacuanha wine, with tr. camph. co. and syrup of Tolu, may be given. As regards treatment by the bath, Henoch makes some very practical remarks. The effects of cold bathing are more pronounced in children than in adults, and conse- quently the first bath is, in some cases, an experiment, and it may be followed by a gradually falling temperature, until a condition approaching collapse results. This may be ob- viated by the administration of wine before and after the bath, but more particularly by trusting to tepid rather than cold bathing, and by not prolonging the immersion beyond six or eight minutes. MALARIAL FEVER. 29I CHAPTER XVIII. MALARIAL FEVER. Ague is not common in children, and its behavior is sometimes peculiar. For this reason it is likely to be over- looked. It may occur even in infancy, and enlargements of the spleen have been found at birth which have been sup- posed to be due to the malarial poison. But the disease is more usually seen in those of four years old and upwards. It may sometimes occur in typical form, with cold, hot, and sweating stages. But as a rule well-marked rigors and defi- nite periodicity are absent. Dr. West states that the place of rigors is taken by a condition of extreme nervous depres- sion, sometimes by convulsions. As other peculiarities he notes the long continuance of the hot stage, the absence of any distinct sweating stage, and a continuous form of malaise and even pyrexia. This description will show how easily malarial fever might be mistaken for some continued fever of doubtful nature ; an error all the more likely from the infrequent occurrence of the one disease, and the very com- mon occurrence of the other. The acme of the pyrexia, as in adults, may be very high (105 ), and possibly this fea- ture might in some cases convey a hint of the true nature of the disease. But more important, as I think, than these anomalies of the more typical symptoms is the necessity of recognizing that malarial anaemia is not uncommon — some- times associated with enlargement of the spleen, sometimes not — and that extreme anaemia may exist without any his- tory of pre-existing fever. Anaemia is a characteristic 292 THE DISEASES OF CHILDREN. symptom of ague at all ages, but it rarely reaches such an extreme in adults as is sometimes the case in childhood. It is said to come on very rapidly. Enlargement of the spleen is a common disease in children in the malarial regions of the tropics. The spleen under such circumstances will attain an enormous size, and many children die from this cause. [As above stated the first and last stages of the disease are frequently not as marked as in adults. The first stage is often overlooked by the parents, but when the rigor is absent there are slight tremors or the face becomes shrunken and pallid and the lips and finger-tips livid. The second stage is much prolonged, while the third is usually very short and sometimes altogether absent. During the inter- val between the paroxysms the child does not regain its usual buoyant spirits, but remains dull, fretful and feverish. After the fifth year the disease presents about the same fea- tures as it does in adults.] Diagnosis. — This must be arrived at first of all by bear- ing in mind the possibility of the occurrence of ague, and next by inquiring into all the circumstances of the case. There are no means by which to distinguish the enlarge- ment of the spleen due to ague from that due to other causes. But as regards the anaemia, the skin has a simple or sallow pallor with a bluish tint of the lips, which may help to suggest the nature of the case. Prognosis. — Ague is difficult to eradicate thoroughly at any time of life. With this qualification, it answers to the same remedies as in adults. But the enlargement of the spleen may be troublesome and slow to disappear. Treatment. — Quinine and arsenic are the remedies to apply to. Quinine is usually taken readily by children — it may be given in sweetened milk or with syrup and liquorice. Arsenic should be commenced after the quinine is discon- MALARIAL FEVER. 293 tinued. Five or seven drops of the liquor arsenicalis* may be given in syrup of orange and water, three times a day after meals. It is often good to combine it with iron. With the syrup of the lacto-phosphate of lime and iron it makes a good tonic. * Fowler's solution. — Ed. 2S 294 THE DISEASES OF CHILDREN. CHAPTER XIX. DISEASES OF THE RESPIRATORY SYSTEM. The physiological differences in the respiratory organs between the child and the adult are numerous, and, as re- gards the examination of children, they are by no means unimportant. The breathing is diaphragmatic in children, and as it is difficult sometimes to detect the movement of the upper part of the thorax, it is very necessary to have the chest thoroughly bare for the purpose of examination. Infants under two years breathe quicker than adults, thirty or more to the minute, but above that age the respirations are at about the same rate as in older people, though quick- ening at very slight disturbing causes. Children, also, breathe irregularly; often paroxysmally ; after what maybe called a modified Cheyne-Stokes type. The Cheyne-Stokes rhythm consists of a series of short but gradually lengthen- ing inspirations culminating in a deep-drawn breath, from which in a descending scale the respiratory movements flutter down to an elongated pause ; and this type of respi- ration, though much modified, and its sharper characteristics destroyed, may often be seen in infants. Pauses in respira- tion are a feature of childhood, and they are particularly marked when the child is crying. To auscultate a chest at such a time requires the greatest patience, the pauses are of such long duration, but the information gained from the in- spiration at these times is peculiarly valuable, each long- drawn breath after the temporary arrest is so full and deep. Infants and children not only breathe irregularly, but they breathe often with asymmetry. It is quite a common thing DISEASES OF THE RESPIRATORY SYSTEM. 295 to find a child breathing fully, now with this side, now with that, and unless this is ever present to the examiner he will be not unlikely to make mistakes when it comes to be a question, as so often happens, of the nature of the disease ; nay, even of the side upon which it is located. I take this to be due not to the muscular weakness, as some aver, but to the as yet imperfect education which is seen in all the muscles, whether of speech or of voluntary movement. Hence also the Cheyne-Stokes type of respiration, which is a paroxysmal one. Children work paroxysmally, whatever the movement in hand. The nervous discharge takes place, and then comes a pause — another discharge, and another pause — and so on ; and it is only as the nerve cen- tres reach a higher state of training that the discharges are so regulated as to become more continuous. I know a little child, and this is not uncommon, who learning to talk will carry on a conversation to the full extent of his knowledge of words, for a few minutes, and then he becomes quite fuddled for a while, and after a rest, on he goes again. The same child, if he is at all out of sorts, will stammer badly ; he becomes in fact aphasic intellectually, and his w T ord- memory is for the time exhausted — or his ill-nourished brain loses its discharging force, and acts intermittingly. It is but little otherwise with the respiratory centres, they act irregularly, and soon become exhausted. A point or two connected with the physical examination of the chest may next be mentioned. Percussion is ahvays to be gentle — apart from the reason that there is the likeli- hood of frightening the child, heavy percussion may lead to quite an erroneous conclusion. It will often elicit resonance, whereas the note is really dulled. This more readily occurs in dealing with fluid in the chest, and is probably due either to the heavy percussion displacing the fluid — bringing the stroke down upon air containing lung beneath — or else to THE DISEASES JF CHILDREN. the greater readiness with which, in young subjects, the stroke is transmitted to other and sounder parts of the lung. The chest of a child is said to be more sonorous than that of an adult — all that this means is that a more resonant note is more easily elicited ; and all that this can mean in turn is, that the percussion acts upon the lung more readily. Probably this is largely due to the more yielding nature of the ribs in young people, and to a thinner covering of soft parts over them. Again, it is not difficult to obtain a dull note which is not due to the condition of the lung underneath. A very little difference, for instance, in the level of the two shoulders will effect this, and the irregularity of respiration so noticeable in children will do the same. Therefore, in cases where the differences are slight, it is always as well to be cautious in our opinion, and probably to wait until a second examina- tion has confirmed or negatived the original conclusion. Percussion should be carried out by one finger laid fir: on the chest, and one or two fingers tapping it vertically, slowly and lightly With these precautions, a good reso- nant note ought to be elicited anywhere, although, as in adults, the apices and scapular region van' much in differ- ent children. I see no reason for confining the examination to the back, or for postponing percussion until after auscul- tation. There is but little difficulty with children if they are left unrestrained and the percussion is gentle. It is usually well to commence with the examination of the back, so that, if the child is shy, the more important part of the examination may be conducted out of sight; but in a very large number of cases it is perfectly easy to even auscultate the front of the chest if the examiner sets to work with pa- tience, and allows a child to play with the end of the stetho- scope at intervals. Nor do I agree that auscultation is better conducted by the ear than by the stethoscope. The chest DISEASES OF THE RESPIRATORY SYSTEM. 297 diseases of children are so apt to be partial in their distribu- tion, and the accommodation of other parts of the lung is apt to be so much more perfect, that it is very necessary to go over the chest carefully inch by inch, to compare the corresponding sides of the chest, and to trace the intensity of the respiratory murmur from one side to the other. The ear covers too extensive a surface, and — taking in too much at a time — is thus likely to miss a small patch of consolida- tion or the deficient expansion which occurs so often. The student will have many a difficulty also with the quality of the respiratory murmur. He is usually told that the child's respiration is puerile — that is, that the inspiratory murmur is very harsh ; the expiratory being but little altered. But, as a fact, his most frequent difficulty will be to know whether he is dealing with bronchial breathing which is the result of disease, or with that which is due only to a temporarily ac- celerated respiration. In young children the expiratory murmur in the upper two-thirds of the back is frequently of a bronchial nature — longer than it should be, higher pitched than it should be — and the question of the meaning of this can only be settled by close examination of both sides and an appeal to one's experience. The observer should pay special attention to the pitch of the expiratory murmur, this being the best criterion of the nature of the sound. If it be not only long, but persistently of high pitch, it is well to be cautious. As another hint, I would say this : If the tubular breathing is of exactly the same quality on both sides, doubt your diagnosis, should you have decided that it means dis- ease. It is so likely under these circumstances to be a tracheal respiration, transmitted, either from exaggeration on its own part, or too little damping by the vesicular murmur in a small chest. [Puerile need not be confounded with tubular respiration. The former has for its distinctive char- acter intensity; in other respects there is no alteration. 298 THE DISEASES OF CHILDREN. Tubular or bronchial breathing, on the contrary, while it may be intense is otherwise anomalous. Thus the inspira- tory element is shortened, there is a distinct interval of silence between it and the expiratory sound and the latter is higher pitched, louder, and more prolonged ; features exactly the reverse of healthy breathing.] As regards this necessity for careful comparison of the two sides of the chest, pleurisy and pleuritic effusion are very liable to mis- lead. Pleuritic effusion controls the action of the lung on the diseased side, but hardly otherwise alters the quality of sound, except at the apex, where it often compels tubular breathing; thus it happens that listening over fluid, the res- piration is soft and vesicular, and may seem natural, whilst an examination of the other side discloses what seems to be an excessively harsh and abnormal sound, of doubly puerile character, if so we may express it. Thus, the report is made that the sound side is diseased and the diseased side healthy. This is quite a common occurrence, and can only be avoided by paying exclusive attention to no one sign in particular, but by examining both sides of the chest throughout — not only by auscultation, but by percussion also — and by a care- ful scrutiny of their movements. With these few hints, we may pass to the consideration of special diseases, and there seems no reason for departing from the natural arrangement of working from above downwards. The Nose. — There are some children who are always " catching cold." This means that they begin to sniffle, and gradually a copious, glairy, and thin mucous discharge makes its way from the anterior nares. This state may last several days, the upper lip ultimately becoming excoriated and sore from the discharge and its frequent removal combined. During all this time the child is usually fretful, often fever- ish, thirsty, and without much appetite. Its nights are also frequently disturbed, for young children breathe so much DISEASES OF THE RESPIRATORY SYSTEM. 299 through their nose, that the existing state of things prevents the natural respiration. Stand over the cot of a child with a " cold," and you will hear it sniffling away with quickened respiration, and then suddenly waking up and crying, tossing itself down on to the pillow again, and so on repeatedly. These cases run their course, so far as the nose is concerned, in two or three days ; but they are frequently succeeded by a cough, due, no doubt, to the extension of the catarrh along the mucous membrane to the posterior nares, tonsils, and fauces, and occasionally down to the epiglottis or rima as well. A cold, therefore, if severe, requires care, as at any time it may extend and set up a general bronchitis, or even laryngitis. Causes. — Whether colds are due, as is thought, to chills, or to atmospheric-borne germs, and so on, it would perhaps serve no useful purpose to discuss. But it is of practical import to remember that in many cases they are unques- tionably contagious. They are also frequent concomitants of dentition. Coryza should also be remembered as heralding often the advent of measles, and as being sometimes associated with diphtheria, generally, though not always, with its more fatal forms. Ozsena. — In unhealthy children, particularly the scrofulous and syphilitic, nasal catarrh is liable to become chronic. The swollen mucous membrane becomes excoriated or deeply ulcerated, and in the most prolonged cases the bone may become exposed and die. In any case there is likely to be ozaena, as the secretion is not merely mucoid, but purulent and bloody. It crusts upon the surface of the mucous membrane, becomes decomposed, and thus the fetor which is so characteristic and so loathsome. The sense of smell often becomes destroyed in the worst cases, a happy thing for the afflicted child. 300 THE DISEASES OF CHILDREN. Treatment. — For simple catarrh very little treatment is necessary. Children from a few months old up to three or four years are those that give the most trouble, and perhaps from nine months to two years is the age at which colds are liable to be most severe. The child must be kept in one room at an even temperature, in bed if it is very feverish or fretful, and some saline may be given it, such as the citrate of potassium and a little fluid magnesia to act upon the bowels, if necessary. It is generally as well to give a sleep- ing draught at night of bromide of potassium and hydrate of chloral, five grains of the one, and half a grain or a grain of the other. West remarks that an intractable catarrh is sometimes cured by gray powder, even though there may be no evidence of the syphilitic taint, and my own smaller experience certainly corroborates this. In the chronic cases two ends have to be kept in view, the build- ing up of an unhealthy body, and the cure of the diseased mucous membrane. The local treatment is usually neglected in whole or in part. The parents will make their children take any quantity of medicine, but they will not take the trouble to secure efficient local applications ; and, unfortu- nately, local applications are of the first importance. The chief object of these is to keep the surfaces moist and sweet; the disease is so troublesome, because the discharges crust on the surface and become offensive, and thus in the various movements of the nose the mucous membrane beneath the crusts and at their sides cracks and bleeds. Therefore an antiseptic must be applied to keep the parts sweet, and glycerine or oil added to it to keep them supple. A com- bination of iodoform, eucalyptus oil and glycerine makes a nice and effective preparation (F. 40), or an ointment in which vaseline is substituted for the glycerine may be used instead. The glycerinum boracis, or glycerine and boracic acid, are also useful preparations. But whatever be used, DISEASES OF THE RESPIRATORY SYSTEM. 301 it is essential that it be applied freely and frequently, and this is not easy of accomplishment. Sometimes astringents, such as equal parts of glycerine and the glycerine of tannic acid; or that and sulphate of zinc, in the proportion of two grains to each ounce; syringing with permanganate of potas- sium, or with a borax and bicarbonate of sodium lotion, are very useful in older children. But the difficulty of local application is greatly enhanced, if not altogether impossible, in young children when the syringe comes to be used. The best way of syringing the nose is undoubtedly the hydraulic method — an india-rubber tube, leading from a small cistern or jug containing the lotion, and placed at the requisite height, plays the part of a siphon. The nose- piece is placed in the nostril, and a most perfect syringing is thus accomplished. But very young children are much frightened by this. The sensation produced by the water in the nose is not pleasant, and some of the fluid runs down into the pharynx and interferes with respiration. Moreover, the operation, to do it properly and cleanly, requires the attention of three people — one to take the child, one to col- lect the water that flows from the nose, and the third to manage the douche. Therefore this treatment is not often carried out thoroughly, and it is necessary to trust to the- thorough application by a brush of the remedies already mentioned. It is more practicable with older children; and, with them, in addition to other measures, a plug of iodized cotton-wool should be kept in each nostril. For general treatment these children require good food, milk, cream, good air — particularly, bracing seaside air — -and iodide of iron, cod-liver oil, maltine, stout, etc. [While nasal catarrh is a trifling disease in children who have cut their teeth and been weaned, it is serious in nur- sing infants, because it greatly interferes with alimentation by preventing nasal respiration, a necessity during the act 26 302 THE DISEASES OF CHILDREN. of sucking. The danger is increased proportionately to the length of the attack. In obstinate cases, in addition to keeping the nose clean, by frequent swabbing, and thor- oughly anointed externally and internally with vaseline, it is well to make the patient wear constantly a light flannel cap. This plan was suggested by Dr. Charles D. Meigs, and sometimes it seems impossible to effect a cure without it. The cap should be removed slowly by cutting away a small piece at a time ; in this way the risk of a relapse from tak- ing cold is avoided.] The greatest perseverance is necessary in the treatment of ozaena. Epistaxis is a very common affection in childhood, and under conditions so varied that it is impossible to enumerate them all. Some children suffer again and again, whenever they are out of sorts, and this without any tendency to bleeding elsewhere. It is one of the commonest forms of haemophilic outbreak, and is also, as might be expected, a symptom of purpura from any cause. But perhaps it is more noteworthy as most frequently ushering in some acute disorder, be it one of the exanthemata, typhoid fever, per- tussis, acute pneumonia, or nephritis. It but seldom requires treatment save it be the outcome of haemophilia. Should it do so, the ordinary rules for the arrest of bleeding will at once suggest themselves — viz., ice to the nostrils, cold applications to the face and neck, and an inflation of tannin or matico snuff. LARYNGEAL SPASM LARYNGITIS —WARTY-GROWTHS, ETC. 303 CHAPTER XX. LARYNGEAL SPASM— LARYNGITIS— WARTY-GROWTHS— FOREIGN BODIES IN TRACHEA, ETC. Catarrhal Spasm — Pseudo-Croup. — " My child is very subject to croup," is a common tale of a mother to the doc- tor; and as when a patient states that he or she has had a weak heart for years the medical man knows it to be the exception to find any organic disease, so here, the croup of domestic medicine is not the croup of the nomenclature of disease. Here is such a case : A boy, aged five and a half. He had a croupy cough three months ago, but got well in a day or two with some castor-oil. He had been quite well since until the day before he came to the hospital, when the cough had returned. He had a loud brassy cough but no dyspnoea, and seemed otherwise quite well. The fauces were injected and the tonsils large. Some castor- oil was administered and a simple expectorant, and he was well in a day or two.' The mother had already lost one child by true croup — tracheotomy having been performed in the hospital — and she was therefore very anxious about the symptoms in this case. Henoch gives one of the best and most natural accounts of this affection with which I am acquainted. These chil- dren have usually been the subjects of repeated attacks of subacute tonsillitis, and they have enlarged tonsils. This condition of parts is usually accompanied by a more or less fleshy or swollen state of the palate and mucous membrane around the laryngeal orifice, and, as a result of some fresh but often slight catarrh, the ary-epiglottic folds become im- 3O4 THE DISEASES OF CHILDREN. plicated," and some slight glottic spasm occurs. The child has usually had a slight " cold," perhaps wakes up suddenly at night with an ugly laryngeal " brassy," " clanging," " croupy " cough, and perhaps with some temporary diffi- culty of breathing. This soon passes off, and it lies down to sleep again, breathing without discomfort, as soon as the fright of the awaking has passed off. This shows that the essential of the laryngeal trouble is spasm. The cough remains " croupy" for a day or two, and then disappears. Diagnosis. — This is arrived at by giving attention to the following features : The tendency to recurrence which these attacks evince ; the pre-existence of a cold or cough ; the presence of large tonsils. In the attack itself, there is the absence of persistent inspiratory stridor, the unchanged cry, and the speedy subsidence of the momentary inquietude — nothing remaining, in fact, but the cough. All these things tell of the absence of any material obstruction, and in favor of a temporary laryngeal spasm, provoked by some catar- rhal state of the upper laryngeal orifice. At the same time, as a word of caution, it may be remarked that it is only natural to suppose that a condition of this kind, if neglected, might readily pass on into an attack of definite laryngitis ; and, no doubt, care is requisite lest, in treating such an attack as of no moment, we should find that an exceptional case might prove in the issue to be one of true croup. Treatment. — The croupy cough is one that invariably causes anxiety to the mother, and there is therefore but little risk of such cases being neglected. But the treatment should be decided, nevertheless. The child must be kept to its bed until the cough has assumed a less menacing sound, and the room must be kept warm and the air moist by means of a bronchitis-kettle. Poultices or warm fomen- tations are to be applied to the throat, and some expecto- rant is to be given frequently. Tr. benzoin, co., ffUc; syrup. LARYNGEAL SPASM— LARYNGITIS — WARTY-GROWTHS, ETC. 305 scillae, 5ss. ; ext. glycyrrh. liq., 5ss. ; aq. ad 5ij, may be given frequentty, or some similar combination of expecto- rants. Subsequently, the treatment of the tonsillar enlarge- ment becomes again prominent, but this is discussed in its proper place. I have called this condition catarrhal spasm rather than pseudo-croup, not for the purpose of inventing a new name, but because it suggests the nature of the chief features of the disease, and because it is in harmony with a series of other spasmodic affections of the larynx which occur in childhood, and which I now pass on to mention. These are — 1. Direct Spasm, or crowing of con- vulsive nature, often rachitic. 2. Reflex Spasm, or dyspnoea, due to spasm of the larynx, incited by enlargement of the mediastinal glands. 3. Infantile Spasm, orthe crowing due to a congenital valvular forma- tion of the upper orifice of the larynx. Laryngismus. < An objection may perhaps be taken to such an arrange- ment, that it exalts a symptom at the expense of the cause, and thus tends to destroy the more stable basis of classifica- tion — that of structural change. This has no doubt been felt by other writers, and has led them to treat of laryngis- mus amongst diseases of the nervous system. But laryn- gismus is so essentially laryngeal that in this symptom lies most of its interest, both as regards theory and practice. Direct Spasm of the Glottis is one form of laryngismus stridulus. I call it direct, because being largely associated with rickets, a complaint, which, by the convulsive affections 306 THE DISEASES OF CHILDREN. which attend it, indicates a state of instability of brain — it may be regarded, so to speak, as centrally ordained. Some, perhaps, may still prefer to consider it a reflex spasm. But if so, the discharging stimulus is so frequently varied that it is impossible to fix upon it with any precision, and in the majority of cases all that can be said is — this is laryngismus, and the child is rickety. Of its convulsive na- ture, in many cases, there can be no doubt: it is frequently associated with convulsions, and not uncommonly with tetany as well. Of thirty cases of laryngismus now before me, eight had had convulsions, two others carpo-pedal con- tractions. Dr. Gee notes that nineteen of fifty of his cases had had eclamptic fits. Laryngismus is so frequently asso- ciated with rickets that, again appealing to Dr. Gee,* we find him stating that spontaneous laryngismus is always asso- ciated with that disease — forty-eight of his fifty cases being unquestionably so. Twenty out of thirty-four of my own cases were also rachitic. I have not noticed the association of laryngismus with craniotabes — that condition of skull in which the bones yield under pressure with the crackle of parchment — but this has been remarked upon by several observers. Many have held that dentition is the exciting cause of the laryngeal spasm in these cases, and no doubt the disease occurs about the time the teeth are commencing to make their appearance. All the thirty cases alluded to were under two years of age ; and most of them were under a year, from the eighth to the eleventh month being the favorite period. One other point must be alluded to — viz., that the disease is much more prevalent in the first than in the second six months of the year. For this observation we are again indebted to Dr. Gee.f Of sixty-three cases spread over * On Convulsions in Children : St. Barth. Hosp. Reports, vol. iii , 1867. I On Laryngismus: St. Barth. Hosp. Reports, vol. xi., 1875. 1 LARYNGEAL SPASM LARYNGITIS WARTY-GROWTHS, ETC. 307 three years, fifty-eight occurred from January to the end of June, and only five from July tQ December. Dr. Gee very reasonably supposes that inasmuch as teething and gastro- intestinal complaints, which are well-known producers of convulsions, are prevalent all the year round, the weather must in this instance be at fault. But not directly so. Dr. Gee attributes the disease to a nervous erethism begotten by close confinement to ill-ventilated rooms ; and this idea is, I believe, well worthy of consideration. Infantile Spasm. — There is a class of cases met with in the out-patient room in no inconsiderable numbers, in which there is laryngismus of a mild type, but so persistent as to make it clear that some local laryngeal fault exists. Such children may show no evidence of rickets — no tendency to convulsions — although, seeing that rickets is a disease so prevalent, it is not to be wondered at that slight evidences of it may exist in some of these cases. The respiration in these cases is more reedy than in most of the cases of direct or spontaneous spasm, and it is more persistent, being even to some extent present during sleep. Nevertheless, it is distinctly aggravated, and to this extent spasmodic, under any excitement. The history of these cases is that whenever excited — on suddenly awakening from sleep, when they are suddenly taken from a warm to a cold atmosphere, when they cry, sometimes when their position is suddenly changed, or when from sitting up they are placed in bed — a croaking noise is made as if the child were going to choke. I have long thought that these cases must result from the confor- mation of the upper part of the larynx in early infancy. I had supposed that at this time of life the larynx was too yielding, and that when a rush of air was produced by means of deeper or more hurried breathing than usual, it could not pass fast enough. It seems probable, however, from an ob- servation made by Dr. Lees, that it is not so much a yield- 308 THE DISEASES OF CHILDREN. ing of the parts as a natural condition which exists in some cases. Dr. Lees made an inspection of one of these cases which had died from other causes, and he found that the epiglottis was excessively recurved in its vertical axis — as if it had been bent in half down the middle, and that thus the ary-epiglottic folds were brought almost into apposition, and a mere chink left between them. Now, more or less of this recurvation of the epiglottis is a common thing in infancy and early childhood, and I can quite believe that some such condition as this may explain some of the cases of laryngis- mus, which would otherwise be swept into the net of con- vulsive laryngismus on account of the coexistence of a very moderate rachitis. The history of so many of these cases is that they breathe quite naturally until they begin to breathe hurriedly ; but as soon as this happens, no matter what the cause, then there is dyspnoea and crowing. And more than this, these cases are very little, if at all, relieved by treat- ment, and the symptom gradually passes off as the child grows older. Reflex Spasm, due to excitement or worry of the medi- astinal branches of the vagus, is, without doubt, a real oc- currence ; but it has. to some extent, got into bad odor from the fact that some authors have endeavored to make all lar- yngeal spasm, apart from actual laryngitis, due to this cause. Thus, we have the spasm of pertussis due to bronchial gland enlargement, thymic asthma from engorgement of the thy- mus, and other conditions due to other forms of mediastinal trouble. This view does not appear to me to be tenable. Mediastinal affections have their sphere in the provocation of laryngeal spasm, but not to the exclusion of other causes. I have seen laryngeal spasm associated with cheesy bron- chial glands, with cheesy bronchial glands softening, with suppuration in the mediastinum from other causes, with fleshy swelling of the mediastinal glands from acute inflam- LARYNGEAL SPASM — LARYNGITIS — WARTY-GROWTHS, ETC. 3O9 niation, and even with a swollen condition of the thymus. Something of the same kind, too, occasionally occurs in as- sociation with acute pericarditis and pleurisy. It is no argu- ment against the potency of these conditions that they are not always, or even mostly, effective in producing the spasm. All convulsive affections are so largely due to individual proclivity, to disorderly nerve discharge, that no doubt a personal element is requisite as well as the local condition ; but that the local condition is sometimes associated with laryngeal spasm, distinguished by associated symptoms which allow of a correct diagnosis, there can, I think, be no doubt. Symptoms. — The classical laryngismus is thus described by West : " The child throws its head back, its face and lips become livid, or an ashy pallor surrounds the mouth, and slight convulsive movements pass over the muscles of the face. The chest is motionless, and suffocation seems im- pending. But in a few moments the spasm yields, expiration is effected, and the crowing inspiration succeeds/' Others depict it in still more alarming terms. But of a disease of this severity I know but little. A large number of infants, most of them nine or ten months old, are brought to the out- patient rooms of hospitals. Some are very rickety ; more are but moderately so ; and some are not evidently rachitic at all. Sometimes there is a history of convulsions of one kind or another. But the child is usually in moderate or good health; all that is supposed to ail it is that as soon as it is the least excited — no matter what the cause — a fit comes on, and it is unable to get its breath ; and this is followed by a long-drawn inspiratory crow, of a similar character to that of pertussis, only not being preceded by such violent paroxysmal emptying of the chest by cough — it is, of course, less violent, noisy, and prolonged. There may be a wheeze 3IO THE DISEASES OF CHILDREN. in its character which, as West says, is something between the whoop of pertussis and the stridor of true croup. The crow over, there is perhaps a fit of crying, and the child returns quickly to its natural playful habit, or else it remains fretful and out of sorts, with a continuance of carpo- pedal contractions, perhaps until there is a general convul- sion or the attack slowly passes off. The spasm due to an infantile conformation is not, by any means, easy to distinguish clinically ; but the cause being persistent, the dyspnoea will be more or less continuous, and slight inspiratory crowing will often occur two or three times during one inspiration. The inspirations may be of a more reedy or croaking character, and the crow is less associated with rickets — less of a convulsive affection — the child can hardly be said to be much, if at all, distressed by it — and it is less amenable to treatment. Reflex spasm is sometimes, one hardly dare say generally, associated with more or less persistent wheezing, as if from general bronchitis. Thus, such cases are liable to be mis- taken for spasmodic asthma. Asthma may occur, and very severely in children; but the possible existence of some en- largement of the bronchial glands should always be in mind in such cases. Cough is another symptom of great value ; there may be a persistent laryngeal tone about it which is peculiar, and it may be paroxysmal, and so make the parent think the child must have whooping-cough. The likeness to pertussis is sometimes further increased by the occurrence of vomiting after the cough. Hoarseness is sometimes present. These features should be remembered after severe and prolonged attacks of pertussis, and the attention turned to the possibility of the existence of some bronchial gland enlargement. Prognosis. — Most writers allude to a considerable risk which is supposed, by some, to attach to laryngismus, but it LARYNGEAL SPASM — LARYNGITIS WARTY-GROWTHS, ETC. 3 I I is clear that no definite opinion can be formed upon this point by using so vague a term. If laryngismus be due to a variety of causes, some may be dangerous, others not. This, I think, is how the case stands — a spasm of the glottis due to convulsions will necessarily be dangerous, because all convulsions in young children are attended with risk of sudden death ; and, in the same way, the reflex spasm, due to enlargement of the bronchial glands, or excitement of the peripheral branches of the nerves in the mediastinum, are dangerous, because the cause is a more or less persistent and usually an organic one ; but the other forms are, at any rate, less dangerous. To that form of spasm which is due to infantile narrowing of the glottic aperture, I should say hardly any danger attaches, and little more to the catarrhal spasm, although I suspect that this disease is more closely allied to, or rather more liable to run into, true laryngitis and croup than is usually taught. It is, in fact, the milder form of laryngitis, which at the other end of the scale shows as croup — the distinction between the two extremes of the scale being the somewhat arbitrary one of quick recovery in the one case and not in the other. Treatment. — Catarrhal spasm has already been dealt with. For infantile spasm but little can be done, save, perhaps, to give tonic medicines, and await the growth of the child and the fuller development of the larynx. The direct spasm, associated as it is with rickets, dentition, and general convulsions, must be watched and treated care- fully. If there be any tendency to general convulsions, as indicated by carpo-pedal contraction, etc., the bowels should be freely opened by a couple of grains of calomel, or syrup of senna, cathartic acid, jalapine, cascara sagrada, or what not. The first named is as good, or perhaps better than any. After the bowels have acted well, bromide of potassium, or sodium, or ammonium, in three to five grain doses, is to be 312 THE DISEASES OF CHILDREN. given, with some syrup of Tolu and aqua anethi, three times a day. The bromide may be combined with half a drachm of the syrup of chloral, and subsequently, when the imme- diate tendency to convulsion has passed away, the syrup of the lacto-phosphate of lime and iron, or Parrish's food, or steel wine and cod-liver oil, should be given regularly for some time. The greatest attention must be paid to the ventilation of the rooms inhabited by these children. Rach- itic laryngismus requires no close confinement to hot and stuffy rooms, but plenty of fresh air, and the body is to be sponged with cold water regularly every morning. In the reflex spasm, all such things as will tend to reduce enlargement of glands must be adopted ; these are a pro- longed sojourn at the seaside; the inhalation of iodine; chloride of calcium in doses of four or five grains three times a day ; iodide of iron, and cod-liver oil given internally ; and possibly some local applications applied between the scapulae over the fourth and fifth dorsal vertebrae. Laryngitis in children maybe classified thus: Acute | Sim P le ' 1 Membranous. Chronic (usually syphilitic). Acute non-membranous laryngitis is by no means un- common. It occurs with, or after, measles, whooping-cough, pneumonia, scarlatina, and diphtheria ; and also, amongst the lower classes at any rate, without any known cause, and it must be supposed, therefore, from simple exposure. I have notes of nineteen such cases, seven of which, being urgently ill, were admitted to the hospital, under the care of my col- leagues, Dr. Taylor and Dr. Baxter. They all got well with- out exception — most of them with the simple treatment of a steam tent. On looking over the admission book at the LARYNGEAL SPASM LARYNGITIS — WARTY-GROWTHS, ETC. 3 I 3 Evelina Hospital, from 1874 to 1880, 1 find that about forty- five cases of laryngitis were admitted, twelve being called croup and diphtheria. To these I have added my own cases. The age which is most liable to the disease comes out with remarkable precision as from one to four years : Under Under . . . . . .6 I 14 7 4 3 10 4 17 9 o 5 5 10 3 Of a series of sixty-one cases, thirty-six were girls, twenty- five boys. The following case is a fairly typical one : A girl, aged four years, had measles three weeks before she came to the hospital. Her cough had continued ever since, but she was not noticed to breathe badly until four days previously. The breathing had since then rapidly become more difficult. The child was livid-looking, with a noisy inspiration and expiration, and at the least disturbance the dyspnoea and the retraction of the thoracic walls was considerable. The tongue was furred; the temp. 101.5 ; the pulse very quick and irregular; no lymph could be seen on the fauces. She was admitted under Dr. Baxter, and placed in a tent and the atmosphere well steamed, and she quickly improved. Many similiar cases could be given. In the one or two cases that I have been able to examine laryngoscopically, the epiglottis has been, perhaps, a little swollen, and the ary-epiglottic folds also, but the visible changes were not- great. There is some difference of opinion as to the feasibility of using the laryngoscope in children. Some think the practice quite possible with patience, but I doubt whether laryngoscopy can be often available. [We agree with Steiner that simple laryngitis and pseudo- 314 THE DISEASES OF CHILDREN. croup are but modifications of the same disease. In both the anatomical lesion is catarrhal in nature, in the former, however, the whole mucous membrane of the larynx is affected, in the latter chiefly that of the rima glottidis, the epiglottis and the ligamenta ary-epiglottica. It is also true that in severe cases of laryngitis, spasmodic attacks of difficult breathing or false croup are very apt to occur. This we have but recently seen in a case of acute laryngitis complicating rubeola. An attack may begin suddenly — usually at night — or may be preceded for a day or more by sneezing, running at the nose and huskiness of the voice or cry. When fully developed the voice is hoarse and rasping ; there is dry cough of a peculiar brazen tone, a sensation of tickling in the throat and hurried somewhat difficult breathing. These symptoms are worse or only present at night, when, too, there may be moderate fever. They last for three or four days ; when the cough becomes loose and recovery is rapid. In severe cases the voice is more brazen, and occasionally temporarily lost. The cough is harassing, paroxysmal and painful, the difficulty in respiration is more apparent and the movements are accelerated, and there is consider- able pyrexia with the usual frequent pulse, dry skin and in- creased thirst. It is in these that well developed paroxysms of pseudo-croup arise. The spasm occurs at night and wakes the patient in a fright from his sleep. The face, head and neck first flush deeply, then become livid, the eyes are staring and the breathing labored and stridulous as if suffoca- tion impended. The voice and cough are very hoarse or their sounds may be almost extinguished during the height of the seizure but soon return after it is over. The pulse is frequent, the skin hot and there is great restlessness and anxiety. These paroxysms last from half an hour to an LARYNGEAL SPASM LARYNGITIS —WARTY-GROWTHS, ETC. 3 I 5 hour, and when the first occurs in the early part of the night it is apt to be followed by another, and unless mea- sures of prevention be used a repetition may take place on the next and even on the third night. The first is usually the most severe. Such severe attacks last somewhat longer than the milder ones, but the symptoms still show a tendency to remission or even intermission, being much lessened or disappearing during the morning or early afternoon.] Diagnosis. — This seems to me to be very aptly expressed by the old proverb, " the proof of the pudding is in the eat- ing." A child comes with symptoms such as I have narrated, and it is generally impossible to say offhand whether it has membranous or simple laryngitis. If no membrane can be seen on the fauces, and there is no local inflammation, no enlargement of the glands of the neck, but little fever, and no albumen in the urine, a fair hope may be indulged that the laryngitis is simple. No more can be said at first; the case must be allowed to unfold itself. But to show how impossible is a diagnosis sometimes, the student may be reminded that many a case thought to be croup has speedily recovered under a treatment of simple warmth and mois- ture ; that many another case, perhaps made light of at its commencement, has slowly matured into a fatal membra- nous laryngitis ; and — though it is hardly relevant, yet not wishing to lose any opportunity of insisting upon a point so important, I will further add — that as regards membra- nous laryngitis, assuming for the moment the non-identity of this form of disease and diphtheria, many a case thought to be the one has indubitably proved to be the other. Prognosis. — All cases of laryngeal obstruction require a cautious forecast for reasons just given, but no reliable opinion can be formed until the patient has been seen in bed, and after some hours of restriction to a regulated atmosphere of warmth and moisture. All such cases are 316 THE DISEASES OF CHILDREN. naturally attended with risk so long as the breathing re- mains stridulous. But the dread symptoms will often quickly subside when the child is placed in a tent and the air steamed by the bronchitis-kettle, Treatment. — Of the first importance is a small tent not far from the fire, and from which a steam-kettle can be directed towards the patient. The child must not, however, be kept too hot — a temperature of 65 ° is not to be exceeded. Somewhere between this and 6o° will be proper. In warm weather, all that will be necessary will be a tent and the steam produced by means of a spirit-lamp placed under the kettle by the side of the foot of the cot. It is a good plan to medicate the vapor by some compound tincture of ben- zoin ; and, when there are suspicions of membranous in- flammation, the mixture of creasote and carbolic acid, recommended at page 231, is good. If the case is a severe one, it is well to give an emetic, and the simple powdered ipecacuanha root is at once harm- less and effective; five grains is usually sufficient ; a tea- spoonful of the wine may be given if it be preferred, and the dose is to be repeated if not successful within half an hour. Considerable relief to the breathing is often procured by this means ; and, by a judicious repetition of the emetic as the breathing becomes embarrassed, the pressing symp- toms are shortly quite relieved or kept at bay. In the meantime, however, it is well to give small doses of antimo- nial wine, five minims every two or three hours, and to act upon the bowels with a little hyd. c. cret, or calomel. In very severe cases, many recommend that four or six leeches be applied to the top of the sternum, and that a blister should be applied to the throat. I cannot regard either remedy with much favor. Emetics seem to me to be less dangerous and more reliable. Ice-cold compresses may be applied to the throat, and should all these means fail and LARYNGEAL SPASM — LARYNGITIS WARTY-GROWTHS, ETC. 3 I 7 there be a risk of suffocation — as happens in the worst cases — tracheotomy must be performed. Upon this head, how- ever, it is worth saying that the student is often too urgent as regards operation. A child breathing stridulously no doubt requires most careful watching, but does not necessa- rily require an immediate operation. The larger number of cases of laryngitis, even with symptoms of some severity, are amenable to treatment, and therefore delay is always advisable until it be seen what effect the remedies may have upon the disease. Should an operation be resorted to, let me repeat that success will, in a large measure, depend upon the strict practice of the principles already advocated under the head of tracheotomy for diphtheria. Acute membranous laryngitis will not need much con- sideration here, as it would be only to repeat what I have said under the head of diphtheria. There are many who hold that all membranous laryngitis is diphtheritic ; others, who are equally dogmatic, that it is sometimes so, and some- times due to simple inflammation. And in this regard it is no doubt to some extent apposite that scalds of the throat, which are not very uncommon, seem liable to produce a membranous form of inflammation. But there are objec- tions to cases of this kind, because the local irritant acts by producing physical changes in the mucous membrane, some- times even to the boiling of the surface and the detachment of a slough. But there are extreme difficulties surrounding the subject on all hands. The diphtheritic poison is one which appears to originate under a variety of circumstances, the absence of which is seldom possible to prove; there are many cases of croup in which the existence of membrane is uncertain, yet they make part of the case in favor of an in- flammatory membranous disease when it is quite possible all the time that they may be cases of simple laryngitis. There is equally no doubt that many cases called croup at first, *1 3 18 THE DISEASES OF CHILDREN. have proved to be diphtheritic by the fact that they have carried contagion ; and diphtheritic membrane may unques- tionably be confined to the larynx. The only ground upon which a distinction can be really maintained is that of clini- cal symptoms, but this is a ground which I do not feel dis- posed to yield. If in a long course of years a large number of most experienced men say that membranous laryngitis is sometimes attended with high inflammatory fever — at others with low fever, requiring the brisk administration of the strongest nutriment at frequent intervals and plenty of stimu- lant, I think we should be careful how we neglect such statements. Many different conditions will produce a pneu- monia, yet the pathological changes will be indistinguishable in one and the other. And so with membranous laryngitis. A similarity of local change is no conclusive argument in favor of a common cause, and I say if it can be established that at the bedside there are two groups of cases, the one with one set of symptoms and requiring antiphlogistic reme- dies, the other with another set and requiring other remedies of an opposite tendency, I for one should be inclined to trust to the symptoms as the best indication of the reality of the difference. The only doubt I have is whether in diphtheritic laryngitis the symptoms are, as is maintained,, markedly those of an asthenic or prostrating disease, as they certainly are in some of the worst cases of its tonsillar variety. Chronic Laryngitis is more often of syphilitic origin than due to other causes — sometimes it is a remnant of former membranous laryngitis. Various diseases are met with from simple hoarseness to considerable inspiratory stridor. I have a child under my care at the present time of eight or nine months old, who has had snuffles, rash, and ulcer- ating condylomata of the anus, and who is completely aphonic ; it cries with a hoarse whisper, and had at one time LARYNGEAL SPASM — LARYNGITIS — WARTY- GROWTHS, ETC. 3I9 some dyspncea. This has subsided under mercurial treat- ment, but the loss of voice remains, and no doubt there has been considerable laryngeal disease. Another case, of a girl of four, I watched for a longtime; she was hoarse and breathed badly, and had a sunken nose. She gradually got worse, and tracheotomy became necessary. She also im- proved under mercurials and iodides, but the hoarseness continued, and she was ultimately lost sight of. I could give notes of several other cases which have been improved or cured by mercurials or iodides in the hospital or as out- patients. I must, however, mention two cases. One a male infant, aged four months, was admitted to the Evelina Hos- pital, and I saw it soon after its admission. It was one of six children. The mother had had three miscarriages. The child had had a sore mouth and snuffles for a month. It was pale and emaciated, with purulent ozaena, snuffles, ul- ceration of the tongue and mouth, and it had a hissing- aphonia with stridulous dyspnoea. Clean-punched deep sores were present about the anus and scrotum, and there were large brown discolorations in various places. The dyspnoea was very great, but the child was so emaciated and so young that no chance was offered of relief by opening the trachea, and it was therefore treated by mercurials alone. It died a short time after its admission, and at the autopsy a large vertical ulcer was found in the larynx at the base of epiglottis and perforating the thyro-hyoid membrane. The second case, a girl of four, was brought as an out- patient for noisy breathing, which had been getting worse for three months. She was a healthy-looking child, but breathed with a constant slight stridor which increased when she coughed or exerted herself. Her voice was but little altered, its pitch being slightly raised without loss of tone. There was a distinct elastic fulness of a peculiarly soft char- acter over the thyroid body, but no distinct enlargement of 320 THE DISEASES OF CHILDREN. the body itself. The carotids were displaced outwards, and there was bulging of the posterior wall of the pharynx. She was under view for about three months, and Mr. Clement Lucas, who saw her with me, inclined to the view that retro- pharyngeal abscess existed with an enlarged thyroid. She was subsequently admitted under Dr. Taylor, and her breathing becoming worse, tracheotomy was performed, and she died not long after. The autopsy showed a large fatty tumor extending from the base of the skull down be- hind the pharynx.* With this case in view it may also be mentioned that an enlarged thyroid sometimes causes dysp- noea from pressing on the trachea, and that occasionally also the pressure of enlarged and caseous glands may do the same. Diagnosis. — This must be attempted rather by bearing in mind what are the possibilities, and by excluding those af- fections which in the particular case are contra-indicated. The symptoms of chronic laryngitis may be produced by syphilitic inflammation of the larynx, by warty growths in the larynx, by chronic thickening resulting from a bygone croup, or by extension of the disease from the mucous membrane around. It may also be simulated by disease outside, such as a retro-pharyngeal abscess or a new growth of any kind. But in this class of cases there is usually marked dysphagia, and there are likely to be peculiarities in the case suggest- ing that it is not a straightforward one of laryngitis. As regards the cases of pressure upon the trachea to which I have alluded, Gerhardt has stated that immobility of the vocal cords during the respiratory act is a symptom of pres- sure upon the trachea below the glottis ; this might possibly be of use when a laryngoscopical examination can be made. Of other conditions than these which cause laryngeal * This case has been published by Dr. Taylor in the " Trans. Path. Soc." 1876-7. LARYNGEAL SPASM LARYNGITIS — WARTY-GROWTHS, ETC. 32 I dyspnoea, warty growths in the larynx and retro-pharyngeal abscess are perhaps the more important; but oedema glot- tidis may be occasionally met with, though I think but rarely, from the extension of inflammation from the tonsils or the mucous membrane of the nose and pharynx. Per- haps more common than any is a certain amount of obstruc- tion to the respiration from a general thickening and hyper- trophy of the pharyngeal mucous membrane — a state of things which I have seen several times. The mucous mem- brane under these circumstances is spongy and warty-look- ing — sometimes thrown into rugae, and altogether consider- ably narrowing the faucial passage. I have several times been puzzled in such cases to know whether I was dealing with this disease or with some retro-pharyngeal abscess, the complete examination of the throat in young children being a matter of so much difficulty. The pharyngeal conditions are described more in detail in their appropriate place, p. I IO. Prognosis. — This will, of course, depend upon the origin of the disease. So far as the dyspnoea is concerned, these cases do remarkably well. But one must be rather cautious in expressing an opinion as to the return of the voice, as the aphonia appears to be a less remediable condition. Treatment. — If the dyspnoea is at all urgent, and probably in any case, it will be advisable to try what a moist atmo- sphere will do, and either iodides or mercurials should be given internally. In very chronic cases, where the dyspnoea is considerable and intractable, it may be well to consider tracheotomy as a remedial measure. It certainly would seem that the continued action of a larynx, reduced to a mere chink, although sufficient perhaps for the purposes of aeration — not without discomfort — tends to perpetuate its own ill by keeping up spasm and augmenting the products of inflammation. Tracheotomy puts the parts at rest, and therefore favors their return to a healthy state. Moreover, 322 THE DISEASES OF CHILDREN. although at no time would I counsel a resort to laryngotomy or tracheotomy until all other means of relief had been dis- cussed or exhausted, yet treated secundum artem y I believe that the operation is less dangerous in such cases than those in which it is performed for diphtheria, croup, or acute inflammation about the respiratory passages. Warty-growths in the larynx are rare, and their diagnosis very difficult; in one case, a child of about two, though examined by the most expert of laryngoscopists, and after tracheotomy, no diagnosis was arrived at. In another, an older child of four, the growths were seen in the larynx by the laryngeal mirror after tracheotomy had been performed. Lon^-standincr hoarseness and difficulty of breathing, unas- sociated with fever, and when syphilis or phthisis can be excluded, are very probably due to a new growth ; to say this is to give a very concise and practical summary of our means of diagnosis. Laryngeal warts always have a well- marked cauliflower-like aspect ; they are true warts or papil- lomata, and they grow from the surface of the true vocal cords, or from other parts of the larynx, usually below them. Treatment. — This must necessarily be a difficult matter. If the growths can be attacked from the mouth, they may be swabbed with chromic acid solution, or still better, per- haps, painted with some salicylic cream or salicylic acid in glycerine; and occasionally it is possible to remove them from above by operation. Two or three such cases are on record in children of such tender age as from three to five years. But in most cases the persistence of symptoms of chronic laryngitis ultimately leads to tracheotomy, and it is only after the operation that the throat becomes tolerant enough to enable anything to be done by the mouth. Pos- sibly the warts may then be removed by this channel ; they are easily detached if they can be reached. In several cases now on record, however, the continuance of dyspnoea has LARYNGEAL SPASM LARYNGITIS — WARTY- GROWTHS, ETC. 323 led to the operation called thyrotomy ; the thyroid cartilage is slit up in the middle, the larynx opened, and the warts removed, some solution such as I have named being applied to the diseased surface afterwards, and the parts again care- fully adjusted and secured by sutures. This was done three or four times in a case under the care of my colleague, Mr. Davies-Colley, and with ultimate success, and the boy was still well eight years later, save that he could only talk in a hoarse whisper. The operation of tracheotomy for these growths has been performed, according to Gerhardt, fourteen times — six suc- cessfully at the ages of fifteen, eleven, six, six, five and a half, and three and a half years ; the remainder unsuccess- fully at the ages of eight, three, three, two and a half, two and one-third, and two ; and from these data the conclusion is drawn, which is probably a sound one, that the younger the child the greater the risk from operation. Thyrotomy has been performed in twenty-one cases, but the results do not appear to have been very successful if we take into ac- count that some patients died, and that in many the growths recurred, necessitating, in some cases, a repetition of the ope- ration. Nevertheless, it should be performed when other means have failed. Foreign bodies in the trachea, if not expelled by cough- ing, will require surgical treatment, and probably trache- tomy. They produce more or less general bronchitis and paroxysmal attacks of urgent dyspnoea. The history of these paroxysms is no doubt that the body, usually a pea or some- thing round, is^drawn into the trachea and plugs the bron- chus. There it remains for a time until the mucous secre- tion set up by its presence induces a more than usually violent fit of coughing. This dislodges the body and drives it into the upper part of the trachea, perhaps into the larynx below the cords, where the irritation provokes spasm. By- 324 THE DISEASES OF CHILDREN. and-by the body falls down again into its former spot and the spasm subsides, to be again renewed until expulsion of the body is procured or broncho-pneumonia is set up by the worry of its presence. But there is a further point upon which I would insist — viz., that if the foreign body becomes fixed in the bronchus, there will probably be no paroxysmal dyspnoea. And it is not uncommon for fish-bones and other bodies to become fixed in one or other bronchus — usually the right — and there to set up a unilateral bronchitis, the cause of which may be puzzling and overlooked unless the possibility be borne in mind. Numerous cases are on record of pieces of bone, wheat-ears, etc., becoming impacted in the bronchus, and thus setting up a fatal pneumonia. Dr. Wilks has published a case in which an ear of grass worked its way down the bronchus to the surface of the lung, there set up an empyema, and was discharged by the opening made for the evacuation of the pus. Treatment. — Foreign bodies may be expelled by cough- ing, or by emesis. Their expulsion has sometimes been apparently favored by holding the patient up with his head downwards ; but tracheotomy is often necessary, and the prognosis in such cases is not favorable unless the body is quickly expelled. Mr. Durham has successfully performed thyrotomy in one case, a cherry-stone being impacted in the larynx. [Dr. H. R. Wharton, one of the surgeons to the Chil- dren's Hospital, Philadelphia, has recently reported three cases in which tracheotomy was successfully performed for the removal of foreign bodies from the tracrjea and larynx. The first case was a boy, aged seventeen months, a patient at the Children's Hospital. After the production of anaes- thesia, the trachea was exposed and laid open, when a forci- ble expiratory effort occurred and a small white bean was expelled from the wound. A small silver tracheotomy tube LARYNGEAL SPASM LARYNGITIS — WARTY-GROWTHS, ETC. 325 was inserted as a matter of precaution. The child did well after the operation. The tube was permanently removed on the fourth day and he was discharged, the wound having entirely healed, two days later. The second case, a boy, aged nineteen months, was ad- mitted to the hospital on May 3d, 1883. Four days before he accidentally inhaled a portion of a grain of gourd-seed corn, and was at once seized with violent coughing and dyspnoea. When admitted the symptoms were so urgent that immediate tracheotomy was deemed necessary. Dur- ing the operation, which was performed without anaesthesia, the respiratory movements ceased and artificial respiration had to be resorted to. This was kept up for some minutes and hope of resuscitation had almost vanished, when sud- denly a voluntary respiration occurred bringing the foreign body into the wound, whence it was removed. Afterwards respiration was performed freely so long as the tracheal wound was kept open by retractors, but so soon as these were removed and the edges fell together dyspnoea came on; consequently a small tracheotomy tube was inserted. The operation was followed by no unfavorable symptoms, the patient quickly recovered and was quite comfortable while wearing the tube, though the recurrence of dyspnoea ren- dered its removal for any length of time impossible until July 23d, eighty-one days after its insertion. Besides early age there are two other features of interest in this case, namely, the respiratory arrest after opening the trachea, and the delay experienced in removing the tube. The arrest depended upon a falling together of the edges of the tracheal wound during the inspiratory act. Whether this was due to the natural flexibility of the trachea in early life, or to the prolonged presence of the foreign body hav- ing resulted in general inflammatory softening, the reporter does not attempt to decide, though he is inclined to regard 28 326 THE DISEASES OF CHILDREN. the softening as an important factor, since the first case, not- withstanding its youth, was uncomplicated by dyspnoea after the removal of the foreign body. The permanent removal of the tracheotomy tube is sometimes a matter of great diffi- culty, although it can usually be ultimately accomplished if enough patience be exercised. The trouble arises both from the fact that the granulations arising in healing may act like a valve-leaflet during inspiration, and from the irri- tability and disorderly action of the glottis muscles so likely to follow the operation. In both of these cases the operation was performed by Professor John Ashhurst, Jr. The third case was a girl, aged seven years, also a patient at the Children's Hospital. On the night before admission she supposed she had swallowed a pin which she was hold- ing in her mouth, but was convinced to the contrary by a sudden attack of coughing and by pain referred to the upper part of the larynx. On examination the only symptoms were pain, a sensation of 4< sticking " in the region men- tioned, and cough ; by the finger the point of some sharp body could be felt beneath the skin a little to the right of the pomum adami. After etherization Dr. Wharton made an incision a little to the right of the median line of the neck, where the point of a pin was seen -imbedded in the right ala of the thyroid cartilage, it was seized with forceps, drawn down until its head impinged upon the inner surface of the cartilage, and its complete removal accomplished by a trifling incision. Very little air escaped through the inci- sion, there were no unfavorable sequelae and the patient made a rapid and complete recovery. The reasons for selecting the external rather than the internal method of removal were the extreme difficulty of controlling the child, and the fear that a delay might be followed by some unfavorable change in the position of the foreign body.] BRONCHITIS AND BRONCHI: CHAPTER XXI. BRONCHITIS AND BRONCHIECTASIS, Bronchitis is :-r.e of the commonest affections of child- hood. It is most common as a disease of the large and medium-sized tubes, but is very apt to read from :*/. : the smaller tubes, and to lead to broncho-pneumonia an atelectasis. It is in respect of these d : s e ? ises that its impor- tance chiefly lies. It is usually \ iscr ibed tc the effects of chill, but, without denying this in any way, I believe its cause to be far more often intrinsi : than e::: rinsi :. if I may s : Sf There are many children who have an ronchitis, mostly of the larger tubes, when tee:/, .-.re ;ust coming through the gums ; there are others, usually older children, whose irregularities in diet and in the gastro-intest secretions are revealed in the same way. The ascaris lum- bricoides may provoke similar disturbances, and the symp- toms possibly subside on the expulsion of the urns. Su ch ts are probably of neurotic origin, and are examples :f reflex nervous disturbance, the worry at one end of a nerve being transmitted to some other station in communication with it. Tie:: there are the specific poisons, such as that of measles, of pertussis, or of typhoid fever; there are local peculiarities of action in the muscle of the bronchial tut there are all the conditions of catarrh in the upper passag there are the series of tubercular conditions which, in any n case, must all be taken into consideration; and but not least, there are the chronic cone .n en dent upon atelectasis, which are ever ready to excite catarrh. No ill these, there are many ot 328 THE DISEASES OF CHILDREN. causes of which we know even less ; exposure of the skin to chills will interfere with its action, will disturb the balance of the circulation, and tend to throw undue stress upon all the viscera, the lungs amongst them. Atmospheric disturb- ances, electrical and other, abnormal constituents of the particulate dust, must also be of importance ; but it is of very little use discussing these things at length, for at best it could be but as the blind man offering to lead his fellow. In dealing with bronchitis, however, and all such things as are supposed to be determined by chill, I would have the student interpret this in the widest sense, and think out carefully for himself how much or how little it may mean. Symptoms. — Acute bronchitis, as it is seen in any of these cases, is a pretty definite disease. Its onset is usually sud- den, attended with hig.h fever (102 or 103 ), rapid labored respiration, dilating alae nasi, and usually with a good deal of perspiration. The tongue is thickly furred. There is a frequent, short, dry, and subsequently a moist, cough. On examining such a case, the chest will be rising very rapidly, the sternum plunging forwards, probably the lower ribs at the same time becoming retracted inwards, and the diaphragm moving forcibly downwards, so as to round the abdomen into a ball-like shape at the end of inspiration. The more the impediment to the entrance of air into the lungs, the more will these features be noticed, and the severity of the case may in great measure, therefore, be judged in this way. In the worst cases the features are livid and the child very restless. On percussion, nothing will be made out with certainty, and on auscultation there will be bubbling and squeaking all over the chest. At the apices the inspiration will be harsh and the expiratory murmur long and snoring, while the sounds at the bases are moister, and will be trans- mitted more strongly to the -ear, should the disease be asso- ciated with broncho-pneumonia. BRONCHITIS AND BRONCHIECTASIS. 329 As a rule, there is no expectoration, and the cough need not be a prominent feature. Sometimes it is frequent and distressing, and occasionally it comes on in paroxysms, and is attended with the passage into the mouth of muco-purulent material, not unlike that in pertussis, which should be re- moved by a pocket-handkerchief. At other times, although the respiration is very rapid, the cough indicates by its harshness that the upper parts of the air-passages are mostly affected. The disease is one of variable duration — seven or eight days may be given as perhaps an average. It is usually accompanied by anorexia and thirst, whilst the urine is stated by Meigs and Pepper to be frequently temporarily albuminous. But a large number of children who apply for treatment in the out-patient rooms of hospitals have a much milder attack than this. They are out of sorts, often rickety, and have cough with some slight pyrexia, and on auscultation some coarse and fine rales are heard in various parts of the chest. An equally important group of cases is related to the acute bronchitis which follows a persistent dilatation of the tubes and atelectasis. In these cases, again, the respiration is very rapid, shallow, and often labored; the child is restless, blue, and bathed in perspiration, and there is a frequent short," moist cough. The temperature generally rises to 102 or so. The tongue is thickly furred. The auscultatory signs are much like those in the former case, but, supervening as the disease does upon collapse and bronchiectasis, there may be very little air entering the bases of the lungs, more or less dulness, and even signs of considerable consolidation. Diagnosis, — Two difficulties may be noticed — one as re- gards the general symptoms. There are many children during the period of the first dentition who suffer from an 330 THE DISEASES OF CHILDREN. acute febrile condition of sudden onset, and in which the respiration quickens in proportion to the fever. It is not difficult to mistake the appearances in such a case for those of bronchitis, but the auscultatory phenomena are not those of bronchitis, and after two or three days — perhaps before, perhaps on the eruption of a tooth, perhaps on the adminis- tration of some aperient or diaphoretic — down drops the temperature, as suddenly as it rose, and the child is practi- cally well. A more serious difficulty is to determine whether there is any actual consolidation of the lung. Very careful aus- cultation of the lung, inch by inch, will be required to de- termine the point, and a careful weighing of the character of the mucous rales that are to be heard. And when the acute disease supervenes upon a chronic condition, the amount of dulness towards the bases from the pre-existing collapse makes the question a difficult one to decide. Bron- chitis, collapse, and broncho-pneumonia, are, however, so frequently associated that in one sense the importance of the question is minimized, and it is often decided rather upon the general symptoms than upon the physical signs, which may be hard to gauge with accuracy; in another sense it is of the more importance, determining, as the existence of pneumonia often will, a fatal issue. Under special circum- stances also the diagnosis becomes difficult. For instance, at the termination of whooping-cough, the wasted condition of the child, and the excess of pulmonary impediment, may easily simulate phthisis. I have before alluded to the bron- chitis of typhoid fever being occasionally so severe as to mask the essential disease. Prognosis. — This must depend upon the general symp- toms rather than upon the physical signs. Where the respi- ration is very rapid and labored, the dyspnoea increasing, the child blue and exhausted though restless, cool, and BRONCHITIS AND BRONCHIECTASIS. 331 clammy, somnolent, and taking food badly, the prognosis must be grave. If, too, there be much inspiratory retrac- tion of the sides of the chest, or the sharp rales of broncho- pneumonia in addition, or if the child be very drowsy, or the Cheney-Stokes* type of respiration become at all pronounced, there is of necessity an added risk. All the same, the opinion should be a cautious one ; for, with careful treatment, the worst-looking cases may slowly pull round. Treatment. — The child is placed in bed, and in a tent with a steam-kettle in the neighborhood to moisten the air. A little carbolic acid may be put into the vapor — one in eighty will be sufficient. A jacket of cotton-wool should be made to lightly envelop the chest. The food should be easily assimilable, not necessarily milk or beef-tea only, but egg, custard, blanc-mange, jelly, sponge-cake, etc. For medicinal administration, some expectorant should be given — bicarbonate of potassium, nitrate of potassium, syrup of squills, and ipecacuanha are all good. They may be given singly or combined, and some syrup of Tolu and aquae anethi added to make them palatable. If the prostra- tion be great, carbonate of ammonium and ipecacuanha wine make a useful combination as the secretion from the bron- chial tubes becomes more fluid. An emetic may sometimes be given to clear the tubes — a teaspoonful of the vin. ipecac. or five grains of the powdered root. Subsequently, a little syrup of squills, with the lacto-phosphate of lime and iron, may be given. The bowels should be kept gently open by aperients, as may be necessary; and, in the later stages, quinine may be useful, as well as cod-liver oil and other general tonics and restoratives. Chronic Bronchitis is sometimes a result of an acute at- tack, or several such; it sometimes remains after whooping- cough; sometimes it is the sequel of atelectasis ; and some- times all we can say is that it exists, but how it came about 332 THE DISEASES OF CHILDREN. there is no evidence to show. Under any or all of these conditions the child is more or less blue, with short breath and a deep chest, flattened from side to side, with a promi- nent sternum ; the finger-ends are bulbous; it moves about in a lethargic way, as if life were an exertion, and has a frequent short moist cough. Sometimes the chest is full of moist rales, both large and small; sometimes there is little to be heard, except that the inspiratory murmur is clipped or shortened, and somewhat labored. A long expiratory murmur is not, I think, a very marked feature of bronchitis in childhood. In the more advanced cases, the cyanosis and clubbing of the fingers may be extreme; the inspiratory recession of the lower and lateral parts of the thorax is very great. There may be evidence of distension of the right side of the heart, in the fulness of the veins and epigastric pul- sation; but the lungs, being emphysematous in front, do not often allow of the detection of any increase of the praecordial dulness on the right side. The copious expectoration of pus, and sometimes of offensive pus, has been said to occur in older children, and to be indicative of dilatation of the bronchial tubes, but this must, I think, be of very excep- tional occurrence. Morbid Anatomy. — Such cases as these are apt, in the end, to be fatal by the repetition of the attacks. Each attack leaves the lung in a worse state than it was before, and the child's condition is one of gradual deterioration. The ap- pearances usually found are patches of solid collapsed lung in various parts, more particularly towards the base and round the lateral region of the thorax ; and the bronchial tubes are considerably dilated and full of thick pus. Thicken- ing, roughening, and ulceration of the mucous membrane of the tubes have been described, but I think such conditions are rare. It seems to me to be much more remarkable how seldom there are any marked changes in the tubes commen- BRONCHITIS AND BRONCHIECTASIS. 333 surate with the extent of disease, if dilatation be excepted. The tubes are generally dark colored and congested, but not swollen or roughened in any way. The dilatation of the tubes is seldom other than a uniform one; saccular dilata- tions are quite uncommon. The lungs are usually moder- ately emphysematous along their anterior borders, at their edges elsewhere, and at their apices. In addition to the morbid appearances in the lungs, there will be found, more or less, those associated conditions of the viscera dependent upon the obstruction to the pulmonary circulation — viz., a large and probably dilated right heart, a nutmeg liver, and congested kidneys. Prognosis. — These cases usually go on for a long time. Their history is for the most part one of chronic ailment, with intercurrent attacks of more acute inflammation, in all of which they are very ill, and the issue for the time doubt- ful. In one of these attacks they may ultimately die. Such cases, however, repay care; for again and again they may pull through a serious attack, when apparently in an almost hopeless state, and I think one is justified in saying that, in many cases, something amounting to repair goes on. In young children, it is not incorrect to say that they may " grow out of it," for they greatly improve as their ribs stiffen. But there are other risks — one is of acute pleurisy, another of some ulceration of the lung; both these come about by the medium of dilated bronchial tubes. The secre- tions collect in them, near the surface of the lung or else- where, and, decomposing, set up an acute pleurisy, or some destructive broncho-pneumonia. Treatment. — This is much the same as for other more acute cases. They require always to be kept very warm, to be warmly clad, exposed as little as possible to the vicissi- tudes of climate, and in any acute attack to be kept in bed. Alkalies are useful in promoting expectoration, and some 334 THE DISEASES OF CHILDREN. stimulating expectorant may be added to them. Four or five drops of sal volatile with a similar quantity of tincture of senega, and some bicarbonate of potassium with some syrup of Tolu, make an effective mixture at this time. In the later stage, when the expectoration is very copious, alum or gallic acid may be given. (F. 25, 36, 41.) Besides internal reme- dies, daily friction of the back and sides of the chest by soap liniment or simple oil seems sometimes to be of service. Later still, these cases usually do well upon mild ferrugi- nous tonics. Quinine is also advised at this stage, and there can be no objection to its administration in half-grain doses three times a day. Quinine is best administered in milk, but it may be given with syrup or liquorice, and the recom- mendation of Meigs and Pepper, to combine it with a little curacoa, is a good suggestion, if there be much repugnance to it in other ways. Maltine, cod-liver oil, and such like remedies, are also often valuable in improving the general health of the child. Bronchiectasis. — It may be quite an open question whether this is to be considered a distinct disease; my rea- son for devoting a separate paragraph to its consideration is that it has been taught that there are special symptoms disclosing its existence, and one would like, therefore, to in- dicate what these are. It would appear that it occurs mostly between five and nine years, twelve out of twenty cases being within that period. Bad pertussis frequently antedates it. From notes of twenty cases in which I supposed this condi- tion to be present, there is expectoration, sometimes vomit- ing of large quantities of thick, purulent, possibly offensive pus. The chest is usually deformed, either pointed in front or flattened on one or other side, and there is often an ir- regularly distributed dulness perhaps at one apex, and on one side, or in patches in different parts of the lungs. The physical signs are those of bronchitis of the larger tubes, BRONCHITIS AND BRONCHIECTASIS. 335 nally some sharp rales in various parts of the s. It is but seldom that anything suggestive of cavita- tion is heard, probably because these dilatations usually occur in the substance of the lung and are surrounded by cular pulmonary tissue. There is usually more or cyanosis, clubbing of the fingers, and a generally labored breathing and indolent habit. With the exception, perhaps, of copious expectoration of pus, these symptoms indicate not so much dilatation of the tubes as that condition of lung to which the dilated tubes owe their existence, and this may be sometimes an old chronic bronchitis, sometimes extensive collapse, sometimes some old fibroid changes on one side or the other. It has been supposed by some that there is a special significance in fetor of the expectoration. I am in- clined to doubt this. I believe it to be much more near the truth that when fetor of the bronchial discharges exists there is generally some destructive disease of the lung or ulcera- tion of the bronchial tubes. Morbid Anatomy. — The commonest form of dilatation is a uniform one. A section of the lung shows the tubes unduly large, and the scissors run along them with ease to the surface of the pleura. They generally contain more or thick pus. Their lining membrane is red or livid; thickening is not a noticeable feature. This state of things is very usually associated with emphysema at the anterior and basal edges of the lungs, and also with some collapse. Saccular dilatation is rare. The tubes are in these cases thin rather than thick, and form sections of cysts on the cut surface of the lung. These occur in the substance of the lung rather than near the surface, and are often surrounded by a small nodule of consolidated lung. An exaggerated form of this disease is met with occasionally in which these cysts are very numerous and very large, the sections of the lower parts of the lobes being thickly studded with them. 336 THE DISEASES OF CHILDREN. The lung-tissue intervening is at most only emphysematous and the pleura is usually adherent. Very little is known about this condition ; it has seemed to me that it might possibly be of congenital origin, the physical signs have been so little pronounced, and the evidences of the disease so obscure. There is yet a third condition, in which usu- ally one or other base of the lung is contracted and con- densed, and the tubes are more or less widely dilated. The dilatation in these cases is neither uniform as in the condi- tion already described, nor saccular as in the other, yet on slitting them up along their course there is a good deal of irregular dilatation, and the cavities so exposed are puckered by the existence of transverse rugae. These also are found chiefly in the substance of the lung. This state of things is usually dependent upon some old pleurisy or chronic pneumonia. The prognosis and treatment are much the same as for chronic bronchitis. These children require to be kept in as pure an air as possible, in as equable a temperature as pos- sible, and, save when any acute attack threatens, in a dry atmosphere. If there is much accumulation of mucus in the tubes, an occasional emetic will relieve them, and for the rest they require tonics and fattening. PNEUMONIA. 337 CHAPTER XXII. PNEUMONIA. Pneumonia. — It is usual to describe this disease as lobar or fibrinous* ; and lobular or catarrhal and broncho- pneumonic ; but, time-honored though such a description may be, it is liable to mislead the student. An acute pneumonia — which has the clinical features of the croupous pneumonia of adult life — is not uncommon in childhood ; sudden onset; high fever; crisis; and sudden fall of tem- perature. But the difficulty is that the larger proportion of cases of pneumonia are not quite this, and yet they are lobar pneumonias as regards their physical signs. They run a less typical course, and whilst partaking in some respects of the nature of the one form of disease, in others they are more like the catarrhal form. Nor is the difficulty lessened by appealing to the facts of morbid anatomy ; for acute pneumonia, be it clinically lobar or lobular, seems to me to present such appearances in every case, as make any dis- tinction between the two forms, save one of degree, a very difficult matter. I am not familiar with the red and grey hepatization which are described as occurring in childhood as in adults, when the disease is of the fibrinous form ; but the clinical data are sufficiently precise to forbid all doubt that such a disease as acute fibrinous pneumonia has a very real existence. The student must bear in mind, however, that the labor pneumonia of children is more often catarrhal than fibrinous, and that, therefore, the disease here de- scribed as such has a wider range than that usually given * Croupous. — Ed. 338 THE DISEASES OF CHILDREN. to it. The remarks which follow are, indeed, chiefly based upon the commoner form of the disease, and the morbid anatomy is described from the fatal cases resulting from this form. Possibly the fibrinous pneumonia is but seldom fatal. This catarrhal origin may explain the fact that the lobar pneumonia of children so often begins at the root of the lung, and spreads upwards or downwards; here also may possibly be found an explanation for another fact — viz., that pneumonia at the apex of the lung is, as is usually supposed, a commoner disease in children than in adults. The pneu- monia of adult life commences as a parenchymatous change at the base of the lung, and extends up the posterior part, reaching the apex and front last of all. But if the root be the more frequent seat of onset, it is clear that the apex and base are equally exposed to the risk of extension, and an apex pneumonia might be expected to be more common. I have analyzed all my cases with a view to giving some in- formation upon some of these points, and one or two inter- esting facts are arrived at by this means. Out of 165 cases, forty-five were lobular pneumonia, with a mortality of twenty. Such a small number of cases of lobular pneumonia is, in part, accounted for by the fact that — being more common — less careful notes have been taken of such cases, and, in part, by many cases being in- cluded with those of bronchitis. One hundred and twenty were lobar ; fifty-one of the left base, with fourteen deaths ; seventeen of the left apex, with two deaths ; thirty-four of the right base, with two deaths ; eighteen of the right apex, with seven deaths. Apical pneumonia appears, then, to occur twice to five cases where the disease is basal ; whilst disease at the right apex is the most fatal, and that at the left base next. Henoch gives seventy-four cases, two in which the disease attacked the entire right lung ; two both lower lobes ; twenty-one the right upper lobe ; eighteen the right PNEUMONIA. 339 lower lobe ; four the left upper lobe ; and twenty-seven the left lower lobe. As regards the mortality, my figures are, however, open to the exception that four-fifths were from out-patients. The mortality is, therefore, probably higher than it need be. I have made no mention of double pneu- monia, because in all these cases it was essentially one- sided ; but in several cases patches here and there were discovered from time to time in the course of the disease^ which make me agree with the opinion of Dr. West that double pneumonias are not uncommon. There is some difficulty in being sure of the fact in the absence of an autopsy, for the sounds of consolidation are transmitted from side to side, particularly about the root, with great readiness ; and it is also quite common in the auscultation of the lungs of children suffering from pneumonia to meet with evidences of consolidation at one visit which have gone at the next, or within a short time, and which must, I think, indicate a still more ready interchange of collapse and expansion than has, possibly, hitherto been appreciated, notwithstanding all that has been written on the subject. For this reason I hesitate to say that the disease attacks one side more frequently than the other. These figures tell rather in favor of a small left-sided preponderance ; but other authors have thought it otherwise, and I suspect, therefore, that there is not much difference in this respect over a large range of cases. Sex, — Of the above cases, seventy-seven were girls and fifty boys. This is not in accord with general experience, but, as is well known, different sets of statistics are liable to give contradictory results. It appears pretty certain that, taking a large number of cases, pneumonia occurs more often in boys than in girls; but I give my own numbers for what they are worth. Nor am I in more than partial agree- ment with others as regards the age of patients suffering 340 THE DISEASES OF CHILDREN. from lobar pneumonia. No doubt nearly all cases occur under five years (eighty-two out of ninety-three) ; fifty-one cases were under two, and thirty-one between two and five. Such discrepancies as exist may be explained in great measure, if instead of taking an anatomical basis of classification, we take the clinical one — the younger the child, the more is the disease associated with bronchitic symptoms, in which the disease may often originate ; the older the child, the more likely is the disease to have a sudden onset, perhaps by convulsions, and all the signs of bronchitis to be absent. Morbid Anatomy. — The lobar pneumonia of childhood, as seen in the post-mortem room, differs from that of the adult in wanting the distension or solidity that is found in adults, and also the granular or dull rough surface which is so characteristic. As in adult life, it is often associated with pleurisy. The child's lung is smaller, denser, darker colored than natural, of a bluish, violet, or leaden tint, and the cut surface is comparatively smooth. It is often very finely sanded, and may look vesicular, or almost gelatinous. When the disease has progressed some few days, the sur- face thus described is generally studded over with circinate patches of granular yellow or yellow-red color. These are the terminal bronchi with the pulmonary vesicles around them full of inflammatory material, on its way towards grey or fatty changes. The intervening parts are solid, dark- colored, and hardly granular. They are more solid than in the solidity of collapse; less so, at any rate less bulky, than in the lung of acute croupous pneumonia. This is the con- dition which has no doubt given rise to so much questioning and discussion— some calling it collapse, others pneumonia. I shall, perhaps, not better matters much. by saying that it is neither one nor the other ; but, none the less, such a state- ment is strictly true. In childhood the respiratory move- ments and the circulatory conditions are not exactly the PNEUMONIA. 34I same as in adults. As I have before said, if we listen over a child's chest we frequently hear that now one part, now another, is moving more fully, depending upon a less uni- formly equable expansion of the chest; and with dissimilar conditions come dissimilar morbid changes. The common form of pneumonia is due to a complex series of changes : in part, and no doubt a prominent part, due to collapse ; in part to catarrhal changes in the tubes and air-vesicles ; in part to blood-stasis simply ; in part to swelling and thickening of the connective tissues surrounding the smaller bronchi and the septa of the lung. The last-mentioned conditions are very prominent features of the pneumonia of childhood, while the exudation of fibrin is of very limited occurrence. I am by no means sure also as to whether some process of adhesion may not go on in the walls of the inflamed air-vesicles. If not, they become much thickened and fibroid-looking, and in parts of such lungs the vesicular structure may be quite obliterated, and the observer appear to be looking at an unbroken field of fibro-nucleated tissue. It is most difficult in some cases to say what is the exact nature of the changes histologically ; but this I know, that appearances quite unlike those of the acute pneumonia of adult life present themselves. Neither are such changes comparable to those met with after com- pression by fluid. The peculiarities in the anatomical ap- pearances have been described by several writers. Rilliet and Barthez ascribe them, in part, to the interstitial exuda- tion to which I have alluded; others to a lessened amount of fibrinous exudation. I should suppose that both these departures from the adult type are of importance. The absence of fibrinous exudation may, however, be particularly insisted upon, because, if such be the case, it will be apparent khow difficult it must sometimes be to distinguish between pneumonia and collapse of the lung. The nature of the later stages of a lobar pneumonia in 29 342 THE DISEASES OF CHILDREN. children is also by no means free from obscurity; but from what is seen in lobular pneumonia and from an occasional case of fibrinous pneumonia, it has been more surmised than proved that there is some such change as that denominated grey hepatization, and through which resolution comes about. Nevertheless, remember that children hardly expec- torate at all ; nor are they in many cases troubled much with mucus in the tubes. The breathing has been said to be easy in these cases, in contradistinction to the labor of bronchitis ; therefore, probably in many cases some process of liquefaction and absorption occurs; in fact, that which is occasional in the adult is common in childhood. In the more chronic cases no doubt there is a tendency to the formation of patches of cheesy pneumonia, or to a condi- tion, presently to be described, in which a considerable part of one lobe may become converted into a solid cheesy mass. The morbid appearances of lobular pneumonia differ in distribution, but not much otherwise. A section of a lung thus diseased shows an uneven surface, from the existence of eminences and depressions. According to the stage arrived at, so will the eminences be either simply dark- colored from congestion, and their relations to the smaller bronchi perhaps not very distinct; or else actually solid, with a central dilated bronchial tube containing pus. In the latter case the eminences will either be of a dark livid color, almost translucent near the central bronchus, with no well- defined margin, or yellow or fawn-colored from the degen- erative changes in the inflammatory products. In this way are produced clusters of nodules, the cut section being often finely granular; and these may run more or less together, solidifying the whole lobe, or part of it, and producing a nodular solidification, which gives to the diseased part a somewhat peculiar feeling when grasped between the finger PNEUMONIA. 343 and the thumb. Histologically, the smaller bronchi are often very much thickened by a crowded cell-growth in their submucous tissues, and the air-vesicles around such affected tubes are full of inflammatory products , but accompanying these changes, and in proportion to the diffusion of the centres of inflammation, and to the duration of the disease, is a very similar state of things to that described under the head of lobar pneumonia. The smaller bronchi are often dilated. Hillier describes lobular pneumonia as disseminated or generalized, and when the latter, closely resembling the lobar form. He also alludes to a description by Ziemssen of chronic cases of this variety taking origin in collapsed parts, a change which sometimes involves a whole lobe. The ap- pearances of this disease seem to be identical with what has been here described as the common form of lobar pneumonia in children. Causes. — Little is known of the cause of fibrinous pneu- monia. It generally appears to be spontaneous, but its etiology is involved in as much doubt as is the like disease in adults. Some consider it due to exposure ; others to atmospheric disturbances ; others to septic conditions, etc. All, however, seem to agree that a child attacked once may be so several times. It is more common in the strong than in the weakly, and in the winter and spring than in the sum- mer months. Of that form of lobar pneumonia intermediate between the fibrinous form and the catarrhal or lobular pneumonia — which last I have more particularly described because of its more frequent occurrence — it is almost impossible to say anything for certain, save that it more often follows measles and other acute specific diseases, and is the termination of not a few cases of atelectasis and chronic bronchitis. 344 THE DISEASES OF CHILDREN. Acute lobular pneumonia is usually secondary to measles, pertussis, or some chronic bronchitis. Symptoms. — We must now more sharply distinguish between the fibrinous and the catarrhal forms of the disease. Acute fibrinous pneumonia is, as in adults, a disease of sud- den onset. There may be rigors or convulsions, headache, vomiting, muscular pain, pain in the side, and high fever (103 to 105 ). It is a disease of a few days only, ending in a crisis, but it may last any time, from three or four days to seven, eight, or nine. It is usually associated with pleu- risy, and this to some extent masks the disease, and gives its symptoms a special color. The pain may be very acute for a day or two, and the child's features, particularly if it be very young, may become pinched. The cough is stifled, or with it there comes a cry, or sometimes a shriek. As be- tween bronchitis and pneumonia, Meigs and Pepper, I think, allude to a distinction which is not unserviceable, that the child with pneumonia breathes easily, though very rapidly, whilst the bronchitic gets his breath with labor. Of course, with much pleurisy this is modified, and the child with acute pleuro-pneumonia sits up in bed giving vent by turns to short grunts and a harsh, dry, short cough. The child's face is flushed, its skin hot and dry, the lips, perhaps, cov- ered with herpes. Some cases are ushered in with violent cerebral symptoms, and have been described by Rilliet and Barthez as a distinct variety, " cerebral pneumonia." In fre- quently recurring convulsions, and in headache, vomiting, delirium, and drowsiness, these cases may resemble, and be mistaken for, meningitis. Moreover, they are usually severe, and Hillier and others consider them more likely to occur with pneumonia at the apex than elsewhere, and this has certainly been our experience at the Evelina Hospital. It may be worth w T hile to point out, in reference to this obser- vation, that some have thought that apex pneumonia in adult PNEUMONIA. 345 life is not only severe, but liable to own a septic origin. Pos- sibly, also, the fact that I have already insisted upon, that a pneumonia of the apex is often a pneumonia of the root of the lung, may also have its meaning in this respect. The disproportion between respiration and pulse is usually well marked, the former rising to sixty or seventy per minute. The alae nasi dilate with inspiration until the severity of the disease lessens. The temperature generally falls suddenly from 103 or 104 to normal, or below it, and may rise again slightly at night for a fortnight before it finally rights itself; and here I may mention, with regard to this, that Dr. Newn- ham, our present resident medical officer at the Evelina Hos- pital, tells me that it has been no uncommon thing for him to receive a summons from a nurse to come at once to such a case, because the temperature has fallen, quite suddenly, perhaps from 103 or 104 to below 98 , and the nurse has feared something was going wrong with the child. If, after the crisis, the temperature should again rise, particularly at night, the formation of fluid, and perhaps pus, in the pleura, or some fresh mischief in the lung, may be suspected. These acute forms of inflammation of the lung are not at all un- commonly succeeded by empyema. Associated with the crisis there is usually copious perspiration. Recovery after the crisis is often astonishingly rapid ; the solidification, as judged by the physical signs, will sometimes disappear within a day or two, nor is it necessarily accompanied by much evi- dence of softening in the way of mucous rales. Steiner makes a note that in several cases he has found complete absorption to go on without the occurrence of any moist rales. The tongue is naturally often thickly furred ; vomiting maybe obstinate for the first day or two ; the bowels are confined ; the urine scanty, and its chlorides absent. Physical Signs. — In a typical case there will be more or less rapid onset of tubular breathing, associated with dulness 34-6 THE DISEASES OF CHILDREN. on percussion, the latter often deepening as the case pro- gresses, by reason of its frequent association with pleuritic exudation, either of lymph or fluid. But it is well to remember that bronchial breathing is sometimes slow in appearance, and this, I think, in cases in which one would expect it quickly — viz., those which from general symptoms seem very acute. Hillier notes this delay in the appear- ance of bronchial breathing in cases of apex pneumonia. But it is not only the delay of the appearance of a morbid quality of respiration; the vesicular murmur is sometimes absent altogether, and the lung appears to be almost silent — so much so, indeed, that in some cases it seems possible the tubes may become filled with fibrinous coagula, which might bar the entrance of air into the solidified part. I have lately had a child under my care who illustrates this and other points very well. He is a little Jewish boy of six, and was admitted with excessively acute symptoms and a temperature of 104 . I saw him first on the fourth day of his illness, and the respiration was so nearly absent over the apex and in the axilla of the left side that I suspected fluid. A needle was passed into the chest in the axillary region, but nothing came out, and at my next visit well marked tubular breathing had developed all over the apex of the lung, back and front. The symptoms continued severe, although he gradually improved, till the eighth day, when, between nine and twelve midday, the temperature fell from ioo° to 97 , but it rose again at night to 10 1°, and after that, for two or three days, rose even to 102 at night. A careful examination had revealed a similar absence of respiration again over the front part of the lung; but now, in addition, the heart-sounds were distinctly louder to the right of the sternum than in the proper position, and, although the praecordial dulness did not appear to be altered, the pulsations were decidedly most marked behind the sternum. An exploring needle PNEUMONIA. 347 was again passed into the chest in the axilla, in the same spot as before, and some pus was withdrawn. This was evacuated by incision on the fourteenth day of his attack, the chest was drained for a few days, and he rapidly got well. The percussion is often misleading to students. If there be pneumonia at the apex, it is usually absolutely dull over the disease ; but when there is disease at the base or up the back, quite commonly there is a high-pitched tympanitic note in front on the same side. It is the so-called Skoda's tympanitic resonance. It is best heard in pleuritic effusion, but is by no means absent in cases of consolidation. A good deal of information is also conveyed to the practiced finger by the want of elasticity of the chest-wall, which co- exists, it may be, with pneumonic consolidation or with pleuritic effusion. A cracked-pot sound may also often be elicited under like conditions, only it is not worth while to thump the poor child to obtain it, as it conveys no additional information. I have occasionally heard a peculiarly harsh inspiration in the earliest stage of pneumonia ; but the respiration is often faintly bronchial rather than harsh. The fine dry crepitation is often absent. When the consolidation begins centrally, it may be some days before much is heard at the surface of the lung. Careful examination should then be made daily over the root of the lung. It is but seldom that bronchial breathing, when it exists, cannot be detected there. In the catarrhal form of lobar pneumonia there is often some previous history of ill-health — the child is rachitic, its chest deformed, or it has frequently suffered from colds and coughs, or it has lately had measles, whooping-cough, or some other exhausting ailment. The symptoms are acute enough ; nevertheless, there is hardly perhaps that painful 34^ THE DISEASES OF CHILDREN. severity about them which may be seen in the fibrinous cases. The temperature does not average so high a range, the pain is less, the skin more moist. In place of a flushed cheek there may be lividity, and there will be more bron- chitis. The course of the disease is very variable, but, as a rule, it ends in no definite crisis. The temperature falls gradually, and it has a more prolonged course, — any time, in fact, from one w T eek to six or eight, although here also with careful treatment it will sometimes clear up with great rapidity. It is not uncommon thus to meet with these cases in our ward devoted to whooping-cough, and to find the evidences of consolidation all disappear within a day or two, and the same applies to the disseminated form of broncho-pneumonia. It must also be said that it is in whooping-cough that broncho-pneumonia finds its most lingering cases. Complications. — Acute pleurisy and acute pericarditis are met with ; the former commonly, the latter rarely. Diagnosis. — Anything which produces consolidation of the lung may resemble a pneumonia in some respects. I have noted as specially worth caution, that fluid at the base of the lung, by leading to pressure upon the lung, will fre- quently give rise to bronchial breathing at the apex under the clavicle, and so to a suspicion of the existence of pneu- monia. This is more liable to occur in chronic cases of effusion, and therefore in those where the elevation of tem- perature is unlike that in pneumonia. Perhaps, however, the best method of distinction is to take this axiom, that whenever there is evidence of fluid at the base of the lung we must distrust any indication there may be of consolida- tion at the apex. Fluid collected in the front part of the pleura may simu- late pneumonia. I have seen this twice or three times, and have cleared up the doubt on more than one occasion by the PNEUMONIA. 349 use of the exploring syringe in the second or third inter- costal space. In pleurisy the temperature is not usually very high ; vocal resonance is diminished ; there is often a peculiarly damped tubular breathing of sniffling character, and the vis- cera may be displaced. Acute caseous consolidation may also have to be distin- guished. The disease is less rapid, the temperature less high and more oscillating, and the previous history, family history, and general conditions must all be taken into ac- count. Meningitis may be discerned by its lower and oscillating temperature; by the irregularity of pulse and respiration, and by the absence of any quickening of the latter, of dilata- tion of the alae nasi, or of physical signs. In atelectasis, although the signs of consolidation may be considerable, the fever is little or none ; and there is in addi- tion a lividity with labor of respiration quite uncommon in pneumonia. Acute tuberculosis gives signs, if any, of acute bronchitis, not of pneumonia; although one case has occurred to me in which what during life appeared to be an apical pneumonia, proved at the autopsy to be a case of acute tuberculosis, with much solidification of the lung. Prognosis. — Acute fibrinous pneumonia is rarely fatal. But if we take all cases of lobar pneumonia as they occur, the mortality is by no means inconsiderable — about one in every five, though figures of this kind are not very useful. An opinion can only be reliable when based upon a careful survey of the condition of the child. In acute lobular and disseminated pneumonia the outlook will be bad, according as it occurs in rachitic or young chil- dren (under twelve months), or is associated with much lividity. Convulsions are usually followed by death. 30 ::: TI-II ziszasz-s :? ihiizj.z::. Results. — If we except caseous bronchial glands and tuberculosis, which are not uncommon, there a~ suits of an acute pneumonia. I have once seen a red, indurated condition of the lower lobe as the result of some chronic pneumonic process, after acute pneumonia, probably from in; -_:r.\ The ?.rre::ei !:be sr-rrierirr.rs : e: ; :::: r.::-.zztz i : r. into a small fibrous mass of grey or reddish color, with thick septa throughout it, and the bronchial tubes widely dilated. The pleura is generally thick in these cases, and it is a ques- tion how for the disease may not have originated in pleurisy rather than pneumonia. I have also seen three case which there was considerable fetor of breath, so much so as to make me suspect some gangrene of the lung, although in ?.'.'. rr: ivery :: :k c'?.:e. Treatment. — In acute pneumonia the child should be placed in a warm bed in a well-ventilated room ; it is to be warmly clad in flannel, and the chest enveloped in either hot fomentations of spongio-piline or poultices. If it be considered advisable to apply counter-irritants, this is best done not by putting mustard in poultices, but by app a mustard-leaf to the part for as long be requ It should be fed on milk and beef-tea, and egg and farina- ceous diet may be added. Internally some simple saline, such as nitrate or citrate of potassium, may be given, and if there be much pleuritic pain, a dose of Dover's powder should be given at once. A child of six or eigh: :ay have two and a half or three grains of I In acute cases I sometimes give aconite tincture r a drop every hour for a few hour- is useful in promoting per- spiration, and generally in quieting the ^p- toms. If notwithstanding these measures the temperature remains very high, and the child seems to be getting worse, then cold pa: oe resorted to, or a bath, warm, tepid, or cold. Of late e v.orable results have accrued PNEUMONIA. 35I from tepid and cold baths, but they will not probably be of use in the pneumonia of children, as these cases, if they do not speedily get well, become bronchitic, or pus forms in the pleura, etc., so that they are not fit for such a plan of treatment. If there be much exhaustion, some brandy should be given, half an ounce or an ounce in the course of twenty- four hours. When any suspicion of a bronchial origin at- taches to the disease, then the atmosphere should be ren- dered moist by steam, and some stimulating expectorant should be given to the child, such as a few drops of sp. ammon. aromat, vin. ipecac, syrup of Tolu,etc. The chest should be well covered with moist applications, and a little stimulant given. Chronic Pneumonia. — There is very little to be said of this disease which is not included under other headings — for instance, as the result of chronic pleurisy, of rare cases of pneumonia, or of atelectasis, one or other lobe becomes solidified and ultimately converted into a tough, fibrous, con- tracted relic, with its bronchial tubes thickened and dilated. Pleurisy, and particularly empyema, is the commonest cause of this condition, save and except it occur in the middle lobe of the right lung, which appears to undergo some such changes as these in consequence of atelectasis, which is so common there. Pleuro-pneumonia at the apex is some- times followed by chronic apical disease of a destructive and tubercular nature. Then, again, there is the cheesy solidi- fication of parts of a lobe, which may by some be considered as a retrograde change in a pneumonic lung, or a special form of chronic pneumonia. There is one other condition — viz., the syphilitic pneumonia of infants ; this must, I think, be rare, as I have only seen one or two microscopical specimens, but it has been described by various writers under various names, white hepatization, perhaps, being that which best identifies it. Dr. Greenfield has given a careful descrip- 352 THE DISEASES OF CHILDREN. tion of a case which was probably of this nature, and I shall quote from this.* The child, a female, aet. twelve months, died in the out-patient room of St. Thomas's Hospital. There was no distinct evidence of syphilis, but circumstances in the family history rendered its existence extremely prob- able. The right lung was completely consolidated, in a state of full expansion. There was slight recent pleurisy, without thickening. The section was yellow T ish-white, the cut sur- face smooth and slightly shining, differing markedly from the ordinary grey hepafization of acute pneumonia. The tissue, being firm and tough, exuded but scanty fluid, and minute bands of fibrous tissue ran everywhere through it. The microscopical characters of the disease show it to have been a condition of extreme and active fibrosis, in which the septa and. walls of the air-vesicles were thickened by a fibro- nucleated tissue in some parts to complete obliteration of the pulmonary structure. My friend and colleague, Mr. Symonds, has supplied me with sections from another case, undoubtedly syphilitic, for the liver showed abundant and remarkable syphilitic hepa- titis. The child was three months old. In the recent state, the affected lung was in a remarkably solid fleshy condition. Microscopically, it shows all the features exactly as de- scribed by Dr. Greenfield — the excessive fibro-nucleated growth, the extreme vascularity, dilated thin-walled capilla- ries running in all directions, and an inextricable jumble of fibrous tissue with still remaining air- vesicles, the epithelium of which is in many parts intact, in some undergoing pro- liferation, which makes it difficult to be sure that the cells themselves are not helping forward the process of fibroid growth. I would take leave to add, that the histological appearances of the earlier stages show also how difficult it * " Trans. Path. Soc. Lond.," vol. xxvii., p. 43. PNEUMONIA. 353 is in many cases to distinguish altogether between the changes of atelectasis and those of interstitial pneumonia. Looking carefully over this specimen, it is clear that collapse of the air-vesicles plays a large part in the process; and, comparing it with others of atelectasis, it seems equally clear that in them the hyperplastic process, which may go by the name of interstitial pneumonia, is by no means absent, although in a less pronounced form. 354 THE DISEASES OF CHILDREN. CHAPTER XXIII. ATELECTASIS— PHTHISIS. Atelectasis or Collapse is that disease in which the lung either remains in a foetal condition or returns to a state of non-expansion. More or less it is not uncommon at all periods of life, but it never reaches such an extreme degree, and therefore never puts on quite the same appearances, as in infancy. It affects sometimes a whole lobe ; but more often patches here and there, the favorite spots being those which are liable to be placed at a disadvantage in the inspi- ratory expansion, and these are the anterior margins of the lungs, the edges of the lower lobes, and the middle lobe of the right lung, which last is a particularly frequent seat. Some writers distinguish between congenital and acquired atelectasis, but there seems little reason for this, since the explanation of all forms of collapse is practically the same. Anything which prevents the expansion of a lung, either in whole or part, will lead to collapse of the parts hampered. We see this in adults most strikingly. Supposing that some aneurismal or other tumor presses upon, or some syphilitic scar obstructs, a bronchus, the lung becomes collapsed. Other changes may perhaps go on also which to some ex- tent alter the appearance, but the essential condition is one of collapse. Take a case of chronic bronchitis. The tubes are full of pus, the air can get out and cannot get in again, and a lobular collapse is the result. Take, once more, a case of extreme weakness, from old age or fever, or whatever you will ; the feeble power cannot command a sufficient thoracic expansion, and the base of the lung suffers collapse. ATELECTASIS — PHTHISIS. 355 The air becomes gradually less and less ia the unexpanded lung till complete airlessness is produced. In infancy, al- though, as I say, the appearances of the lung thus collapsed may differ from the collapsed lung in adults, the causes at work are essentially the same but with this addition, that whilst in adults the ribs are hardened, the muscles better educated, and the expansion consequently conducted under more fixed and regular conditions — in infancy the ribs are soft, and the muscles act more unevenly ; in fact, the respi- ratory act is in process of being perfected, so that we have a respiratory type which is sometimes almost undulatory, the different parts of the thorax expanding with comparative irregularity. I have already alluded to this in mentioning the difficulties of auscultation in childhood, but that which, in this way, creates a difficulty becomes also a predisposing cause of collapse. There is no need to dwell long upon the point, it is easily intelligible, and — given such a state of the inspiratory act in children — there is a reason for the frequent occurrence sometimes of lobar, sometimes of lobular, col- lapse, and for collapse being such a frequent associate of all other diseases of the respiratory tract. It is thus that we hear of collapse as the result of chronic nasal catarrh, and of enlargement of the tonsils ; of its association with bron- chitis and broncho-pneumonia; of its occurrence in weakly and rachitic children. Further detail is hardly necessary; the immediate causes of collapse suggest themselves. For instance, a child is born in an excessively feeble state, per- haps prematurely ; it wants the strength to take a vigorous inspiration, and the lungs, in consequence, remain unex- panded. Here is foetal collapse. Later on, perhaps, other debilitating causes are at work, and again a gradual expul- sion of the air takes place, and then collapse of more or less of the lung. At another time, perhaps, it is whooping- cough, with a good deal of bronchitis — or some catarrhal 35^ THE DISEASES OF CHILDREN. pneumonia — which leads to it ; perhaps some severe snuffles or chronic tonsillitis ; often the rickety conditions in which soft bones and a great tendency to bronchitis are combined. The student will be well able to suggest himself the many conditions under which collapse occurs. It must also be remembered that in very young children it sometimes comes on with alarming rapidity— a mild bronchitis may perhaps have lasted^but a few hours, when the child becomes pale, with bluish lips, hurried and shallow respiration, and the chest-wall receding during inspiration. Symptoms. — When it occurs within the first few weeks of life, the child with collapse is of puny build, often wasted, and with a weak whining cry. The chest movements are shallow, and there may be a want of resonance about the bases of the lungs without any decided tubular breathing. In cases, also, of great debility there is the same shallow respiration, but usually of sudden onset a short time before death. In other cases where collapse of the lung is the result of pneumonia or bronchitis, the symptoms are mingled with those due to these diseases. In cases of extensive col- lapse of some duration, the lips may be blue, the fingers clubbed, the sternum protruding forwards, and the ribs deeply depressed and concave outwards in the lateral region of the thorax and below the nipples. Posteriorly the chest is rounded, possibly deformed, and on inspiration the whole of the lower part of the chest makes a marked movement inwards towards the median line, increasing the depression already existing. Percussion in such cases may give some slight loss of resonance in the basal regions, below the scapulae. Possibly, on auscultation, some subcrepitant rales may be heard. In cases of long standing the right side of the heart becomes dilated and thickened, and the cyanosis is not only extreme but persistent. It is remarkable, how- ever, how little the heart suffers in proportion to the amount ATELECTASIS — PHTII ISIS. 357 of disease that is present. This is explained by bearing in mind that cases which seem to be of long standing are often not so. A child's chest is so soft and yielding that it will alter in shape within a few days, and one of the most dis- torted chests I have seen had assumed that condition within a month. Another reason is that defective aeration of blood in childhood carries with it defective blood-formation, defective nutrition, development, and wasting — and many such children are dreadfully thin. The right side of the heart is therefore eased of the distension which would of necessity follow the same amount of pulmonary obstruction in a fuller habit. Atelectasis, by hindering the blood cur- rent, may prevent the closure of the ductus arteriosus and of the foramen ovale. And here it may be mentioned that it is more than probable that atelectasis, by leading on to broncho-pneumonia and cheesy changes in the collapsed parts, is no uncommon source for the dissemination of tu- bercle. I have seen this so often in connection with the middle lobe of the right lung as to have very little doubt upon the point. Morbid Anatomy. — The lung puts on a variety of appear- ances according to the extent of the disease. It may be in scattered patches, or confined to the hinder part of the lung, or to one or other lobe; but the aspect of the atelectatic or collapsed part is in all cases much the same. It is shrunken below the level of the air-containing lung, or, in the case of a whole lobe, there is much diminution in size. It is blue or leaden in color upon the surface, and the pleura looks thickened. It is not really so ; the feeling imparted to the fingers being rather that of a flaccid spleen. There is no crepitus ; the tissue is quite flaccid, but solid ; and scattered throughout are felt a number of more or less shotty bodies, which on section turn out to be thickened bronchial tubes and septa. The section is of a uniform dark claret color, or 358 THE DISEASES OF CHILDREN. may be streaked with leaden lines of fibrous septa. It would be uniform in surface but that the thickened gelatinous- looking bronchial tubes project slightly. The tubes are dilated, and often contain much pus. The diseased parts sink readily in water, and will often expand lobule by lobule when the lung is inflated by bellows. When the disease is one of small disseminated patches, then the fawn or buff tint of the spongy lung is studded with small raised irregular patches of pellucid-looking bluish or leaden-tinted tissue, the central part of each of which is a bronchial tube, with its swollen mucous membrane raised above the surrounding retracted lung. In these cases there is often much bron- chitis (pus in the capillary tubes), and those parts not col- lapsed may be emphysematous and over-distended with air. The histology of these patches of collapse is even of more importance. Take it in its disseminated and earliest form, where the small grayish nodules are scattered through the lung, and we find that around the terminal bronchioles the pulmonary vesicles are simply flattened together, presenting the appearance, at first sight, of thickened septa. There may or may not be some thickening of the walls of the bronchi. But in the large masses of more solid tissue the changes are those not only of simple closure, but also of interstitial inflammation. The pleura is thick ; the fibrous septa between the patches and the adjacent lung — for the diseased parts are often shut off from the healthy lung in a very definite way by these septa — are much thickened ; and not only so, there is clearly considerable activity of cell growth in the lymph- atic elements around the small bronchioles, so that collec- tions — such as have been called miliary abscesses, though the term is a bad one — are to be seen in all parts of the section, and I think there can also be no doubt that the whole area becomes, so to speak, glued together by a process of diffused interstitial cell growth. 1 ATELECTASIS — PHTHISIS. 359 These changes seem to me to be of immense importance with reference to the results which may accrue from atelec- tasis, because they seem to show that when collapse has existed for some time a chronic interstitial pneumonia results, and the foci of cell growth which are scattered about the sections suggest, without any knowledge of the clinical course, that caseous or degenerative changes are not unlikely to follow. That this actually does happen, and that these foci are apt to become the source of the dissem- ination of tubercle, is exceedingly probable from the fact that the middle lobe of the right lung, a part unusually prone to collapse, is very liable to become after whooping- cough — a disease particularly liable to produce collapse — the seat of cheesy broncho-pneumonia and to be associated with a subsequent development of tuberculosis. In old-standing cases the right side of the heart is dilated and thickened ; it may be fatty ; the pulmonary artery is dilated and thickened. The liver is large, firm, and a little speckled with fawn-colored points of fat. The spleen is firm, and the kidneys have a peculiar india-rubber-like con- sistency. • Diagnosis. — The chief difficulty lies not so much with the disease itself, as in being certified of the absence of other conditions. For instance, in very young infants a purulent effusion in one or other chest may easily be overlooked in the evident collapse of the lung which it determines. Prognosis. — Perhaps no cases can look worse and less hopeful than those of extreme atelectasis ; but it is to be remembered that these appearances can be quickly produced, and may all disappear when the cause of the collapse is removed. A chest that has all the appearance of permanent distortion, will resume a nearly natural shape as the lung beneath becomes gradually expanded. Collapse of the lung should, therefore, if possible, be remedied as soon as may 360 THE DISEASES OF CHILDREN. be, for the longer it lasts the more chance is there of chronic changes in the lung succeeding, and proving a great hin- drance to the restoration of the thoracic contour. The grad- ual recovery of the natural shape of the chest is one of the surest means of judging; and, on the contrary, if the sides of the chest remain flattened, and the sternum becomes more pointed or bulging, so is the indication that the bases of the lungs are not opening out, and that the anterior parts are becoming emphysematous. Treatment. — All predisposing causes of collapse must be vigilantly sought for and treated. Chief of these are im- proper food, bad hygiene, and congenital syphilis. These determine rickets, and the soft bones of rickets invite the occurrence of collapse. Any indications of debility, in what- ever form they may show themselves, must be treated in the requisite way. The immediate cause of collapse is obstruc- tion to the ingress of air, and bronchitis and broncho-pneu- monia being — in young children, and most of all in those that are rachitic — the commonest cause of obstructed respi- ration, require early recognition and careful treatment. As a rule, the expectoration of mucus from the bronchial tubes is best facilitated by alkaline remedies — such, e. g. y as the bicarbonate of potassium — and by stimulating expectorants, such as carbonate of ammonium and squills. If there be much accumulation of mucus, an emetic of mustard and water, or five grains of powdered ipecacuanha, may be administered. The child must be kept in bed, and in a warm equally-heated room, the atmosphere of which is moistened by the steam from a bronchitis-kettle. Unless there be fever, there will be no necessity for poultices. The chest may be lightly wrapped in a thin wool jacket, a warm bath given from time to time, and stimulating liniments ap- plied to the surface. It is unadvisable to wrap the child up too much, as this provokes much perspiration and reduces ATELECTASIS — PHTHISIS. 36 I the strength. At the same time, in fatal atelectasis the body temperature is apt to fall very low, and in such cases the infant should be thoroughly encased in wool. As soon as possible, quinine, iron, and cod-liver oil, or cream, should be admin- istered, and plenty of bathing and friction to the muscles of the body, either with simple oil inunction or cod-liver oil, the only objection to the latter being its nastiness. Elec- tricity has been recommended to improve the tone of the muscles and thereby to accelerate the recovery of the col- lapse, but it is a remedy which is not easy of application in young children, the sensation frightening them too much, and I believe it is better to trust to good rubbing and kneading night and morning. Phthisis. — I do not intend to discuss the vexed question of the nature of phthisis. I shall proceed upon the state- ment, which is certainly abundantly proved, that in the great majority of cases of destruction of the lung by caseous changes, tubercle and cheesy softening in various stages are found in the same lung, and, to simplify matters, I shall speak of them all as tubercular. In this respect, phthisis in children does not differ from the disease as met with in adults, save that in the former case the rule is even more absolute, but the pattern or distribution of the disease in the lung is less uniform. If we exclude doubtful cases of early apical disease in children, it has certainly not been common in my experience to meet with changes which have excavated the lung from above downwards as is seen so constantly in adults. Any one with large experience amongst children will no doubt meet with such cases not so very infrequently, but other cases are more common, in which there is no cavi- tation, or the lung is attacked less regularly. These appear- ances will be described directly under their morbid anatomy, but I will say here that such differences as exist largely de- pend upon the physiological standard of growth which ob- 362 THE DISEASES OF CHILDREN. tains in infancy and childhood. For example, in malignant tumors in childhood — whether they be of testis, or kidney, or liver, or what not — we do not expect to find a slowly growing disease, such as is ofttimes found in adults. The processes are active, and the growth, wherever it be, rapid. And so it is with tubercle. It runs its course more rapidly; and thus we have often more to do with miliary tubercu- losis, with solidification by gray tubercle, with gray tubercle softenening into yellow in a miliary manner, and but seldom with any large cavities. In the same way, the fibrous forms of disease are less frequent, and other, forms develop by rea- son of the proneness in infancy to degenerative changes in the lymphatic glands. The tubercular appearance is generally made much of in phthisis in children ; and we are all familiar, no doubt, with the description of the pretty child, with its well-formed skeleton, its soft hair, long eyelashes, peach-like skin, good nails and teeth, and intelligent mien — and with its antitype of coarseness, the pale, sallow, stunted, thick-skinned child, who goes the same way, albeit, perhaps, by a modified route of scrofulous glands. These types have sprung out of expe- rience, and should be well remembered. But the student's difficulty will be that he is unable to push these definitions sufficiently to be of use to him, and as soon as he seeks to be enlightened, not upon the tubercular appearance but upon the distinctions between it and others — particularly that which is called by some the rheumatic conformation — so that he may be able to say this is one thing, this certainly another, he finds his teacher fail him. Types of this kind will not bear too close a scrutiny; it would puzzle any one to distinguish many a rheumatic child from a tubercular one. The shape of the chest in tubercular subjects has been alluded to by most writers, and Hillier, who is too good an observer to be ignored, describes three typical forms : (1) the ATELECTASIS PHTHISIS. 363 long, circular chest; (2) the long chest, with narrow antero- posterior diameter ; (3) the long, pigeon-breasted chest. I cannot say that I am sure of these ; it has seemed to me that a rachitic chest is too frequently the cause of collapse, and of subsequent cheesy and tubercular changes, to make the distinctions of great value. Tubercular chests are small chests with the apices contracted. The symptoms of pulmonary tuberculosis in children are often most obscure. In the early stages they are those which the one shares in common with other diseases, and notably that condition to which Dr. Eustace Smith. has given the name of mucous disease. The child is pale, thin, capricious in appetite, and has a dry cough; the bowels are irregular, he perhaps may even have worms. All these are conditions which are often neglected as temporary derangements. The temperature is not taken at night, and perhaps a case thought to be mucous disease develops acute tuberculosis and the child dies rapidly, whilst one as to which suspicions of phthisis are entertained gets well. This uncertainty is in great measure due to the ambiguity which attaches to the physical signs. It takes several very careful and complete examinations to be sure of an early tuberculosis, and even then it is sometimes impossible to avoid mistakes. . The beginner will find, if he looks back upon his notes in after years, that a large majority of his early cases raised the question of phthisis, which subsequent experience solved by the restored health of the children. In looking over my own notes, I find that no less than 152 out of a total of 233 must be considered doubtful. There was dulness at one or other apex, some clicking crepitation, deficient movement, or bronchial breathing, but which has never come to any- thing, and in most of which what seemed certain at one examination was very uncertain subsequently. One passes through phases of experience : at first, all cases are phthis- Advanced Doubt- Phthisis. ful. 2 1/ IO 14 7 IO 4 14 9 18 8 IO 2 21 5 13 3 15 2 8 O 13 364 THE DISEASES OF CHILDREN. ical ; a riper experience shows advanced phthisis to be com- paratively rare. Of the 233 cases mentioned, 64 were pro- nounced cases; 17 others were cases of acute tuberculosis. The ages of such as are detailed are as follows : Acute Tuberculosis. Under i, ....... 4 1 to 2, 3 2 " 3, 2 3 " 4, o 4 " 5. ■ 5 " 6, o 6 " 7, 1 7 " 8, 1 8 " 9. o 9 " 10, o Over, o No age is exempt from acute tuberculosis. In infants only a few weeks old one or other apex will sometimes become suddenly dull, and the child die off with the lungs studded with tubercle within a short time. Nevertheless, it becomes common as the period of dentition is reached, and then it is that a disseminated form of tubercle, associated with cheesy bronchial glands, is so common. Morbid Anatomy. — All forms of tubercle, or rather tuber- cular inflammation, are met with in the lungs of children, and they are all more or less found together ; but for practical purposes, I think we may distinguish four groups of cases, viz.: (1) those in which the disease is chiefly, often entirely, a miliary tuberculosis ; (2) those in which there is a con- glomerate form of gray and softening tubercule— perhaps yellow and gray infiltration — and cheesy bronchial glands ; (3) a more chronic form, with cavitation and fibrious changes ; and, (4) cheesy solidification. It is difficult to obtain figures to tell the relative frequency of these groups. ATELECTASIS — PHTHISIS. 365 The conglomerate form has been the commonest in my ex- perience, miliary tuberculosis next so, and the others far behind. Some authors describe still further a fibroid form of phthisis. I have once met with a peculiar fibroid form of phthisis without tubercle, in a boy of thirteen, who came under the care of Dr. Pye-Smith, and the case is recorded by him in the " Transactions of the Pathological Society of London," vol. xxxiii. The appearances in the lung aiKl liver, which was cirrhosed, were to my mind very sugges- tive of old syphilis. But Dr. Barlow has met with more than one very similar case, and without any history of syphilis ; and no doubt cases of this kind occasionally hap- pen, the cause of which is obscure. There is, however, a more common condition, which I have already described, where the base of the lung is solid and the bronchial tubes dilated; but this is certainly most commonly due to some bygone pneumonia or pleuritic effusion. There is no need to go minutely into the morbid appear- ance of the lungs in the several classes of cases, as the minute changes do not differ from tubercle, as seen in adults, but one or two peculiarites may be mentioned. In the first place, the individual granules of miliary tubercle vary much in size, and are sometimes so minute as to escape detection upon superficial examination. This is particularly the case where death has come about rather rapidly by tubercular meningitis, and it may serve to impress attention upon the fact that the lungs may be perfectly free from any pneu- monic changes, and consequently that miliary tubercle of this kind is beyond detection by physical examination dur- ing life. Its presence can then, indeed, only be suspected by the existence of bronchitis in association with other con- ditions which make for the existence of tubercle. Next, it should be noticed that the distribution of tuber- cular disease is more irregular in the lungs of children. It 31 366 THE DISEASES OF. CHILDREN. is more common to find it distributed throughout the lung than at the apex and from thence downwards, and it is also very common to be able to trace a rough localization of the disease about the root of the lung, whilst there is certainly less evidence of the extension by continuity of tissue which is so common in adults, though perhaps more of clustering around, and extension along the bronchial tubes and septa. Again, the existence of cheesy bronchial glands of consid- erable size and fleshiness is far more common in children than in adults, and last, but not least, there is an allied dis- ease which I have met with several times in children — never, so far as I remember, in adults — and to which I have given the name of cheesy consolidation of the lung. The most remarkable example of this affection that I have seen was in a child of two years under Dr. Moxon's care at Guy's Hospital. The whole of the left side of the chest was dull, and there had been a question of the existence or not of pleuritic effusion. At the post-mortem examination, nearly the whole of this lung was converted into a solid, firm, cheesy mass, quite like an enlarged and cheesy bron- chial gland which has undergone no softening. Towards the front of the lung there was a little spongy tissue remain- ing, and studded rather thickly with yellow tubercles, whilst the other lung was crowded with tubercles. A similar form of disease, but less extensive, in which a part of one lobe has been diseased, I have seen several times, and it is due, I believe, to a gradual growth into the lung from the cheesy bronchial glands at its root. It need hardly be insisted how these points in the mor- bid anatomy are corroborated by, and in their turn enlighten and emphasize the physical signs of pulmonary tuberculosis. They show why it is that the physical signs are so often obscure, for, if the disease begins by preference at the root of the lung, it will long be covered by vesicular structure, ATELECTASIS — PHTHISIS. 367 and the more distinctive features will want that constancy which will alone allow of precision in diagnosis. They will show, too, how carefully the chest must be examined, inch by inch, so that the small patches of disseminated softening so often present may not escape detection ; how with the enlargement of the bronchial glands in the posterior medi- astinum and the extension of disease from them, the inter- vertebral grooves must be carefully examined by percussion and auscultation, and the resulting sounds most carefully weighed with our experience of those of health. I have already alluded to a child in whose case for three weeks great uncertainty existed as to whether his disease were typhoid fever or tuberculosis, but which turned out to be the latter. The physical signs of disease at the root were not of the most distinct, but they were there, and, looking back upon the case, it seems probable that with a suspi- ciously wandering dry pleuritic rub, and slight intolerance of light they were not insufficient to have determined the diagnosis had their value been rather more judicially ex- amined. These cases frequently require all one's powers of mind, a rigorous examination, and the most impartial analysis of symptoms, to enable one to arrive at a right conclusion. The other viscera should always be examined in question- able phthisis ; it may be that an enlargement of the liver or spleen may be detected, possibly some early tubercular dis- ease of the choroid. Such cases as follow are quite com- mon. A female child aet. seventeen months : The lungs were studded with recent tubercular pneumonia, but in addition there was much caseous enlargement of the bron- chial glands, numerous tubercles in the liver and spleen, general cheesy change in the mesenteric glands, and tuber- cular ulceration of the intestines. A boy aged one year : The lungs were stuffed with gray 36S THE DISEASES OF CHILDREN. tubercle in a state of early caseation, the bronchial glands were much enlarged, and there were tubercles in the 1 spleen, and kidneys. Complications. — Death occurs in most cases amongst nger children through the outbreak of a general or acute tuberculosis, and the extension of the disease to the brain and its membranes. Thus we may find tuberc meningitis, yellow tubercle in the cerebellum or otlier parts ; as well as tubercle of the organs already mentioned, of the peritoneum, and elsewhere. In older children, wi- the disease becomes very chronic, the same results are met with as in adults, viz., lardaceous disease of the viscera, fatty liver, tabes, and intestinal or laryngeal ulceration. Diagnosis. — In any case of apical disease caution is necessarv in coming to a conclusion. Over and overa^ain the physical signs which denote cons n pass away. Acute pneumonia running a rather more chronic course than we think it should do, arouses our fears only to dispel them. Pleuritic effusion gives rise to rather persistent tu- bular breathing at the apex. This, again, clears up, if we only give it time, and it is my distinct belief that there is many a local disease at the apex, both parenchymatous and pleuritic, which arouses exaggerated fears only by its posi- tion. Localized pleuritic effusions, both serous and puru- lent, may take place below the clavicle as well as at the base, and if there be any doubt upon the point, this part as well as the base should be explored by the hypodermic syringe. It is, indeed, hardly possible to insist too strongly upon the necessity of always being on the watch for the presence of fluid, and particularly of pus. Empyema is so common in children, and so frequently puts on many of the appearar of phthisis that mistakes are quite common. The case should be examined repeatedly if there be any doubt, temperature taken regularly, and the body weight at suffi- ATELECTASIS — PHTHISIS. 369 cient intervals. After whooping-cough, too, the physical signs are most puzzling. There are plenty of coarse mucous rales and patches of tubular breathing down the front of the lungs and round the nipples, and the excessive wasting makes one apprehensive. Nevertheless, we must not be too hurried in coming to a positive conclusion. Prognosis. — Pulmonary phthisis is in most cases capable of improvement, says Gerhardt ; and there can be no doubt, as I have said, that many cases, too hastily condemned as cases of consumption, improve and even get quite well. The frequency with which scars, relics of various kinds, cal- careous and other, are met with in the lungs of older people, proves conclusively that many of the changes which consti- tute phthisis are reparable if not too extensive. But perhaps the most irrefragable evidence of the possibility of repair of tubercle has been offered since the peritoneum has been dealt with by the greater boldness and success of latter-day surgery. Cases are on record where tubercular granulations have been seen upon the peritoneum during operations, and the patient has subsequently recovered. There is other evidence, hardly less strong. Some time ago I made an inspection upon the body of a lady under Dr. Habershon's care, who died of tubercular meningitis. Many years before, w r hen a girl, she had been supposed to suffer from tubercular peritonitis, and w r e found, in accordance with that view, that the intestines were all matted together by old adhesions, and the greater part of the mesenteric glands converted into chalky concretions. The finding calcareous glands in the abdomen is no uncommon experience to those engaged in making frequent necropsies. Therefore it may be accepted as certain that tubercular disease is sometimes amenable to treatment. At the same time, it is to be remembered that these cases may ameliorate for a time, and then suddenly develop acute meningitis or general tuberculosis ; and that 370 THE DISEASES OF CHILDREN. if they do not show any tendency to improvement, the course of the disease in children is habitually shorter than it is in adults. Treatment. — The essentials of treatment are good feeding and good air. The first presents difficulties in all classes of life ; the latter chiefly for those to whom money is an object of concern. The appetite is generally capricious, vomiting is often troublesome, and these patients cannot take fats. They do well upon a rich diet, if it can be borne, and they should be encouraged to take plenty of good milk, cream, suet, and milk and eggs. Plain beef and mutton, nicely cooked, are most nourishing, but in many cases fish, oysters, soups, etc., are requisite to vary the diet and tempt the ap- petite. Small quantities of stimulant are of unquestionable value. It may be given as stout, or bitter ale or wine, with food. In sucklings, if there be any delicacy about the mother, the child should either be fed artificially or supplied with a wet nurse. The air of large towns is unquestionably harmful, and children with any suspicion of phthisis should, if possible, be removed to a dry seaside place, and have as much out-of-door air as possible. Every possible attention must be paid to the general health, and the rooms in which the child lives and sleeps must be well ventilated. Damp is reputed to be injurious, whether associated with warmth or cold. Cold and damp combined are certainly prejudicial, and there is also a tendency in these cases to w r eather a winter and then suddenly to deteriorate as the showery warm weather at the end of spring comes in. Cold weather, if dry, is often most serviceable for early cases. The soil should be dry and the place protected from the colder north and north- east winds. The clothes must be warm. Of drugs, cod- liver oil, by common consent, is of great service, and what with tasteless oil, almondized oil, biscuits in which the taste of the oil is almost completely concealed, and capsules, a ATELECTASIS — PHTHISIS. 37 I great many children, with whom there was difficulty, can now take it comfortably. It may be given in water, orange wine, milk, or coffee, indeed, in any way that may suggest itself, and the dose is to be increased from half a teaspoonful up to two or more. [The following is a very good formula: R. 01. Morrhuce fgiv. Ext. Malt (dry), gj. Calcii Hypophos., Sodii Hypophos., . . . . . , aa gr. xxxii. Potassii Hypophos., gr. xvj. Glycerine, ....... fgss. Pulv. Acaciae, . . . . . . gss. Aquae, q. s. ad f gviii. M. S. — Two teaspoonfuls three times daily, for a child of six years.] Such children are often very anaemic, and arsenic is there- fore useful. It may be given in five or six minim dos with some simple syrup, or with benzoate of sodium, syrup, and water (F. 42). Many other remedies have been recom- mended which it would be impossible to mention. The most useful are, I think, the chloride of calcium — which should be given in doses of five to ten grains in some ex- tract of liquorice, glycerine and water, three times a day for a long period — and iodoform, which I have latterly been trying on germicide principles. It must be given cautiously, in half-grain or one-grain doses up to two grains or more, with white sugar, in a powder. Some children take it very well, others badly; some it makes sick, delirious, and ill. Counter-irritation may be produced by a mustard-leaf, or some linimentum iodi, but in all cases it is to be remem- bered that a child's skin is very tender and easily vesicates. For the cough, some simple expectorant may be given, * Fowler's solution. — Ed. 372 THE DISEASES OF CHILDREN. and when there is much night perspiration belladonna is by far the most reliable remedy. Twenty drops may be given to a child of four or five at bedtime, or a smaller dose may be added to each dose of any compatible medicine that it may be taking during the day. I have once seen fatal haemoptysis in a child of three or four years from an aneurism on a branch of the pulmonary artery in the wall of a cavity. But haemoptysis is not com- mon. Should it occur, small doses of turpentine — e.g., five or six drops of the oil — may be given with some mucilage of tragacanth, syrup, and dill-water. PLEURISY. 373 CHAPTER XXIV. PLEURISY. Pleurisy is a very common disease, and is a particularly important one, if for no other reason than this — that the fluid effused is so frequently purulent. I have notes of 149 cases, gathered from all sources of my own practice. Of these, 71 were simple, 78 were purulent. This can, per- haps, hardly be considered a fair average, for a hospital physician is naturally likely to see the worst side of all diseases. The subjoined facts may be of interest: Age. Simple. Purulent Under 1, 6. . .4 Between 1 and 2, 15 13 2 " 3, II 9 3 " 4, 7 13 4 " 5, • 6 10 " 5 " 6, 6 12 " 6 " 7, 6 4 " 7 " 8, 2 5 " 8 " 9, • 1 2 " 9 u 10, . 3 3 " 10 " 12. 4 3 Not stated, 4 71 SEX. 78 Simple pleurisy occurred 31 times in females. " " " 40 " in males. Empyema " " 35 " in females. " " " 43 " in males. Fibrinous pleurisy affected the right side 28, the left side 43 times ; empyema, the right 18, the left 59 times ; one case was doubtful. 32 374 THE DISEASES OF CHILDREN. The large preponderance of left-sided empyema over right- sided, four to one, is worth remembering. Pleurisy is usually stated to be most commonly a second- ary disease, and, if we consider how many causes lurk in diseases of the surrounding structures, we shall not wonder that it is at any rate, not unfrequently dependent upon dis- ease of those parts. Tubercular disease of the lung ; acute and chronic pneumonia ; bronchitis ; dilated bronchial tubes ; disease of the bronchial glands ; pericarditis ; inflammatory conditions below the diaphragm, such as localized abscesses between the liver and diaphragm, or the spleen and dia- phragm; general peritonitis; disease of the spine and ribs — these are some of the many affections which may set up pleurisy. Less obvious in their actions, but frequent as causes, must be reckoned scarlatina and rheumatism — the latter of acute fibrinous pleurisy, the former of empyema. The importance of both these affections as causes of pleurisy is, I believe, not fully estimated ; but when all is said with reference to the causes of pleurisy, there will remain a large number, in my experience the greater number, in which it has not been possible to assign any cause, and I should therefore be disposed to think that idiopathic pleurisy is not so very uncommon. Pleurisy may lead to the formation either of lymph, or serum, or pus. It is impossible to make any useful distinc- tion between those cases in which the exudation is fibrinous and those in which it is serous, or, to put it in other words, between those in which there is effusion and those in which there is none, the reason being, that in children the forma- tion of lymph is so active that the presence of fluid is often suspected where the exploring syringe shows the opinion to have been unfounded. In the treatment of empyema, a knowledge of the existence of this excess of lymph is of the greatest importance. PLEURISY. 375 Symptoms. — As a rule they are not very acute, even in simple (non-purulent) pleurisy, although there is a definite onset. Pain in the side is common, but it often needs to be inquired for. Fever, wasting", want of appetite, languor, and cough are the more usual symptoms complained of. Head- ache, vomiting, convulsions, and diarrhoea are also occa- sional symptoms. The time at which the child has been brought for treatment has been very variable, from two or three days to as many months. This will serve to show that the acuteness of onset is liable to vary considerably ; and I would further say that occasionally the onset is so acute as almost to deserve the name of violent — the fever being high, delirium considerable, and the pain in the side apparently an agony. These cases are quite likely to be mistaken for an acute pneumonia, of which, indeed, it would be impossible to deny the existence in some measure, and they are, in my experience, very likely to be quickly fol- lowed by the rapid and copious effusion of pus. The tem- perature in pleurisy is of no characteristic type — it is often up to ioi°, 102°, or 103 in the first day or two (in the very acute cases higher), in the afternoon or evening, and the pyrexia may be prolonged. I have several times enter- tained unfounded fears for the formation of pus from this prolongation of the pyrexia. It is difficult to get any large number of cases in which the disease has been uncom- plicated and watched from the commencement as regards this point. In eleven cases the temperature has averaged not much over ioo° after the first onset, although occasion- ally in several of these making erratic excursions. In infants, pleurisy is apt to produce a pinched and col- lapsed condition, like peritonitis in the adult. When the fluid is purulent, excepting in the very acute cases already alluded to, the onset is still more indefinite than when the products are serous. In this respect, again, 3/6 THE DISEASES OF CHILDREN. the pleura may be compared with the peritoneum, in which the fibrinous or plastic inflammations are very generally acute, painful, and not to be mistaken ; the purulent inflam- mations are apt to be overlooked, by reason not so much of their lack of symptoms as of the vagueness of those symp- - toms which occur. Nevertheless, commencing, as the dis- ease often does, in acute pneumonia and other evils, a sudden onset is noticed in many cases. Of fifteen cases, in eight the child was suddenly taken ill ; in seven, the onset was indefinite after mumps, or scarlatina, or pertussis. Of gen- eral symptoms likely to be present in empyema, emaciation is often rapid and extreme. I once saw a child, a few months old, wasted to the last degree, with a moderate quantity of fluid in the left chest. The wasting seemed to be too extreme for pleurisy alone, and nothing was done to remove the fluid. The child died the next day, and the post-mortem examination revealed nothing but an empyema. There may also be much pallor, and sometimes a puffy ap- pearance of the face, such as suggests Bright's disease. This latter symptom I believe to be sometimes a most valuable one as indicating the existence of fluid in the chest, and, in the absence of renal disease or pertussis, pleuritic effusion should be thought of. Moreover, it is a symptom which indicates a large effusion, and I have seen cases where, except for this sign, the auscultatory and other phenomena were in favor of pneumonia. This symptom is not con- fined to empyema ; it may accompany any large pleuritic effusion. Here, again, the temperature is not to be trusted implicitly. As a rule, it rises by night ; and I have noticed that the suppurative fever is apt to register with particular delicacy the reaccumulation of pus when it has been removed by operation. It is by no means uncommon to find oneself in considerable doubt as to the presence of pus in empyemas PLEURISY. 377 which have not been tampered with ; but after the pus has been evacuated, should it again reaccumulate, the thermo-' meter will indicate the fact with the most sensitive accu- racy. When there is much emaciation, and the disease is chronic, there may be no elevation at all. Sometimes, while on the whole normal, sudden jumps will be made at night; but, in this, empyema accords with serous effusions, which are liable to behave in the same manner. It may be said, again, that we must be cautious how, in pleuritic effusions, we conclude as to the purulent nature of the complaint from the evening rises of temperature, for these sometimes occur night after night for a considerable period in cases where no pus can be withdrawn. Diarrhoea is, also, a valuable sign of the existence of pus in the pleura, and the same remark applies to sweating. There is one other negative sign to which it is well worth while to draw attention, viz., the absence of any indications of distress in breathing. Such a thing might otherwise be thought impossible with one or other side of the chest full of fluid. Yet not only may this be so, but even the heart may be considerably displaced without symptoms. This is noticed in the more chronic cases, and is not difficult to explain. A like phenomenon is present in many cases of phthisis, and it is dependent in great part upon the com- pensation which takes place as the disease progresses, the emaciated body requiring diminished action of the lung. Physical Signs. — There are several difficulties in the detection of fluid in a child's chest, which are far less perplexing in adults, and pleurisy in children requires therefore the greater care. It is frequently overlooked or misnamed. The presence of fluid in a child's chest is very often only established by the concurrence and correct ap- preciation and interpretation of several slight indications. It is therefore necessary to pay attention to slight deviations 3/8 THE DISEASES OF CHILDREN. from the normal. A careful inspection tells us that one side is moving less well than the other; the lessened range of movement may be considerable — if so, so much the better for the diagnosis ; the affected side is rather more flat, or appears generally contracted. In very chronic cases the spine may be bent towards the diseased side. This contraction of the chest may sometimes be verified by the cyrtometer, but exact measurements of the size and out- line of the chest are difficult to make and very liable to lead to a wrong conclusion. Bulging of the ribs and inter- costal spaces is said to be an indication of the existence of pus. It is more common to find the measurement of the affected side natural, smaller, or distorted, than over-dis- tended. If the chest be full of fluid, there may be complete dul- ness all over the affected side, the heart will be more or less displaced (one of the most valuable of all signs of fluid in the chest), and the case will present no difficulties. But such cases are not common. Fewer mistakes will be made if, on the contrary, we look to find modified resonance, not dulness, at the apex of the affected side. But comparing the one apex with the other, the resonance will not be the natural deep resonance, but a high-pitched tympanitic note. Whenever this quality of sound is present, the first thought should be — Is there fluid at the base of the chest ? Pleurisy at the base is the most common cause of dimin- ished or tympanitic resonance at the apex, in children. Oc- casionally this is due to pneumonia or to some consolidation at the apex itself. But should there be any dulness at the base, stronger evidence than usual is necessary to convince us that there is really any disease at the apex. The tympanitic note at the apex is a physical sign which has attracted much attention, and the mode of its produc- tion has been often discussed ; it is spoken of sometimes as PLEURISY. 379 the bruit Skodique, or Skoda's tympanitic resonance. This is usually attributed to condensation of the apex of the lung, but it is obvious that condensation — partial, not total — may be produced in various ways, and the meaning of tympanitic resonance by itself would have to be decided upon the bal- ance of probabilities. Percussion should be gentle. The chest-walls are yield- ing, and it is easy in childhood to displace fluid and get upon spongy lung beneath, so as to elicit resonance where there should be dulness. Then again we must be careful, in dealing with the chest of a child, how we apply the teaching which has been gleaned from adults. The auscultatory phenomena of fluid in the chest are — absence of the respiratory murmur; absence of the vocal resonance ; absence of tactile vibration ; and, if the compressed lung be near the surface, high-pitched distant tubular breathing will be heard. If all these signs are pre- sent, the case presents no difficulty; but such, again, are exceptional cases in childhood. What is usually heard may be illustrated by a reference to the two most common mis- takes which are made by students. I am generally told that there is bronchial breathing upon the healthy side, or else at the apex of the diseased side. It is quite common in these cases to hear all over the affected side a soft vesicular mur- mur of good quality, but deficient in quantity. If there were only the one side to judge from, the difficulty would be extreme to say whether disease were there or not, but, 0:1 auscultating the unaffected side, the exaggeration of the inspiratory murmur excites attention — there is apparent the so-called puerile breathing; but since "puerile" is applied to adult lungs as compared with child's lungs, when com- paring the normal child-respiration with the abnormal the latter must be called " exaggerated puerile/' The inspira- tory murmur is very hoarse and harsh, and the expiratory 38O THE DISEASES OF CHILDREN. is also rather longer than it should be ; but if we gauge the length of inspiration and expiration, the latter is not out of proper proportion as to length. Again, on the diseased side, I am perhaps told, that there is bronchial breathing at the apex, and the case is called phthisis. Here the observation is correct ; the inference from it is wrong. There is often bronchial or tubular breath- ing beneath the clavicle on the same side as the effusion, and this is only what might be expected. The lung is more or less compressed by fluid, and therefore prevented from expanding; hence the more or less bronchial, nay, even sometimes loudly tubular, respiration, just as there is the tympanitic resonance. Again, we have to judge not by the single sign, but by several combined. The tympanitic reso- nance at the apex first puts us on guard ; then, by careful percussion, comparative dulness at the same base is detected, and on auscultation bronchial respiration and a soft, distant, vesicular murmur, with a diminution of the voice-sounds. The latter is often interpreted by the student as broncho- phony, on the other side. I take no note of tactile vibra- tion, as it is often difficult to make out anything positive about this in children, the voice giving but feeble vibrations on either side. We may often get no more pronounced physical signs than these, and with them we must be con- tent. Good though deficient vesicular murmur may be present all over the side which is full of fluid, and unless this is remembered there is likely to be a mistake in diag- nosis. But if we have an opportunity of examining a patient day by day, another phenomenon will probably puzzle us, and that is the variability of the signs ; an examination one day reveals dulness and bronchial breathing ; another day there is much less dulness, and what may be considered as good vesicular murmur : one day the chest looks bulging, another PLEURISY. 38I retracted ; and these variations are apt to quickly follow each other. This is a feature of chest disease in children. The explanation is perhaps not easy to give. It may be due to the difference of inspiratory power at various times. With regard to the bronchial breathing, the presence or absence of crackling or bubbling mucous rales in the chest, particularly at the apex, should be noticed. In the bronchial breathing of condensed lung from fluid in the chest there is often for long an absence of crepitation ; and such persistent absence of crepitation is one point, in children, in favor of the non-existence of phthisis, which is often mistaken for pleuritic effusion. If death takes place from serous effusion, some tubercular or pneumonic affection is usually at the bottom of it. Some hold that a serous effusion is the origin of most of the empy- emas, and base upon that belief an argument in favor of early paracentesis in the former. I think the balance of proba- bility is against this view, and in favor of empyema com- mencing as such, except in occasional instances. Morbid Anatomy. — Death from empyema takes place at different periods, and the condition of the pleural cavity will vary somewhat accordingly. The chest may be full of pus, or there maybe, besides the pus, much thick caseous lymph, or the pleura may be loculated by bands of lymph. I have even seen serum in one cavity and pus in another. The lung may be bound down and quite airless throughout, or one part or another may be compressed by fluid. Histological examination shows sometimes simple com- pression of the lung; sometimes more or less inflammatory cell-growth, running along the septa of the lung from the pleura inwards ; sometimes nests of cells scattered through the bronchial septa, which suggest the possibility of the disease having originated in some pneumonic process. Complications. — When death takes place during the early :Sr THE DISEASES OF CHILD?!; . days of the disease, either after operation or not, pericar : or inflammation of the connective tissue of the mediastinum and of the other pleura, or suppurative peritonitis, are the more likely causes. In the later stages, death results from exhaustion, lardaceous disease of the viscera, and tubercu- losis. It must further be added, that it is the belief of many that pleuritic effusion, particularly if purulent, is the origin of many of the. cases of chronic pneumonia, fibroid pht and dilated bronchial tubes, that are met with in later life, and probably this is true for some cases. Diagnosis. — There are no useful distinctions, as regards s cal signs, between pus and serum. The purulent nature of the collection may be surmised from the cause — if measles or scarlatina, etc., are known to have preceded it, the presence of pus is not improbable. Attention should also be paid to the general symptoms, of which pallor, pyrexia, sweating, and diarrhoea are perhaps the more important. But I have several cases of simple serous effusion, in which the temper- ature has risen regularly every evening ; some cases of pus, in which the temperature has been nearly normal, and pallor and sweating are by no means to be relied upon. The question can only be absolutely settled by an exploration with a hypodermic syringe, a trifling operation which does no harm, and generally suffices to clear up our doubts. The chest must be carefully examined beforehand, and the needle passed in wherever it appears that there is fluid, whether this be at the base, as is most common, or in the axilla, or even at the apex. I have obtained fluid three times from beneath the clavicle when nothing came from other parts. There need be no fear of wounding the lung, it would do no harm; or, at any rate, thr a mere nothing pared with the importance of settling the question of the existence of pus. PLEURI- 383 A caution may perhaps be added with reference to the conclusion drawn from exploration — viz., that it does not always follow that no fluid is in the chest because none comes out by the aspirator. There are several conditions which now and again militate against the flow of the fluid. The lymph within the chest may be abundant and thick, whilst the needle is liable to become choked, or to push the lymph before it, and thus may never enter the cavity. A good deal can, however, be learned, even w T hen no fluid comes, by the passage of the instrument, and its behavior on gentle manipulation subsequently, whether it is in a cavity or not. The risk of failure is somewhat lessened by using as an exploring syringe one with a needle tube longer and of somewhat larger bore than those made for hypo- dermic purposes. The next most important diagnostic difficulty is to distin- guish between phthisis and pleuritic effusion. The two are often mistaken, the pleurisy being called consumption ; but in treating of symptoms, enough has already been said to enable a distinction to be drawn. Of other conditions, the chief are chronic consolidation at the base from pneumonia and collapse of the lung. These may perhaps be distin- guished by the increase of voice sounds in place of diminu- ton; but, as I have said, the vocal sounds, whether auscul- tatory or tactile, are of less value in children than in adults, and cannot be certainly relied upon. If not, it may be ne- cessary to explore by the syringe in these cases also before coming to any positive conclusion. It was in a case of this kind that the only mishap, and that but a slight one, that has ever occurred to me in the use of the exploring syringe came about. Directly the needle was passed into the chest the child coughed up, perhaps, two drachms of bright red blood. It came so quickly, indeed immediately, upon the introduc- tion of the needle, that I feared some large branch of artery 384 THE DISEASES OF CHILDREN. must have been punctured, but no further ill-results accrued, and no more blood came. Prognosis. — Fibrinous or serous pleurisy is but seldom fatal, unless some serious disease, such as pneumonia or tubercle, is behind it. Some think that it is liable to pass into an empyema if the serous effusion is copious, and not removed early; but while allowing this to be possible, I know noth- ing to support the view. As a rule, simple pleurisies clear up with great rapidity. The fluid in these cases is not often excessive. When there is excess of fluid it is more often than not already purulent. The prognosis in empyema is, however, more grave. Naturally, a chest full of pus must be a serious evil. If let alone, it tends to spoil the lung by chronic pressure and inflammation, or by burrowing into the lung. If it should make its way externally, the chances are better, but best of all are its early recognition and evacuation. Of late years this treatment has been very successful ; and in illustration thereof, I may say that in the last six-and-twenty consecu- tive cases under Dr. Frederick Taylor and myself, at the Evelina Hospital, there has only been one death, in a case of my own, where the child had suppurative pericarditis and peritonitis as well as empyema.* Treatment. — Fibrinous and serous pleurisy are best treated by opium in moderate doses to relieve the pain and the coucrh, and salines, such as the nitrate and citrate of potassium, or some effervescing saline, to act as a diuretic and diaphoretic. In the acute stages, warm fomentations are in most request; but cold compresses are also useful, changed every few minutes. In older children, the side should be firmly strapped, and warmth or cold can be ap- * Dr. Xewnham, who, as resident medical officer, has had the charge of all of them, tells me that twenty-three healed up entirely and are quite well ; in one a small sinus still remained ; one freely discharged for five weeks. PLEURISY, 3S5 plied by means of compresses or the ice-pack outside the strapping. After the first few days, iodide of potassium, in one or two- grain doses, should be given with some syrup of the iodide of iron, the bowels being kept gently open by some mild ape- rient. It sometimes happens that although the general symp- toms clear up rapidly, the dulness remains behind ; but this is only to be expected when we consider the large amount of lymph which is sometimes found. It is best, under these circumstances, to apply counter-irritation externally by means of the liniment of iodine;* but more is probably to be gained by exercise and plenty of fresh air, by which it may be hoped to promote free expansion of the lungs. When the disease is acute and the effusion excessive, paracentesis may be advisable ; if so, it is probably better to draw off a moderate quantity than to aim at removing the whole. But I am no advocate for paracentesis merely because of the presence of fluid. There is evidence in abundance that serous effusions clear up rapidly by natural processes ; there is evidence in abundance, also, that the simple presence of fluid is not likely in childhood to harm the lung if the amount is not large and its duration be kept within a mod- erate limit of three or four weeks, and provided that the fluid shows signs of gradual diminution. When the effusion takes place rapidly, when it is in great excess, with displacement of heart, fever, pallor, and puffiness of the face, such are the symptoms which indicate the necessity for aspiration. We have next to deal with the treatment of empyema, and we shall be the better prepared to consider the question * Linimentum Iodi, Br. P., con: Iodine, . . . . . . 1 ^ ounce Iodide of Potassium, . . . . . ) 2 ounce Camphor, ....... ! 4 ounce Rectified Spirit, 10 fluid ounces. — Ed. 386 THE DISEASES OF CHILDREN. in an\- individual case if we remember that the pleura, cavity is one which has difficulties and dangers all its own. The ility of the lung, the rigid nature of the thoracic wall, the nooks and crannies in which pus can form, all would seem to combine to make efficient treatment impossible. Yet it is remarkable — if only the one difficulty of inefficient drainage can be combated, and the cavity kept free from sepsis — how successful the treatment becomes. I have seen a pleural cavity six weeks after the evacuation of an em- pyema so perfectly obliterated by silky adhesions of connec- tive tissue, that, without the knowledge, one could not have believed that any disease could have existed of recent ye There are other less brilliant results, no doubt, and not infrequent, too. such as the persistence of a fistula and dis- gje, until the lung is spoiled, and the child dies ex- : aceous viscera ; but these are far less com- mon now than formerly, and will probably be even yet farther diminished in number as the frequency of empyema is recognized and its presence detected early. But now for the actual treatment. Having assured our- selves by exploration of the presence of pus, how is it to be treated? It maybe left alone, or it may be removed in one of several ways. I. The chest may be aspirated. 2. It may be tapped by trocar and canula, drawing off as much fluid as may be neces- sary, or as much as is possible. 3. After tapping, an india- rubber tube may be passed through the canula into the chest, and the canula being withdrawn, the tube remains as a siphon. 4. The old plan, and a very good one, may be adopted of making two openings in the chest, one above and one below, and passing a drainage-tube in at one and out at the other. 5. And. lastly, a free incision may be made. Each of these methods of removal has its advocates, and all are useful on occasion. But all my latest experience has PLEURISY. $«7 gone to convince inc that, as a rule, a free incision in the seventh or eighth intercostal space — the position of the open- ing being mostly determined by the position of the pus — is an operation which is not attended by any serious risk, and, combined with free drainage afterwards, by means of as large an india-rubber tube as can be inserted, is very suc- cessful. I am inclined to insist less strongly than formerly on the position of the opening; it may be made wherever the ex- ploring needle indicates that the pus is easily reached, either in the front, side, or back of the chest. But it may not be always advisable in very young, deli- cate, or exhausted children, to open the chest thus. The incision is not altogether a trifle, and it may seem better every now and then either to aspirate or tap. In localized empyemas and those of rapid onset it may sometimes be advisable or necessary from surrounding cir- cumstances to aspirate the chest. Dr. Bowditch has had great success with simple aspiration. Dr. Thomas Barlow has also recorded good results, and I myself have had five cases in which nothing more than aspiration was required. This plan will find its most frequent application in very young children, and where the pus is in very small quantity. If the pus is in large quantity, it is of little use to try aspiration except as a preliminary to some more radical mea- sure ; and it is a fatal mistake to aspirate in such cases time after time, as is sometimes done. To do this is to take the surest means of converting the sac into a chronic abscess, and to invite a permanent fistula and collapse of the lung. The siphon plan is of use in such cases as where the materials necessary for incision on the antiseptic method are not ready to hand, or where, for other reasons, aspira- tion or incision are not judged to be the best operations for the case. It is also of use when, owing to extreme disten- 388 THE DISEASES OF CHILDREN. sion of the cavity and displacement of the viscera, the rapid evacuation of the pus by incision seems to threaten some risk. The two openings and a connecting drainage-tube offer some advantages when there is a difficulty in thor- oughly draining the chest. And in such cases where the empyema points spontaneously, it may perhaps be left alone or opened at the spot towards which the pus is tend- ing. In private practice it will often happen, from various circumstances, that the treatment has to be modified to suit those circumstances — in other words, we are not always able to act up to the most modern light as regards a sur- gical operation, and I have sometimes been compelled to advise tapping with a large trocar, and leaving a simple tube in the opening thus made. This is not a plan that is to be recommended ; but, under strict antiseptic precautions, it may be completely successful. The siphon plan alluded to above requires a soft india-rubber tube of some length. One end of this is passed into the chest, and the other lies in a vessel containing some antiseptic fluid, such as weak carbolic lotion. It is convenient to divide it in the centre, and connect the divided ends by a piece of glass tubing ; in this way the perfect action of the siphon is readily gauged. This plan has no doubt some not unimportant advantages over some others : the operation is easy of performance ; it is not a very painful one ; it is convenient if the chest re- quires washing out; and, if all goes well, the chest is kept sweet. But empyema in children is very liable to be accom- panied by large flakes of lymph in the cavity, and the tube becomes blocked and has to be removed, so that incision is to be preferred as giving a freer exit to such material. Next, one or two points with reference to the operation of incision. If the chest is very full indeed, the operation may be followed by severe suffocative dyspnoea. Taking away a quantity of fluid somewhat suddenly must of neces- PLEURISY. 389 sity disturb the intra-thoracic circulation, which has in many cases become accommodated to the abnormal state, and a risk is run thereby of the occurrence of a sudden oedema of the sound lung, which has not so very rarely proved rapidly fatal. Therefore, in cases of extreme effu- sion, it may be advisable to make a preliminary aspiration before draining the chest thoroughly ; or, if incision be decided upon, the pus should be allowed to drain away slowly for the first few hours. Its rate of exit can easily be regulated, for the ribs are so close together, in any case, that the difficulty lies in obtaining a sufficiently free outlet by whatever means may be adopted. During the operation great care should be exercised to insure that the opening between the ribs is as free as pos- sible : and both then and for the first day or two during the dressings every facility should be afforded for the escape of the masses of fibrinous coagulum so commonly present. This is best done by opening the aperture by forceps, while the drainage-tube is withdrawn, and extracting anything that may be within reach. Except in this way, the chest cavity is to be meddled with as little as possible ; and all washing out, though, unfortunately, it must be resorted to occasionally if the cavity becomes foul, is to be depre- cated. Washing out the pleura is as difficult of efficient accom- plishment as washing out the bladder. In either case sepsis must be prevented. When once the cavity has become foul there is small chance of restorative action by any such means. Moreover, it is not without risk ; it may lead to sudden death. A number of cases have of late years been placed on record in which a sudden comatose state culminating in death has come to patients while having their pleura irri- gated. The cause of such a calamity is in much obscurity — by some it is considered to be embolic, by others to be 33 390 THE DISEASES OF CHILDREN. due to some reflex nerve-storm due to interference with the pneumogastric ; but the facts are quite certain, and they must be the mainsprings of our action or inaction. Next, the drainage-tube is to be dispensed with as soon as possi- ble. Inefficient drainage is, no doubt, the cause of many a bad result, but it is equally true that many a case becomes intractable from the too prolonged use of drainage-tubes. After the pus has been removed, the auscultatory signs show conclusively in most cases that the compressed lung soon begins to do a considerable amount of work. Vesicular breathing may often be heard to within a very short distance of the aperture in the chest-wall ; add to this some ascent of the diaphragm and some falling-in of the chest-wall, which is generally quite a noticeable feature of such cases, and it is obvious that the cavity soon becomes much reduced in size. A probe or a considerable length of drainage-tube can no doubt be inserted, but this proves nothing as to the existence of a large cavity. The instruments make a pas- sage for themselves in the as yet unconsolidated lymph. In operating a free incision is made between the ribs, large enough linearly to allow of the passage of the finger into the cavity, should the space between the ribs permit it. This is free enough to allow of the introduction of a large drainage-tube and something over, and thus, to all intents, a double opening into the chest is secured. After removing some of the pus and any masses of lymph that may be within reach, some four or five inches of a freely perforated, stout, but soft, red india-rubber drainage-tube which has been well soaked in carbolic acid is then passed into the chest, and secured in position, and the usual antiseptic protectives, as advised by Professor Lister, are placed over all. The dressings should be removed twice in the first twenty-four hours, and once daily for the first few days afterwards, and the drainage-tube in the chest is to be daily shortened, so PLEURISY. 39I that at the end of five or six days only an inch or an inch and a half remains. This is length enough for keeping the external aperture patent, and the internal parts are no longer interfered with. If the discharge remains very slight, the tube can be removed altogether, the temperature being watched closely : so that, if after its removal any evening rise occurs, it may be at once re-inserted. It not unfre- quently happens that with early removal such as this it becomes necessary to re-insert the tube for a time, but this is a less evil than its prolonged use — indeed, no additional evil at all, if the temperature be taken as a guide. This will give sufficiently early notice to prevent any accumulation. Next, a word as to Listerism — it should always be adopted in the first two or three weeks. Practically it is continued at the Evelina Hospital till the child leaves, and that may not be for some weeks ; but I believe that its continued application is sometimes harmful in keeping small cavities open. Therefore, when there is but a small cavity remain- ing, it is better to send the child to the purest possible air, and apply nothing but a little marine wool, which should be frequently changed. It is not advisable to keep such cases too long in bed ; a week or ten days after the empyema has been opened they may sit up, and even sit out in the open air if possible. Last, and most important of all — unfortunately for hos- pital patients a treatment that cannot often be utilized — comes Margate air. Any seaside air is beneficial, but, weather and season permitting, I do not believe there is any corner of England so quickly restorative to children with empyema as that in which Margate and Broadstairs are situated ; and, personally, I set more store by a change of this kind after the first three or four weeks have passed than in any con- tinuation of antiseptic dressings. This is, I believe, in short, the best that can be done for 39 2 THE DISEASES OF CHILDREN. such cases. But we must bear in mind that the conditions are such as to present obstacles in many cases to successful treatment, and empyema must therefore always be liable to prove disappointing. If we have to deal with an abscess in most other parts the pus can be entirely evacuated, and the walls of the cavity can be adapted to each other and kept in position. In the chest it is not so ; we are dependent upon contraction of the chest-wall, ascent of the diaphragm, granu- lation from the pleura, and expansion of the lung; and it is hardly to be expected that repair conducted under such adverse circumstances should present no difficulties ; we should the rather expect that the cavity is more likely to be diminished in some directions, obliterated in some, and so cut up irregularly as to render complete drainage a mat- ter of great difficulty; and so it too frequently is. But, nevertheless, it can be said that, recognized early and treated secundum artem, the treatment of empyema, from being one of the most disheartening, has become one of the most suc- cessful and gratifying of surgical operations. Of late, finding that the results of the treatment of em- pyema have not quite come up to their expectations, some have advocated the excision of a portion of one or more ribs, with the object of facilitating the falling in of the chest and of obtaining more free drainage. Applied to the ma- jority of cases the practice is unnecessary, and therefore bad. The treatment of empyema by incision, as I have just said, is as successful as it can reasonably be expected to be, if the cases are taken in good time; and in cases which have been long overlooked, or which have been long discharging, what- ever we may do is, in the majority of instances, unavailing. The large aperture that is made by the removal of the rib quickly closes up, and we are no better off than before. ACUTE TUBERCULOSIS. 393 CHAPTER XXV. ACUTE TUBERCULOSIS. Acute Tuberculosis has of necessity been several times touched upon in connection with the different viscera which the disease more particulary affects; nevertheless, it is such a distinct disease, and has so definite a clinical position, that a few words may be devoted to its more general bearings. It is a disease confined to no age, but is particularly one of childhood. Pathology. — But little is known of its nature at present, although of late years several very interesting observations have been made, which, if they ultimately take rank as as- sured facts, are of the greatest importance. First of these maybe mentioned the discovery of the bacillus tubercu- losis. This small body is supposed to be the virus which, introduced from without, forms a nidus in some of the lym- phatic structures, provokes caseation, and thence, by fertiliz- ing, becomes disseminated in all parts of the body. Certain experiments, too, have of late been carried out, which go to show that tubercle is propagated by inoculation only when the bacillus forms part of the virus which is introduced, in contradiction to previous less rigid experiments, which pointed to the probability of any suppurative focus being sufficient for the purpose. Next, there is a disease well known amongst cattle, which, having much of the anatom- ical distribution and histological structure of tubercle, is capable of transmission from the diseased animal to the healthy by means of the milk from diseased cows. Other ig6 THE DISEASES OF CHILDREN. culosis, for jaundice is not common at this age. It, and the enlargement of the liver and spleen, with evidences of ema- ciation and disturbed respiration, suggested tubercular dis- ease of the liver and general tuberculosis. Even now the opinion was not altogether an unwavering one, for the jaun- dice disappeared and the child improved and left his bed for a day or two. Then he had a relapse, and his temperature ran up to 104°, and he died seven weeks after admission. The most that his chest had revealed was a good deal of dry crackling, chiefly below the nipples and in the scapular region, and occasional moist sounds in other parts. Dulness also came and went in an irregular fashion. At the autopsy, however, the lungs were stuffed with tubercle, and the bron- chial glands were caseous and softening. In the liver were many small nodules of bile-stained tubercle, such as have been ascribed to tuberculosis of the ducts. The spleen also contained many tubercles. Diagnosis. — As I have already said, this is often difficult or impossible ; but inasmuch as it is a general disease, affect- ing all the viscera and serous membranes, some help may sometimes be gained by detecting a slight pleuritic rub here or there, or any evidence of consolidation about the roots of the lungs. Hyperesthesia of the skin and muscular twitchings not uncommonly indicate tubercular formation in the spinal membranes, and any intolerance of light should be carefully considered. Any tubercle in the choroid or changes in the fundus oculi would make things certain. It may be added, that a hard enlargement of the spleen may give occasional help, but we must remember that the en- larged spleen of typhoid fever is sometimes, in childhood, an unusually resistant one, and the disease is most likely to be overlooked or to be mistaken for typhoid fever. Prognosis. — It runs a somewhat variable course, from three to six weeks ; but, so far as is known, is always fatal. ACUTE TUBERCULOSIS. 397 Treatment. — Of late years, one has indulged the hope that some drug might be found to arrest the growth of the nodules of tubercle; but iodide of potassium, quinine, per- chloride of mercury, salicylic acid, iodoform, turpentine, etc., have all been tried, and, as regards general tuberculosis at any rate, have been found wanting, and one cannot say that there is any recognized treatment. 34 39§ THE DISEASES OF CHILDREN. CHAPTER XXVI. SCROFULA— LEUKEMIA— BRONCHIAL PHTHISIS. Diseases of the Lymphatic Glands. — Under this heading come diseases of the mediastinal and abdominal glands and other less-known conditions. The more common affections are : Caseous disease of the mediastinal glands, or bron- chial phthisis; Tabes mesenterica, or abdominal phthisis; Caseous disease of the more superficial glands, or scrofula. To diseases of this kind also belong the various fleshy or lympho-sarcomatous growths, general or local, infiltrating or not infiltrating, as the case may be. Of this latter group, the complex of symptoms called Hodgkin's disease, or lymphatic leukaemia, forms a part. And the leucocythaemic condition may be conveniently considered in the same con- nection. I shall probably treat the subject most intelligibly if I first, in a general way, describe the different varieties of cases which come under notice before taking the local con- ditions seriatim. Starting thus from the simplest form of lymphatic hyper- plasia, and proceeding to the more complex, we may notice, first, the case of the child of six or eight years old, good- looking, or perhaps with the thick skin and irregular fea- tures supposed to denote scrofula, with chronic enlargement of the tonsils. The tonsils repeatedly inflame, and as often as they are examined, they show cheesy secretions filling their follicles and exuding from them upon pressure. By- and-by the glands in the neck at the angle of the jaw begin to enlarge ; in one case, to suppurate quickly and subside SCROFULA LEUKEMIA BRONCHIAL PHTHISIS. 399 again ; in another, to undergo a more slow process of en- largement, followed by caseation and slow ulceration which produces that scarring of the neck so often seen ; in another, to gradually develop into a huge localized tumor, with some caseation in parts, but in which the most noticeable feature is slow and continuous growth. In another class of cases, the local glandular enlargement slowly extends to other glands in the neighborhood, then perhaps stops awhile, and then again extends, and so on, with fitful course. The glands on the opposite side become infected, still all caseat- ing as they enlarge, and the enlargement not being of any great .extent. Slowly the disease extends over the body, the child presenting an oscillating pyrexia, and gradually emaciating, till death comes by tuberculosis, or some disease of like character breaks out elsewhere — a spinal caries, a multiple epiphysitis, with caseous abscesses in the bones, and the chronic exhaustion of suppuration, lardaceous dis- ease, or nephritis. These are the cases called scrofulous. The picture of a child is now before me, with her fair hair, red eyelids, ulcerated and bloodshot eye, her thick lips, spongy gums, offensive breath, and hard and dry skin. Unhealthy sores form on her skin, and the neighboring lymphatic glands enlarge, and although the sores slowly heal, the glands continue to in- crease ; others become affected, and, witli a hectic fever, she slowly emaciates, without the least amelioration by good living or drugs. What the end of such a case may be it is hard to tell ; it may be acute tuberculosis, a more chronic phthisis, bone disease, or scrofulous kidney. Examples in any number of all these varieties, and others intermediate lie thick along the practice of every medical man. Happily, too, few are unfamiliar with exceptions where the scrofulous condition, even in its worst phases, •sometimes strangely THE DISEASES OF CHILDREN. stops — perhaps for good, perhaps, alas ! to light up again suddenly in later years. There is yet another group of cases ; that in which growth replaces inflammation. The commencement of such is much the same. A local tumor of fleshy consistence slowly arises in the glands — most often in the neck, may be in one axilla, more rarely in the groin. At first we think we have tc with the ordinary hyperplastic and caseating gland, and not unlikely some carious tooth may seem to start it ; but it goes on increasing, until at last a huge growth is formed, which buries the structures of the neck and chokes the patient. I have seen several cases of this kind. I give a note of one, because it was carefully watched for some time by Dr. Dukes, of Rugby. It was that of a girl of ten She had always lived at Rugby, and about six months before I saw her she had had dropsy following scarlatina. The glands in the neck became swollen three or four moi ter, commenc- ing on the left side. A lump in the right axilla was no: about the same time. The swelling of the glands in the neck gradually increased until it formed a nodulated elastic ling, which uniformly distended both sides of the neck. The pulse was very rapid, and there was a short systolic : bruit, but no other disease was evident. The lungs, the mediastinum, the liver, spleen, and blood were all normal. Dr. Dukes tried all manner oi drugs, but without success, and the child died eighteen months to two years wards of characteristic Hodgkin's disease, with general enlargement of all the lymphatic glands, though with but slight enlargement of the spleen. The submaxillar}' en- largement was so great as to obstruct the breathing. She much wasted and extremely anaemic. In another case - kind, a seven, a mass ids had been removed from the neck twelve months before ; but glandular masses still existed on both sides of SCROFULA — LKUK.EMIA BRONCHIAL PHTHISIS. J.OI the neck and in the left axilla. There was also some evi- dence of pressure on the right bronchus. The liver reached nearly to the umbilicus, and the spleen was large and firm. There was no excess of leucocytes in the blood. Here then are local tumors which correspond with the local inflammation ; two divergent results of local stimula- tion. But further than this, in the enlargement of the glands in one axilla, we see how liable the local disease is to be- come more generalized, and in the most advanced cases we see the glands rapidly enlarge all over the body ; the spleen, liver, and kidneys undergo characteristic changes, the fundus occuli exhibits a form of hemorrhagic retinitis, the body wastes, the child becomes anaemic, there is hectic fever, simulating that from the formation of pus, and death results from epistaxis, bleeding from the gums, purpura, albuminuria, exhaustion, or some leukaemic form of pneumonia. But even this does not complete the chain of conditions. In these, the more common cases, the hyperplasia of the glands, although generalized, is still confined to the glands; but occasionally this is not so, and the generalized gland dis- ease oversteps its boundaries, and spreads into other tissues. Dr. Frederick Taylor has published a case of this nature in a boy aged twelve, who had leucocythaemia, hypertrophy of the spleen and lymphatic glands, and fleshy lymphadeno- matous growths of the pleura, mediastinum, liver, kidneys, and epididymis. This child had a high temperature and purpura, and died with dropsy, scant}* urine, labored breath- ing, and ulcerated gums. This case may, indeed, be regarded as typical in another way — viz., that the boy not only suffered from enlarged spleen, but he also had leucocythaemia. Some pathologists are inclined to regard the lymphatic leukaemia in which there is no increase of white blood-cells in the blood as absolutely distinct from the splenic form of disease, in which 402 THE DISEASES OF CHILDREN. that is the most characteristic phenomenon ; but there is no doubt that cases such as this are occasionally met with in which the two forms of disease are combined. Now all these grades of lymphatic disease, inflammatory and hyperplastic, we may dissociate if we will, and consider singly. For instance, we may take the slow caseation of the glands, local or general, and calling it scrofula, disown its relations with syphilis, with rickets, with any other form of malnutrition ; but my point is this, that studying the diseases of lymphatic tissues, not only does this particular disease exist, but that such a one is necessary to make the scheme of these diseases complete, and in accord with the changes that go on in other tissues. Pathology, therefore, seems to me to teach that scrofula is, so to speak, a normal process of decay in lymphatic glands : one that is to be ex- pected as an occasional thing under any circumstances of life, and, therefore, that will certainly be aggravated by all causes of malnutrition — syphilitic, rachitic, or whatever they may be. In the same way with the fleshy hypertrophies or growths. We may, if it be convenient, take any one of the more common examples I have given, and give it a name — Hodgkin's disease, for example, where the lymphatic glands are large, fleshy, caseating, but not softening; where the spleen is like hardbake, from the yellow nodules it contains, and the liver and kidneys are diseased by an infiltrating lymphomatous growth. But the student will only be puzzled if he attempts to keep to any arbitrary lines. There is a process of growth in the lymphatic tissues just as there is one for the skin in the way of papilloma and epithelioma; it is only a question of more or less ; and all the conditions I have described form one series, the individual elements of which are apt to combine. I hope in thus attempting to make a disease which is puzzling to the student somewhat clearer from a pathological SCROFULA LEUKEMIA — BRONCHIAL PHTHISIS. 4O3 standpoint, I shall not be considered to have made confu- sion worse, more particularly as, except in regard to special symptoms and treatment, it seems unnecessary to say much here of some grades of this series. Such as do not admit of being thus dismissed now follow : Scrofula. — From what has been already said, it will have been learnt that cheesy enlargement of glands, unhealthy ulcerations of the skin and mucous membrane, and cheesy inflammation of bones and joints, are the characteristics of this disease. Some hold that it is due to a constitutional condition ; others that it is the result of local disease ; but, however this may be, the clinical course of too many cases undoubt- edly seems to show that the disease does spread from one part to another, and the risks attaching to it are based upon that clinical fact. The* treatment of such cases will vary according as we hold the constitutional or the local element to be the more important; but, given a case of cheesy en- largement of the glands of the neck, for example, one can- not but think, in prospecting the future of the child, that its risks lie in the local disease becoming generalized in some way by a process of infection ; or, to take the other view, by the constitutional something, of which we here see the local expression, breaking out in some more general manner. I put these two views thus pointedly for the purpose of discussing the treatment. Those who hold that the disease is a constitutional one treat it by general means — such as seaside air, well-ventilated living rooms, plenty of exercise ; and, internally, good food, cod-liver oil, iodide of iron, and tonics of all kinds. It is usually advised that any local irritation should be looked to, particularly enlarged tonsils and decayed teeth, and various remedies have been sug- gested for acting upon the diseased glands. Chief of these are sulphide of calcium, phosphorus, chloride of calcium, 404 THE DISEASES OF CHILDREN. and bicarbonate of sodium. The glands may be stimulated locally by iodine, and the child maybe made to inhale iodine by keeping some crystals in a perforated pill-box in the rooms which it inhabits. When one looks back over a long series of years, one cannot but admit that this plan of treat- ment has been in many cases successful — how often it fails there is but little opportunity of knowing — but in the im- mediate present it is far otherwise, and such cases may go on week after week without improvement until they are ulti- mately lost sight of. One is not therefore surprised that, with the doctrines of local infection, which have been advo- cated of late years with much persistency, attempts have been made to cut the knot of medical powerlessness by an appeal to surgical aid, and chronic and intractable enlarge- ments of glands are now frequently removed by the knife. There is one practical hindrance to 'the more general adop- tion of this method — viz., that these gland swellings are so common and have so long been treated by less caustic methods that their nature is never regarded in its more serious aspects, and radical suggestions of this sort are often received with surprise and repudiation. Other means less severe are practiced by many surgeons, and I may mention the local galvanic caustic suggested by my colleague, Mr. Golding Bird, as being at once ingenious and useful to hasten the softening down and discharge of these caseous masses. These, however, are the two methods. The time is hardly yet come for a decision upon the value of the new method ; but, so far, it seems to me to be less satisfactory than the other. For, while the ordeal to be gone through in the way of operation is no slight one, the glandular masses have in several instances reformed within a short time of the operation. For the present, therefore, it seems wiser to keep on the old paths, and in the worst cases — certainly in the more localized swellings — where possible to insist upon SCROFULA — LEUK.EMIA — BRONCHIAL PHTHISIS. 405 residence at such places as Margate, Woodhall, Droitwich, Kreuznach, Soden, or others, as the first necessity, and then to practice all those other measures of general hygiene to which I have alluded. For the fleshy gland tumors, a resort to extirpation is more necessary, and should be proposed in young people when the growth is steady and threatening to become un- manageable. It is too late to do anything when the disease has extended to both sides of the neck. The glands must be removed when of moderate size, if treated in this way at all. Of the treatment of the more generalized growths and of leucocythaemia, I need hardly speak ; for, although many things have been tried, nothing has proved efficacious. In leucocythaemia, with enlargement of the spleen, it is worth remark that it has originated after malarial poisoning in a fair proportion of adult cases. Chronic enlargement of the spleen is not uncommon in childhood in several diseases, one of which is ague. It will be well, therefore, to keep a watch on all such cases. Pos- sibly, by so doing, leucocythaemia may in some instances be averted or arrested. Bronchial Phthisis. — By this is meant cheesy enlarge- ment, softening, or calcareous change in the glands of the mediastinum, whether anterior or posterior, but chiefly the latter, and the associated changes, if any, with which it may be accompanied in the lung. It has received from some authors a distinct name for two reasons — first, because some consider it may give rise to a special group of symptoms ; and, secondly, because the pattern of the disease in the lung is often characteristic. The existence of large and caseous glands in the medias- tinum is very common. Rilliet and Barthez say it occurs in 79 per cent, of all cases of phthisis in children. Indeed, 4 creased and me general, the pulse again quickening, and becoming running, the temperature perhaps falling, but the coma continuing. But the difficulties of the student lie in the stages being confused ; in many of the symptoms being absent Nor is the teacher much better off; for added experience only makes it increasingly clear to him how treacherous is this disease, and how impossible in some cases it is t : mistakes Nevertheless, a careful watch of a suspected child will do much towards replacing doubt by certainty. The child that is hatching tubercular meningitis not only wastes and loses appetite, and becomes pale, but he often TUBERCULAR MENINGITIS. 469 changes in disposition, and becomes cross or fretful, with frequent complaint of his head or of being tired. lie will show a dislike to all noise; perhaps he will walk with care, as if his neck were stiff, or totteringly. There may be some slight tremulousness of his arms, an irregular twitching, such as one sees from other causes, sometimes in uraemia. As the disease progresses, there is a causeless vomiting, uncon- nected with feeding, and irregular in its onset. The later symptoms are more headache, perhaps drowsiness or stupor, a high temperature, though usually an oscillating one, and, in the paralytic stage, there may be either general convul- sions, tonic spasm of one arm or the other — or of both legs, or the whole of one side — or clonic convulsion. The pulse may be slow after the first onset, but usually rises again as death approaches. When convulsions come on the fatal termination is not usually long delayed. The case may drag on for three weeks or so in an indefinite way, and the marked cerebral symptoms, either convulsions or coma, be not more than two or three days in duration ; and there are cases in hos- pital practice where the prodromal stage has been altogether overlooked. The child is perhaps brought for convulsions, which have ushered in the final stage, and death occurs within a short time of admission. Local paralyses are not uncommon particularly of the sixth and facial nerves. Pa- resis of arm or leg, or of both, is common, but complete paralysis is rare. In young children, before the fontanelle has closed, there may be bulging, the surface veins may be distended, and there may be evident head pain denoted by the restless knocking of the head with the hands, or, when asleep or in its cot, by the frequent harsh encephalic shriek which is so painful to the hearer. The optic discs should in all cases be carefully examined 40 470 THE DISEASES OF CHILDREN. for changes at the fundus. But in the majority of cases . these are not marked, and would pass unrecognized by any but the most skilled observers. There is even a difference of opinion amongst those most competent to form an opinion — some averring that changes may be seen in many cases, others that they are exceptional. The morbid changes are of two kinds : i. Evidences of swelling and inflammation ; 2. The presence of choroidal tubercle. The latter is unques- tionably rare. As I have already said, there is every proba- bility of tubercle existing in the choroid, either as minute grains, to which Dr. T. Barlow has applied the term tuber- cular dust, after Rilliet and Barthez, or in larger tubercles, but which pass unrecognized during life. But to be able to be sure of the presence of tubercle in the choroid by an ophthalmoscopic examination is certainly the rare excep- tion. It is more common by far to be able to detect some increase in size or tortuosity of the veins, some alteration of the vessels from day to day, some swelling of the disc, some slight cloudiness of the edge, or lymph-like grains about its edge, which tend to obscure the vessels from view. Of the frequency of these appearances there must of necessity be different opinions; of their value if present, some latitude must also be allowed to individual observers. The opinion will necessarily depend upon how much range is allowed for the variations in the appearances of the normal disc. In my own cases, however, I may say that pronounced changes of any kind have been quite exceptional. For a statement on the other side, it may be said, that Dr. Garlick, in some observations made in the Ormond Street Hospital, found them in 80 per cent, of the cases.* The Temperature chart of tubercular meningitis is likely to show considerable excursions. Qf twelve cases, it was over * "Med.-Chir. Trans.," vol. lxii., p. 441. TUBERCULAR MENINGITIS. 47 I 105 ° in three, and in a fourth ran up to that height at death. In two others it went to 104 . In three it was not over 100.5 . The oscillations are often considerable ; even as much as three or four degrees. The highest point reached daily is irregular; sometimes it is in the morning, sometimes it is high both night and morning, sometimes one day at night and another in the morning. Of the many symptoms, some are more reliable than others. Of these are, irregularity of pulse and respiration, vomiting, for which no cause can be assigned, intolerance of light, headache if accompanied by retracted abdomen, stiff- ness of the neck, and hyperaesthesia of the surface. Strabis- mus and convulsions are, of course, equally reliable in their place ; but they usually come at a time when doubt is giving place to certainty. Diagnosis. — Typhoid fever is the great difficulty; in it even strabismus has been known to occur, as if to make the symptoms of the two diseases exactly similar. If, after pay- ing all attention to the previous history and surroundings of the patient, there is still doubt, one must withhold one's judgment. Retraction of the abdomen, hyperaesthesia, and irregularity of the pulse, are here especially valuable indica- tions. Vomiting fails, as it may be present and severe in typhoid ; still, in meningitis, it is usually erratic rather than of the urgency of a typhoid condition. Constipation is of little value, it is so often present in typhoid fever; but it and retraction of the abdomen are not common together. The splenic enlargement sometimes gives a hint. The tache cere- brale is found under such a variety of conditions as to be of little use. From simple meningitis, in the absence of any local source for that affection, it cannot be distinguished with any cer- tainty. I had thought that the temperature ran higher in simple than in tubercular meningitis ; but it does not appear 472 THE DISEASES OF CHILDREN. that this is so on an appeal to facts. Simple meningitis is, however, likely to be more sudden in its onset, acute in its symptoms, and rapid in course. Steiner notes that it may sometimes require the greatest skill to distinguish between meningitis and chronic hydrocephalus. I have seen the mistake made. A case of hydrocephalus terminated in meningitis of a few days' duration ; but although the cere- bral symptoms were not unlike those of meningitis, yet the temperature was persistently low throughout the illness and until just before death. It may sometimes prove difficult to decide at the moment between tubercular meningitis and acute gastric disturb- ances. Attention must be given to the previous state of health — tubercular troubles maturing slowly, gastritis sud- denly. Moreover, the latter is wont to occur at the time of dentition, and to be associated with a foul tongue, whereas a tubercular meningitis is frequently ushered in by a clean tongue. Prognosis is as grave as it can be ; but instances of recov- ery are recorded, and, in this regard, we have frequent op- portunities of noting an important piece of evidence, for it often happens that yellow tubercle in the brain has obviously been where it is found a long time, and yet has caused no symptoms. We have evidence, then, that masses of tubercle, which have been slowly growing, may give rise to no symp- toms ; and that simple meningitis has repeatedly recovered. There seems, therefore, no reason why tubercular meningitis should not occasionally recover, and there is much evidence that it actually does so. Rilliet and Barthez, Meigs and Pepper, and Clifford Allbutt, all concur in the occasional occurrence of such cases. I believe that I have myself seen a case of the kind. We can hardly reach much more than the belief, because recovery precludes the verification, and there must always remain behind a doubt whether the case TUBERCULAR MENINGITIS. 473 might not have been one of simple meningitis. But we may at any rate say that the facts are sufficient to justify us in affirming that the case is not absolutely hopeless. Treatment. — Iodide of potassium should always be given, in the hope that, under its use, the symptoms may possibly ameliorate. The liquor hydrarg. perchlor."* may also be given, in twenty- or thirty-drop doses, or more. It may act as a promoter of absorption of inflammatory products, and it is not a form of mercury which has any harmful action upon children. Here, also, I have of late been trying iodo- form internally, in quarter- or half-grain doses, in very young children, and increasing it cautiously, if necessary, to one grain or even more. As I have already said, it requires watching, as it occasionally makes them sick and ill. Cases of phthisis have done well upon it, but I have not seen any marked effect upon tubercular meningitis. The child should be kept in bed, and perfectly free from excitement of any kind. An ice-cap should be kept to his head ; the bowels acted upon once a day ; and any headache or sleeplessness mitigated by bromide of potassium, chloral, or opium. The diet should be highly nourishing and easily digested, in the shape of eggs, milk, jellies, custard, etc. Children with hereditary tendency to phthisis, or those who look tuberculous, should be carefully watched and guarded. In infants a tuberculous mother should not nurse her child, but let it be fed artificially or by a wet-nurse. It must be kept warm, live as much as possible in a dry air, with porous soil, and the development of its brain must be de- layed as much as possible by keeping it away from books. * Liq. Hydrarg. Perchlor., Br. P., contains ten grains each of perchloride of mercury and chloride of ammonium to a pint of distilled water. — Ed. 474 THE DISEASES OF CHILDREN. CHAPTER XXXIV. HYDROCEPHALUS. Hydrocephalus. — I dismiss the term chronic hydroce- phalus, because it is misleading. Hydrocephalus has often been a bugbear with students, because of the difficulties which have been made to exist by a description of three so- called varieties — acute, chronic, and false hydrocephalus. Acute hydrocephalus has been accepted as synonymous with tubercular meningitis, but in the preceding chapter I have pointed out that the effusion is usually of subsidiary importance, it is so small in quantity. The diagnosis is not made by the evidence of excess of the cerebro-spinal fluid, but by the evidence of inflammation of the membranes of the brain. Cerebro-spinal fluid is often in excess, but the excess is mostly a moderate one, and there are many reasons for questioning the influence of the fluid in the production of a fatal result. But both in this and in simple meningitis, par- ticularly when of a more chronic form and associated with the formation of a large quantity of sero-purulent fluid, the ven- tricles may become somewhat rapidly dilated, and be so found at the post-mortem; and, probably, the younger the child the more likelihood will there be of this. False hydrocephalus is a perfectly distinct affair, and need no more be introduced into the subject, than when discussing coma or collapse it is necessary to call one form true uraemic coma, for example, and all others false ursemic coma. [The condition called " spurious hydrocephalus " may be met with in any of the wasting diseases of childhood, but is HYDROCEPHALUS. 475 most common during the later stages of inflammatory diar- rhoea. It is a result of exhaustion. The symptoms are drowsiness, half-closed eyelids, sluggish and unequal pupils, pinched features, lived complexion, sunken fontanelle, subnormal temperature, rapid intermittent pulse, and irregular sighing respiration. The drowsiness gradually deepens into coma, and slight convulsions may precede death. False hydrocephalus may depend upon the slow circula- tion of impoverished blood through the brain, upon the formation of thrombi in the cerebral sinuses, and, according to Parot, on uraemic poisoning, the symptoms being often — in cases of diarrhoea, for example — associated with marked diminution in the secretion of urine. The main treatment is the use of stimulants, both inter- nally and externally.] Hydrocephalus is a disease which occurs under limited and definite conditions, and it is a disease which has fairly definite symptoms. As with all other diseases, these are sometimes less distinct than at others, and the diagnosis may be mistaken or doubtful ; but difficulties in diagnosis are not peculiar to it, it shares them with every other disease that can be mentioned. By hydrocephalus I understand an equable enlargement of the cavity of the skull by fluid within the cerebral ventricles, and by which it tends to become more globular. The globular shape is somewhat interfered with by reason of the union with the facial bones in front, but, wherever it is possible, bulging takes place — at the fonta- nelle, which becomes much increased in size, at all the su- tures, and at the roof of each orbit. Thus the breadth of skull increases from side to side, the frontal bones become pro- truded forward and expanded, the eyeballs are prominent and their axes divergent. Within the cranium the brain is converted into a cyst, the larger in proportion to the dilata- 476 THE DISEASES OF CHILDREN. tion of the ventricles by the accumulated fluid. The cortex cerebri lies everywhere in contact with its case. A distinc- tion is made between external and internal hydrocephalus — in the one case the fluid being outside the brain, between the skull and it, and in the other internal. I shall allude to the external form presently, but now it will be sufficient to say that internal hydrocephalus is the common form, and I doubt whether the external should receive the name of hydrocephalus at all. Hydrocephalus, then, is usually a cystic expansion of the brain by fluid within the ventricles, so that, if we were about to remove the fluid by tapping, it would be necessary to pass through the skull or its mem- branous equivalent, the dura arachnoid, the pia arachnoid, and the grey and white matter of the cerebral cortex, to get at the fluid. The bones of the skull in such a case are usually thin, sometimes so thin that there may be craniotabes. The fon- tanelles and sutures are perhaps widely gaping or filled up more or less by the formation of Wormian bones. Morbid Anatomy. — The brain is more or less expanded into a loculated cyst by the dilatation of all the ventricles and the iter. In extreme cases the cortical layer becomes so thin that it is impossible to remove the brain without laceration. If this can be done, and the brain taken out with a sufficiency of fluid in the ventricles, the appearances at the base may be somewhat peculiar from the dilatation of the third ventricle and the infundibulum. A thin-walled trans- parent cyst is seen, upon which the optic nerves, corpora albicantia, etc., are perched. Sometimes the optic nerves are cedematous. The lining membrane of the ventricles may perhaps, be a little thickened, but its appearance is otherwise normal. These conditions are important, because they serve to explain one or two clinical facts. In the first place, the extreme swelling of the parts about the optic tract and the HYDROCEPHALUS. 477 chiasma may serve to show why there should be, as there is sometimes, white atrophy of the optic discs and blindn The dilated condition of the fourth ventricle may explain how such cases sometimes die suddenly. The fourth ven- tricle is sometimes so much dilated that all the parts become stretched over it, and the circulation through the medulla and pons must almost necessarily be disarranged, and the nutrition of those parts be feeble. The morbid changes which lead to hydrocephalus are not many, and their action is easily intelligible. I will place them in what is, perhaps, their common order of occur- rence : (I.) Tumor about cerebellum, pons, or tentorium. (2.) Chronic inflammation about the medulla and cere- bellum, leading to adhesion about the margins of the foramen magnum. (3.) Congenital malformation. These no doubt act in one of two ways. They may press upon the veins of Galen and the straight sinus, or they may close the communication between the interior of the ven- tricles and the rest of the sub-arachnoid space. It might be thought that the pressure upon the veins, and the obstacle thus produced to the return of blood from the choroid plex- uses, would be a sufficient and readier explanation of all cases ; but it seems clear from the occasional occurrence of congen- ital malformation, or the post-congenital adhesion and block- ing of the aqueduct of Sylvius, that the mere closure of the ventricles is sufficient for the production of the affection. Others causes are mentioned, such as inflammation of the lining membrane of the ventricles, and true dropsy of the ventricles. Of the first, I think it may be said that it is very rare, except under circumstances such as I have given in a 4/8 THE DISEASES OF CHILDREN. case of simple meningitis (p. 459). Meigs and Pepper think otherwise and state that in many cases the lining membrane of the ventricles is granular and much thickened. I have not found it so. They also state, in correspondence with this, that the fluid drawn off in these cases is frequently like the effusion in pleurisy or pericarditis ; but here, again, ex- cept in one acute case, I have seen nothing in the ventricles in these cases but natural-looking cerebro-spinal fluid. Hil- lier states that dropsy may occur from obstructed veins either from simple or pysemic thrombosis. This would be a form of disease of similar origin to that of other cases — viz., obstructed venous circulation ; therefore whether there is such a thing as spontaneous dropsy of the ventricles, apart from such a cause, must still be a matter of conjecture. Rickets is said by many to be a cause of this disease, but the evidence in proof of this derived from actual demonstration in the post-mortem room is very scanty. Of twenty cases, seventeen were in boys, three only girls. Their ages : two of three months, two of six months, eight between six and twelve months, three at eighteen months, one two years, three four years, and one five years old. Symptoms. — It is difficult to say much about the early onset of the symptoms. In one or two the complaint has come on suddenly after convulsions, or some acute illness ; but fifteen out of the above twenty cases had a history of a gradual enlargement since the child was two or three months old. As to definite symptoms there were generally none. Wasting was noticed in four ; two had head pains — one so severely that I tapped the skull to relieve the pain, and with some success; two had crowing respiration, a symptom noticed by Dr. West ; one, giddiness. The increase in size is very slow, and often irregular. In eleven cases measure- ments were taken from time to time. One had increased J in. in three and a half months; another, 1 in. in two months; HYDROCEPHALUS. 479 another, beginning at \j\ in., had gained j in. in a month, lost J in. in three months, and then increased to 18 } in three and a half months ; another remained stationary. There had been no fever in these cases. As the disease progresses, and the intra-cranial pressure begins to" tell, the child begins to waste ; sometimes it has convulsions; ultimately it becomes blind, has nystagmus, and so dies gradually exhausted. Once or twice there has been some rigidity of the limbs ; once retraction of the head. An examination of the eye in the later stages may show a swollen or inflamed disc, or a white and atrophied one. The latter has been more common in my experience. The cere- bral symptoms vary much. The cases I have seen have seemed to me to present an average intelligence; sometimes an old-fashioned pseudo-precocity, such as Sir W. Jenner pictures in rickets, unless the enlargement be extreme. In the latter case there has usually been blindness, intelligence has failed more or less completely, and the child has lain in bed taking notice of nothing. It feeds and sleeps; perhaps leading a painless existence ; perhaps exhibiting some signs of pain on movement. It is not often that one has the op- portunity of tracing cases on from the early stage of the dis- ease to its completion. They are met with either early or late ; if the former, then the symptoms are of equivocal meaning; in the late stage, the wasting, the pain, the blind- ness, and the enormous head cannot be mistaken. Diagnosis. — The term " water on the brain," both to doctor and the public, occupies a very similar position in cerebral nosology to consumption of the bowels for abdominal dis- eases. • It is the refuge of the destitute, and has often been made to apply, not only to acute and chronic brain disease, but also to the convulsions of rickets or teething, the onset of an exanthem, or one of the many gastro-intestinal de- rangements which may be met with in profusion. The first 480 THE DISEASES OF CHILDREN. point in the diagnosis is to eradicate from the mind the notion that a bulging fontanelle of necessity indicates excess of fluid in the ventricles. It much more often means merely a congested brain. Not long ago I saw a child with Mr. Irwin Palmer, which had had constant convulsions for four days, an unusually bulging anterior fontanelle, a widely open posterior fontanelle, a retracted head, and a wearing cry. There were many points in favor of some acute meningitis with effusion. But another view seemed quite possible; dentition was proceeding ; and the parents asserted that food brought on a fit ; the diet was accordingly reduced, chloral and bromide of potassium given to quiet and thus lessen the loaded cerebral circulation, and the treatment was quite suc- cessful. I suppose there can be no doubt that there was no meningitis and no effusion. We must look suspiciously upon all cases of supposed sudden effusion, and first deter- mine whether there be not some temporary cause in the form of preceding or threatening convulsions for the swell- ing of the fontanelle. If the bulging be persistent, and the head slowly enlarges, if there be head pains certainly not of rachitic origin, then we may begin to think of hydrocepha- lus. In making a diagnosis the characteristic features of hydrocephalus are a very gradual increase in the size of the head, without any pyrexia, and often without any evidences of ill-health. There may be a history of bygone meningitis, or something which denotes the present existence of some cerebral tumor. It is liable to be mistaken for rachitic en- largement of the skull, but this cannot be often. The rachitic skull is quite different. It wants the enlargement in all direc- tions which is seen in the hydrocephalic skull, and thus the width and overhanging of the forehead, and the prominent and divergent eyeballs. The rachitic skull is long and later- ally compressed, the forehead is high and square, and the bones may become thickened, soft, and tender. Moreover, HYDROCEPHALUS. 48 1 there is the evidence of rickets elsewhere, and the evidence of tender bones in all parts. The disease may perhaps be. confounded with hypertrophy of the brain, which will be described a little later; but this condition is so rare and obscure, both in its symptoms and in the morbid changes which produce it, that no definite means of distinguishing it can be given. Prognosis. — A case of advanced hydrocephalus lives, at best, a precarious life; but it is certainly instructive to notice how long the less serious cases live. Children thus affected attend at hospitals for a year or two — at any rate, for several months, and then disappear from view; and it is my belief that many of the moderate cases hold their own, and, so to speak, get well. The pathology of hydrocephalus is a subject of great interest. Space has, unfortunately, pro- hibited my entering upon it; but putting aside such cases as are due to incurable conditions, such as pressure upon the veins by cerebral tumors, there is no reason why, if hydrocephalus be due to the shutting off of the ventricles from the general sub-arachnoid space, the ventricular cavi- ties should not strike a balance in many cases, as is often seen in hydrocele, for instance, and the equilibrium of secre- tion be restored. Whether this be so or not we cannot tell, but this much is certain, that hydrocephalic heads in consider- able number are seen in the out-patient room at children's hospitals. The general health of these children, as a rule, is not bad ; the evidences of cerebral trouble are few or none ; the enlargement of the head is very slow, and often stationary ; the majority are ultimately lost sight of, and only the few extreme cases are known to die. Even these linger on for a long time, perhaps fairly intelligent, most probably dull ; but in the end intelligence fails, sight fails, and the child lives a vegetative existence. Death comes sometimes by convulsions; sometimes suddenly; sometimes, and this I 4§2 THE DISEASES OF CHILDREN. think most commonly, by progressive emaciation, deepen- ing stupor, failure of the respiratory centres, the accumula- tion of mucus in the bronchial tubes and asphyxia ; or else, by failure of deglutition, food enters the air-passages, and latent broncho-pneumonia develops. Treatment, — Unfortunately, one is not often in a position to be able to come to any conclusion as to what is the cause of the disease. All that is possible, in many cases, is to hope for the best, that there may have been some bygone local inflammation, the effects of which being tided over, the equilibrium of secretion may be restored. In all cases, therefore, it seems to me advisable to apply systematic support to the exterior of the skull as long as possible, and — in the hope, again, that something capable of absorption may be present — from time to time some mercurial ointment or oleate of mercury (five per cent, sol.) may be applied, or some iodide of potassium ointment rubbed in. This treatment has been recommended by Golis, Trousseau, West, and others ; and, although it will often fail, it sometimes seems to do good. It must be carried out with care. A child's skin is a very delicate texture, and the strapping requires to be frequently changed and the surface rested, otherwise ugly sores may be made which hinder the treatment very seriously. It is better, therefore, to strap for three or four days, and then rest a day or two, during which time the surface must be regularly and care- fully cleansed and bathed now and again with some spirit lotion. Obviously, to carry out the intent of the treatment, the head should be strapped continuously for as long as possible, and the intervals for rest be as short as is compat- ible with the preservation of the skin. Internally, iodide of iron may be given, or cod-liver oil. Careful attention to feeding must be given if the child is wasting. As regards tapping, it is not often successful, but there HYDROCEPHALUS. 483 does not appear to be much risk attaching to it. Therefore, in advanced cases, if the skull is not too consolidated to allow of it, and the child be wasting and in any pain, it ap- pears to be worth the trial. The parents must be prepared for the possibility of convulsions after and a possibly fatal result, and for no very visible success in the way of relief. A fine trocar and canula are used and passed into the lateral ventricle in the coronal suture at the outer angle of the anterior fontanelle, or at a distance sufficient to well clear the longitudinal sinus. The amount to be drawn off is usually limited by the amount that flows readily, and which is often not much. The bones must be carefully supported during the flow of fluid ; and, as soon as the tension inside the skull is in-sufficient to expel the fluid, the canula should be withdrawn and the head carefully strapped. In one case, the fluid withdrawn allowed the bones at the sagittal sutures to overlap each other, and the head assumed a most peculiar appearance from the lateral compression that followed. Pressure was kept up by strap- ping, and the fluid never reaccumulated. The child was alive and in good health eighteen months afterwards. In a second case, in a younger child with more acute symptoms, tapping was resorted to for the relief of the tension and the pain, only two ounces of fluid would flow but the pain was certainly relieved. The child died a fortnight later, but death had been expected, as there was in all probability some meningitis associated with it. In a third case, tap- ping was resorted to, but very little fluid would flow, and the operation did neither good nor harm. External Hydrocephalus. — This term applies to fluid collected outside the brain, either in the arachnoid or some sac formed either in, or in connection with, one of the mem- branes. The origin of this condition is obscure. Most authors speak of it as due to hemorrhage into the arach- 484 THE DISEASES OF CHILDREN. noid, and subsequent changes in the clot. It and pachy- meningitis interna, or blood cysts of the dura arachnoid, are not easily to be distinguished, and the latter are now generally believed to be of inflammatory origin. It is also occasionally associated with atrophy of the brain, the resulting vacuum being filled by cerebro-spinal or serous fluid. Of symptoms, this condition can hardly be said to have any that are well recognized as belonging to it ; but, being a cortical affection, it might be expected to be more associ- ated with convulsions and rigidity of the limbs on one side or the other. The diagnosis of such a case will present great difficul- ties. It will depend much upon the irregular shape of the head, such as a local bulging in one part or another, or, perhaps, a local condition of craniotabes. Perhaps it may be well to say that local enlargement of the head is a char- acteristic of some tumors, particularly of the posterior seg- ment in cerebellar tumors. Treatment. — This form often gives more hope of suc- cessful treatment. Tapping, and even repeated tapping, has already cured such cases ; and it seems reasonable to hope that, with all the modern improvements in surgical pro- cedure, tapping or other means for removing the fluid might be carried out with a fair chance of a permanent cure. INTRA-CRANIAL TUMORS. 485 CHAPTER XXXV. INTRA-CRANIAL TUMORS. Encephalic Tumors. — The brain substance may be occu- pied by tumors of many kinds, but the large proportion of those which occur in childhood are of a tubercular nature, and are situated for some reason or other in the cerebellum, or, at any rate, below the level of the tentorium cerebelli. That masses of tubercle should be a frequent cause of dis- ease of the brain in childhood is only what might be ex- pected, when we remember the remarkably lymphoid struc- ture of the peri-vascular spaces in the brain, and the frequency of tubercular meningitis. It is less easy to say why the cerebellum, and perhaps the pons, should be so frequently attacked. Several reasons might be suggested, but inasmuch as no single one carries any conviction of its sufficiency, they need not be stated. The fact remains — tubercular tumors are very common in the cerebellum and the pons Varolii. The realization of this carries with it an aid to the diagnosis of the several varieties of intra-cranial tumors. Symptoms. — It is well known that tumors of the cerebral substance, unless they are of large size or attack particular strands of nerve substance, give very indefinite signs of their existence. Tumors in the cerebellum or pons give symp- toms which very seldom allow room for mistake. These are — intense occipital headache and vomiting, congestion, swell- ing, and neuritis of the optic nerves, followed by white atrophy and blindness, a reeling gait, tonic convulsions or rigidity, movements of the eyeballs, enlargement of the occi- 41 486 THE DISEASES OF CHILDREN. pital segment of the head, and hydrocephalus, or craniotabes. Some of these are symptoms we should naturally expect from a tumor, at any rate of any size, taking up its position in parts closely surrounded by such unyielding structures as confine the posterior fossa of the skull. We are familiar with the terrible pain of an abscess pent up in fibrous structures, and it is more than likely that a tumor in the region in ques- tion acts similarly — it deranges the circulation, produces congestion, tension, and other abnormal relations in parts of a sensitive and vital activity, and the resulting distress is the natural outcome. Hydrocephalus is also easily explicable from the pressure upon the tentorium which must ensue, and the consequent liability to closure of the veins of the choroidal plexuses, or of the communications between the ventricular cavities and the sub-arachnoid space. The un- steadiness of gait is also a well-known feature of cerebellar disease ; rigidity, also, and movements of the eyeballs. These have all been proved to occur by experiments made by Fer- rier with the object of determining the functions of the cere- bellum, or those of its parts. Some of these symptoms are more constant than others, and of particular importance are the unsteady movements in walking and evidences of optic neuritis or congestion. These are rarely wanting, and optic neuritis particularly may be an early symptom. Rigid- ity comes next. Perverted movements of the eyeballs are less constant ; and enlargement of the head is often absent, and can hardly be expected where the bones of the head are ossified. In this case there may be craniotabes. Morbid Anatomy. — Solitary tubercle is the commonest form of tumor in the cerebellum, and its most favorite seat appears to be the hinder part of one or other lateral lobe ; occasionally there is a smaller mass in the opposite lobe. But other tumors exist sometimes — gliomatous growths and either cystic tumors or simple cysts. The latter, although INTRACRANIAL TUMORS. 487 not common, maybe kept well in memory. I must have seen some five or six cases, and one can never see a fatal ending in such as these without regretting that surgery was not allowed a chance to cure. Diagnosis. — The symptoms of cerebellar tumor admit, as I have said, of little mistake; but it must, of course, be un- derstood that tumors in this part are liable to implicate by continuity the neighboring parts, and thus produce other symptoms. Tumors in the pons Varolii, or growing from the tentorium, might compress or spread to the cerebellum, and thus produce the symptoms of a tumor of the latter. A tumor, if located in the pons, may produce nothing but general tremor of the acting muscles. More often there is some paresis of the extremities on one or both sides; some- times paralysis of the third or sixth nerves, and so on. Glio- mata in the pons, moreover, have a tendency to enlarge the pons uniformly, so that, on section, the disease looks more hypertrophic than of foreign material, but when they reach the surface, they may become sub-lobulated and implicate the trunks of the neighboring nerves. I have seen three such gliomatous enlargements, of one of which a short note follows. A boy of 9 years was stated to have been quite well one month before his admission. He then began to fall about, complained of inability to swallow his food, and once or twice almost choked. He was admitted with right facial paralysis and paralysis of the right side of the tongue, and a staggering gait. His optic discs were normal (this seems to be a point in the case which might prove of diagnostic importance in similar cases). After a short stay in hospital, he gradually lost power in his left arm and then in his left leg, and lastly he became rigid on both sides. He died in a semi-comatose state. At the post-mortem, the entire pons and medulla were swollen by a general hypertrophic enlarge- ment, so that it was impossible to say, from the naked-eye 488 THE DISEASES OF CHILDREN. examination, where the disease began or ended. The sur- face of the tumor was very peculiar from the number of small lobules over it, and which gave it somewhat the appearance of the wattles of a fowl. Dr. Angel Money has described two similar cases,* and gives a typical representation of one ; Dr. Gee and Dr. Percy Kidd have each recorded another, and it is probable that others have gone unrecorded rather than that they are very rare. Gliomata are slowly growing tumors ; they infiltrate the part, so that it is impossible to state precisely the boundaries of the growth. Between tnmors of the pons and cerebellar tumors it will sometimes be difficult to decide. The existence of muscular feebleness, or general paralysis, or local paralysis of the nerves, will be in favor of the affec- tion being located in the pons ; and it may probably be said that, given a lesion limited to each part, the muscular irreg- ularity is more of a general tremor when the lesion is in the pons — a more irregular and jerky form of ataxia when the cerebellum is affected. Rigidity may, it would seem, go with either. Prognosis. — This resolves itself into a question of how long. If we can, by the general aspect of the case, exclude a mass of yellow tubercle, then glioma, being the next most probable condition, is liable to go on a long time, but the ultimate result is no less sure. Tubercular masses also are sometimes of very slow growth, and sometimes become quiescent for a time, but ultimately they cause death, either as tumors, or by the extension from their margins of a tu- bercular meningitis. Treatment. — With perhaps an exception to be mentioned directly in the case of simple cysts, the treatment resolves itself into the relief of pain and careful nursing. For the relief of pain, iodide and bromide of potassium, chloral hydrate, or opium must be given ; and in one case, these * " Med.-Chir. Trans.," vol. lxvi. INTRA-CRANIAL TUMORS. 489 means being insufficient and the pain apparently terrible, I considered myself justified in resorting to trephining. It was in a child of three years, with evident indications of a cere- bellar tumor. Mr. Jacobson trephined the skull in the left half of the posterior fossa, as low down as possible, so as to avoid the lateral sinus ; and in the bare hope that the tumor might be cystic, a fine trocar was passed into the cerebellum, but without any result. The trephine wound was made as large as possible, with the idea of relieving the tension below the tentorium, and for a time the screaming fits were some- what relieved. The part healed very rapidly, and deep down in the neck a firm membranous covering closed in the aper- ture, and the relief gained was not for long. The case ulti- mately proved to be tubercular. Nevertheless, this treatment seems to be worthy of consideration, not only for the relief of pain, but in other cases for another reason — viz., the ten- dency that exists in the cerebellum for the formation of simple cysts. There is no means of arriving at a diagnosis without the trephine, and it seems to be quite worth the while, in a disease which is hopeless without it, to give the patient just the faint chance trephining offers of coming upon a cyst and evacuating its contents. Modern antiseptic sur- gery has taken away much of the danger that attached in former times to trephining, and there is probably no extra- ordinary risk in the operation, nor in puncturing the mem- branes and lateral lobes of the cerebellum with a fine trocar. 49° THE DISEASES OF CHILDREN. CHAPTER XXXVI. HYPERTROPHY OF THE BRAIN.— CEREBRAL HEMORRHAGE.— THROMBOSIS OF THE CEREBRAL SINUSES. Hypertrophy and Sclerosis of the Brain are usually mentioned by all writers on diseases of children, but it may be noted that the literature of the subject increases very slowly, and that writers allude to their own personal knowl- edge of it in a somewhat vague manner. The only recent addition to our knowledge appears to be that, whereas, in former times the nature of the disease was unknown, of late years the condition has been definitely described as due to an increase of the neuroglia of the brain — to the disease therefore which is now called sclerosis. I see no reason why both diffused and disseminated sclerosis should not occasionally occur. I have said elsewhere that children occasionally come under notice with symptoms very closely resembling those of disseminated sclerosis in the adult. But the actual demonstration of the condition by post-mortem evidence is scanty in the extreme, and I do not know that as yet it can be said to have been shown to have occurred. In reading over the cases of hypertrophy of the brain re- corded, one cannot but be struck with its close association with a rachitic skeleton ; and inasmuch as a thick skull is found in rickets, one is doubtful in some cases, in the absence of actual weights, how far the large head was due to actual increase of brain matter, how far to the size of the skull. Dr. Gee has recorded two cases,* however, in which the brain was very heavy. A boy aged 2^, highly rickety, and * " On Convulsions in Children," St. Barth. Hosp. Reports, vol. iii., p. 109. HYPERTROPHY OF THE BRAIN, ETC. 49 1 suffering from convulsions ; the body weighed 17^ lbs., the brain 59 oz. ; the average at this age being 38.71 oz. A girl of the same age, and also rickety, weighed 15^ lbs., and the brain 42^ oz., the average being 34.97 oz. In both cases the brain appeared to be perfectly healthy. I should myself be disposed, while calling attention to its possible existence and to the necessity of closely investigating all curious brain symptoms that occur in cases of rickets or elsewhere, to emphasize the remark of Dr. West, made long ago, but still true, " I am not sure that an undue importance has not sometimes been attached to it, as though it were of much more common occurrence than you will find it to be in practice." I have not hitherto met with such a case. Dr. Hillier says of it that it comes on slowly at an early age, and is attended with loss of health, dulness, and apathy ; the head seems too heavy for the child, and it frequently bores in the pillow. Cerebral Hemorrhage is a rare disease, but it is never- theless an important one. It may be meningeal or intra- arachnoid (the two cannot be separated), or into the substance of the brain. The former is most probably more common than it has been proved to be upon the post-mortem table, for the reason that in many cases there can be no obstacle to recovery, and looking to the many possible causes of such a condition in early life, it is very likely indeed that some, if not many, of the chronic thickenings, cysts, and other affections of the membranes, which are denominated inflammatory, may have their origin in surface hemorrhage. It cannot, however, be said that this is certainly so, except in a few instances. Meningeal Hemorrhage may be of all degrees of severity, from mere capillary ecchymosis to a diffused layer of clot of some standing. It appears to be more common in new-born children, the reason for this no doubt being 492 THE DISEASES OF CHILDREN. the disadvantageous conditions of the circulation which occur during delivery, whether natural or instrumental, and the circulatory changes that take place within a short time of birth. Of other conditions, whooping-cough and severe purpura will at once occur to any one as liable to lead to it, and cases are on record due to both these diseases. Throm- bosis of the sinuses, the various abnormal blood conditions met with in the exanthemata and other fevers, are also noticed as being occasional causes. Symptoms. — It cannot be said to have any which are pathognomonic, but in any case in which its existence is rendered probable a sudden coma or collapse, a weakness of the limbs on one side or the other, perhaps a convulsion also, might lead to a guess that something of the kind had happened. Prognosis. — It might fairly be hoped that by quietude and careful feeding absorption of the clot would take place and recovery ensue. But for such a case it may be well to say that although the prognosis might be very favorable, there is abundant evidence in adult life to show that menin- geal extravasations are slow in disappearing completely — pigment and thin layers of lymph are found, many months after extravasation of this kind. Consequently the greatest care is necessary to preserve the patient as much as possible from excitement or active brain work for a considerable time after such an occurrence. Hemorrhage into the substance of the brain has in very rare cases been due to atheroma of the vessels, but it is commonly due to embolism from heart disease, and the hemorrhage is commonly preceded by the formation of an aneurism. Symptoms. — These would be those of apoplexy in the adult — viz., sudden onset of right hemiplegia with more or less coma, or some general paralysis if the plug should HYPERTROPHY OF THE BRAIN, ETC. 493 block the basilar artery, instead of the more usual seat of left or right internal carotid at the base of the brain. The diagnosis would mostly depend upon the evidence of the existence of heart disease, or of some reason for the formation of clots on the valves or in the cavities — either from recent rheumatism, or chorea for the valves ; or scar- latina, or typhoid, or other exhausting illness for dilatation of the left ventricle. It will often be difficult to say whether the embolism remains as such, and the paralysis is embolic only; or whether an apoplexy has followed it. Prognosis is grave in all cases from valvular disease, because the embolism most commonly occurs, or at any rate produces such severe symptoms, in the worst cases only. The valvular disease is likely to be of fungating or ulcerative form; the patient to be febrile and anaemic; very likely with albuminuria from a dilated ventricle, because hemorrhage following upon embolism denotes extensive softening, and, in the rare cases due to atheroma, because the disease has been usually basilar and the hemorrhage into the pons or its neighborhood. Supposing that hemor- hage could be excluded and the case diagnosed to be one of embolism only, probably a slight distinction might be made in favor of clots discharged from a dilated ventricle. I think that these, not having an inflammatory origin, are less likely to provoke a local inflammation in the vessels in which they lodge than are those which are discharged from an inflammatory focus on the valve. Treatment. — Absolute rest ; ice or cold lotions to the head ; the bowels should be kept active, and food adminis- tered carefully. Here, too, as in adults, the lungs should be watched and preserved from the accumulation of mucus at their bases, by attending to the position of the child which should be frequently changed from side to side. In the more common cases of apoplexy, due to valvular 42 494 THE DISEASES OF CHILDREN. disease, one- or two-grain doses of quinine should be given if there be any pyrexia, and the heart's action should be quieted and sustained by bromide of potassium, belladonna, or digitalis. Thrombosis of the Cerebral Sinuses. — In the larger number of cases the lateral sinuses only, one or both, are affected. The longitudinal sinus also, but rarely. In these cases the lesion is due to disease of bone, and in infancy chiefly to disease of the ear, whilst the inflammation of the petrous portion of the temporal bone causes phlebitis of the petrosal or lateral sinus. But there are also many other cases, and the majority children under two years of age, in which no such causes can be found. In these it has been noticed that the clot is less in the lateral than in the longi- tudinal sinus. Virchow originally pointed out that not only in the cranium but in the pelvic veins and the veins of the lower extremity, the blood current is at times so slow as to render spontaneous coagulation a risk, and in the longitudinal sinus of the cranium the shape of the channel, and the fact that the tributary veins run into it in a direction against the current, have always been considered as in favor of throm- bosis. Thus, when no cause has been found for the coagu- lation, as has often happened, it has been assumed that the coagula are due to these natural conditions telling disadvan- tageously upon an unnaturally feeble current. A very good division, therefore, of the cases of thrombosis of the cerebral sinuses is that given by Steiner, into exhaus- tive and inflammatory. The exhaustive essentially concern the longitudinal sinus, and are found in any feeble depressed conditions, such as cholera infantum, scrofula, rickets, etc. The inflammatory form affects chiefly the basal sinuses, and can be traced to disease of the ear, and injuries or local in- flammation of the cerebral membranes. HYPERTROPHY OF THE BRAIN, ETC. 495 The symptoms arc very obscure, and the thrombosis is found by accident at the autopsy. Lethargy, stupor, or coma are the more common — epistaxis, occasionally result- ing from plugging of the longitudinal sinus. Any obstruc- tion in the cavernous sinus — which, however, is very rare — might be detected by the morbid appearance of venous congestion visible by the ophthalmoscope at the fundus oculi. Treatment. — The exhaustive form is one for prevention rather than cure. The risk is to be remembered in feeble infants, and wine and good food administered. So also is the inflammatory form one for prevention, seeing that it arises so often from disease of the temporal bone, and that this follows upon discharge from the ear. Much may be done by paying careful attention to cleanliness and the application of antiseptic collyria in cases of this kind, and — should any evidence of disease of the bone unfortunately arise — timely surgical interference by an incision over the mastoid and trephining may possibly give an outlet for foetid material and thus avert a fatal result. 49& THE DISEASES OF CHILDREN. CHAPTER XXXVII. DISORDERS OF MOVEMENT. Infantile Paralysis. — The alpha and omega of the stu- dent's knowledge on this subject comprises often no more than a few facts about what has from time immemorial received the name of infantile paralysis. But there are at least several other forms of paralysis which, if not quite so disproportionately infantile, are nevertheless common in childhood, and deserve to be reckoned among the diseases of children. And others, again, though occurring more often in adults than in children, which must be enumerated as occasional occurrences, lest being unexpected their import may be mistaken. I shall not attempt any scientific classi- fication of these, because our knowledge of their causes, or rather of the lesions by which they are produced, is still very meagre. Some are due to cerebral, others to spinal lesions ; some, probably, to no lesion at all. I shall take them as they most frequently come under the notice of the student. Infantile Palsy, as the most familiar form of the disease, may be taken as a starting-point. " Essential paralysis" it is sometimes called, because at one time it was supposed to be due to a disease of the muscle. Some still contend that a muscular lesion is the primary fault, and that the nerves or cord undergo subsequent changes from an ascending neuritis. But the generally received doctrine is that the paralysis is due to a primary disease of the nerve-cells of the anterior cornua of the spinal cord. It is a disease which is not confined to infancy, but so largely preponderates then DISORDERS OF MOVEMENT. 497 that 154 cases, out of a total of 205, occurred between the ages of six months and two years. It has been noticed within a few days after birth. (Ross.) It is liable to affect the healthiest children, attacking either sex equally, and is said to be more common in the summer months. I have sometimes thought that a rheumatic parentage might have something to do with its production, but nothing is known regarding this. Duchenne states that he has not been able to associate it with nervous disease of any kind in the family. Of exciting causes, exposure to cold is often mentioned, and of this the following is a striking instance : A male child of five months old was sent to me by Mr. Richardson, of Croydon, with this history. Its father had suffered from rheumatic fever badly. The child was taken out in October, when six weeks old, and kept out on a cold day, for two and a half hours, late in the afternoon. It was brought home " perished " with cold, and with its eyes drawn up, and snatching its breath. It was in a burning heat all night, and kept starting as if falling. It was uncon- scious for a week or more, and was continually moaning. It gradually recovered from the coma, and at the end of a fortnight its right arm was found to be quite useless. This had recovered somewhat since, but was still useless in great measure. Symptoms. — These will be best illustrated by a case. The one already given is a typical one, but another may be added. A boy ten months old went to bed quite well one night, and when taken up the next morning was " paralyzed all over " — that is to say, his head dropped about, and he had no power of sitting or moving — the trunk muscles being paralyzed. He was also feverish, but no teeth were being cut at that time. The leg was noticed to waste afterwards, and use in it was never regained, although the general par- 49§ THE DISEASES OF CHILDREN. alysis improved. The child was brought to the hospital two months after the attack. His right leg was mottled from cold ; it hung flaccid from the pelvis, and was perfectly- powerless. On passive movement, it could be put into almost any position, the hip being unnaturally lax, without any pain. In all other respects the boy seemed quite healthy. Dentition had progressed rapidly, and he was not rickety. The muscles failed to respond to the Faradic current, but reacted slightly to galvanism. Such is the short and usual history of infantile paralysis. A healthy child sits in a draught, gets cold, cuts a tooth — anything possibly, nothing certainly — and becomes feverish, fretful, is perhaps convulsed or semi-comatose, and is shortly found to have general .paralysis. The child often cries when it is moved about, or when its limbs are touched ; but it is doubtful whether this is due to pain or merely to the dis- turbance when it is not feeling well. In a day or two the fever passes off, and with it, perhaps, some of the paralysis ; leaving a leg or an arm, or both legs, or perhaps one side, or perhaps only this or that group of muscles, completely paralyzed. If the child is taken to the doctor he recognizes at once the dangled limb, and finds more or less complete absence of response to the Faradic current ; more or less qualified action with the galvanic current, but no alteration of sensation. This, however, is hardly a common hospital experience. Three or four months usually elapse before medical aid is sought. By that time the limb is much wasted ; the skin is often livid from the sluggish circulation consequent upon the reduction of temperature ; all the soft parts are flabby, and the electric irritability to any form of current is quite destroyed. Perhaps years elapse, and then, in addition, there is dwarfing of the affected limb from dimin- ished growth, and sometimes deformity from the unbalanced action of those groups of muscles which are not paralyzed. DISORDERS OF MOVEMENT. 499 Deformity is, possibly, less common in infantile than in other forms of paralysis, excepting perhaps that of talipes equinus and varus, because it so frequently happens that the entire limb is affected. The characteristic features of the disease, then, are : The initial fever, the sudden onset of motor paralysis, the rapid loss of electric contractility in all those muscles which are severely affected, followed by their progressive atrophy, and the gradual restoration subsequently of all those muscles in which the electric contractility is preserved at the end of the first fortnight. There is no progressive character about the disease — the mischief appears to be worked at once and then ceases. The affected muscles atrophy, but no fresh ones are attacked ; and while perfect recovery is perhaps seldom seen, a partial recovery is the rule. All reflex actions are lost in the affected muscles, to be regained, however, as the muscles recover themselves. Sen- sation is unaffected. As regards the fever at the onset, Duchenne states it to be usually, but not invariably, present — of seventy cases it was absent in seven. But no negative statement of this kind is of great value when such young subjects are concerned. Moderate fever is so often unappreciable except to the ther- mometer. The seat of the paralysis is very variable. The following table is from Duchenne's & Electrisation Localise e, as given by Dr. Poore. In sixty-two cases there were : 5 of general paralysis. 9 of paraplegia. 1 of hemiplegia. 2 of crossed paralysis. 25 of paralysis of right leg. 50C THE DISEASES OF CHILDREN. 7 of paralysis ofleft leg. 10 of paralysis of right or left arm. 2 of lateral paralysis of the upper limb. I paralysis of trunk and abdomen. In my own cases the right leg was paralyzed in six; the left leg and left arm once each ; the right arm twice ; the dis- tribution was hemiplegic once, general twice ; in both legs three times ; in five out of sixteen cases the pain at onset appears to have been pronounced. Morbid Anatomy and Pathology. — This form of paralysis has been supposed to be due now to muscular disease, now to disease of the nerve-endings in the muscles, or to disease of the efferent trunks. But all the examinations of recent years have gone to show that there is an actual disease, inflammation it is called, of the spinal cord. The affected muscles, undergo rapid fatty degeneration, but only in con- sequence of irreparable destruction of the motor areas in the cord. The changes which occur are as follows : In the earlier stages small foci of softening are found in the grey matter of the anterior cornua. They are usually of small size, run in vertical streaks, and are particularly liable to attack the cervical and lumbar enlargements. They maybe of reddish color, and under the microscope show an increase of the capillary network, and cedema of the vessel-walls, with a nuclear growth in more or less profusion. In the later stages, as might be imagined from what is known of the laws of pathological changes, the appearances are those of the so-called sclerosis — that is to say, the connective tissue between the nerve-fibres undergoes increase and thickening, and the nerve-cells and nerve- fibres become atrophied. The common appearances in old cases of infantile paralysis are diminution in size of the affected part of the cord — diminu- tion of the one anterior horn of grey matter as compared DISORDERS OF MOVEMENT. 50I with the other, and shrivelling and over-pigmentation of the nerve-cells. Sometimes the corpora amylacea of nerve de- generation are found also. The nerve-trunks related to the affected limb are smaller than those on the other side, and the muscles are atrophied, and, in many cases, replaced almost entirely by fat. Finally, it is worth remark that the bones of the affected extremities are stunted, and that not in proportion to the extent of the paralysis, i. e. } to the want of movement. Very slight paralysis may be* attended with much shortening, and in extreme paralysis the affected limb may be no shorter than its fellow. The disease which produces all this mischief in the cord is an acute anterior polio-myelitis, or an acute inflammation of the motor cells ; and this opinion is based upon all the hitherto recorded microscopical examinations of the spinal cord. Some have discussed whether the change is in the nerve-cells or in the interstitial matter surrounding them, but this is a matter upon which we have no evidence, and which is not of importance. In one or two cases the appearances have been those of a small extravasation of blood in the cord, rather than an inflammatory condition. But, at the same time, it must also be remembered that the cases examined are by no means many, and the majority of these have been procured many months, in most many years, after the lesion has occurred. Only in one or two has the disease been so recent as two months after the onset of the paralysis. In saying this I am by no means wishing to call in question the facts recorded, but only to impress more strongly that we are as yet quite in ignorance of the essen- tial cause of the disease. Even allowing the morbid anatomy to be as I have stated, we yet require to know what leads to the disease in the spinal cord — it is still to clinical data that we have to appeal in great measure to support our view 502 THE DISEASES OF CHILDREN. of its nature. Now these data are of two kinds, and seem to point in different directions. 1st. One class of cases is attended with fever, often high, and the paralysis is at its first onset a general paralysis, and I believe often associated with pain. This class furnishes a conclusive proof of a central nervous affection, for a general paralysis can hardly be anything else. It is impossible to suppose any sudden general affection of the muscles or of the peripheral endings of the nerves. It would seem not so very improbable that this initial fever might be the essential disease, and the nervous affection the result of it. Acute febrile conditions are dangerous to the vitality of all tissues, but most of all to the nervous system of a rapidly developing infant. All acute febrile disturbance in infancy is liable to be ushered in by a convulsion, or, what is still more common, by the rigid spasm of arms and legs, fingers and toes, which goes by the name of tetany. This is a not infrequent his- tory of the onset of a case of infantile paralysis, and there is no great improbability in the hypothesis that the paralysis is due to some acute febrile disturbance. But it may, per- haps, be deemed curious that the febrile state should spend its force exclusively on the nerve-cells of the anterior cornua, and be, indeed, but partially distributed amongst them. To such an objection it might in part be replied, that the nervous affections of childhood are largely motor disturbances. Chil- dren do not complain of pains and aches with anything like the frequency that adults do. Convulsions, spasm, chorea, etc., replace pain in great measure, and one would therefore suppose that, given a cause, acting equally on all parts, those used most and most sensitive would most show the results of the working of the cause ; and in childhood, therefore, the motor-cells would be likely to fail first. But it is un- necessary to adopt this line of argument, because a better is at hand — viz., that the pyrexia does not act solely on the DISORDERS OF MOVEMENT. 503 anterior cornua, it acts upon the entire cord, often upon the brain and coid, and thus we have at the onset coma or a general paralysis and some pain. If this be the case, the only peculiarity that needs explanation is the partial distribu- tion of the disease, as evidenced by the subsequent symp- toms and also by the morbid anatomy. But this is quite explicable by what we know of the physiology of the cord. In the first place, the cause of the affection being a very transitorily acting one, much of the original paralysis gen- erally clears up, and thus in the end only a small lesion in the cord is discoverable. Then the paths of sensory impres- sions are not strictly localized, like the motor. How far more common it is to find motor paralysis at any time of life, than it and anaesthesia combined ; there may be a com- plete loss of motion from even diffused changes in the cord, and yet no anaesthesia, a fact that can only be explained by assuming, what has indeed been proved by experiment, that the sensory currents filter through the cord, rather than run ' in streams. Minute lesions in such a case would naturally be more difficult to detect when we have no immediate op- portunity of examining the diseased structures, and are, indeed, mostly unable to do so until many months or years after the original affection. Some hypothesis of this sort takes away the chief difficulty in understanding the disease, or, at any rate, a difficulty which is a stumbling-block to many — viz., the impossibility of giving any satisfactory suggestion why, as it were with- out rhyme or reason, a few motor cells should seem to be picked out here or there, and the rest of the cord go scot free. It is probable that what seems so apparent is never- theless not the real state of the case, but that there is a gen- eral acute disturbance, inflammation it may be called provi- sionally, of the entire cord, which rapidly subsides as its cause, pyrexia, subsides, leaving here and there some parts 504 THE DISEASES OF CHILDREN. shattered by the storm. The parts most conspicuously affected will naturally be those in which the motor nerve- cells largely congregate, for not only is the motor lesion concentrated while the sensory is not, but the motor func- tion that is destroyed corresponds with an absolute loss of nerve-centre, and this entails other secondary consequences of trophic and atrophic character, which must add to the primary lesion. I have only to add that it is by no means uncommon to find some evidences of mental weakness, ap- proaching in one direction or another to imbecility, in the subjects of infantile paralysis, though, perhaps, they occur less often than one might think, if we carefully distinguish between the spinal and cerebral paralyses of childhood. This group of cases confirms then, I think, from clinical data, the opinion derived from pathological observation, that the spinal cord is at fault. Before parting with the subject, the student may be reminded that, although we call this disease infantile paralysis, yet there is an exact counterpart of it in adults, called acute atrophic spinal paralysis of the adult, a rare dis- ease, but one which is sometimes seen in the form of general paralysis of sudden onset and sudden recovery, for the most part^ leaving only groups of muscles paralyzed here and there. 2d. There is, however, another group of cases, in which the evidence of a primary spinal affection, although such an affection is assumed to be existent, does not appear to be by any means so conclusive. There is no evidence of any gen- eral paralysis, none, perhaps, of pain. All that can be told of the case is that a loss of power in this limb or that has been noticed quite suddenly. It often happens that we are told that the child was left playing on the floor far some time and when taken up was found to be affected, or that it went to bed well and woke up paralyzed. This is, no doubt, the history which is obtained at first in many un- DISORDERS OF MOVEMENT. 505 doubted cases of anterior polio-myelitis, and to that affection all these cases are now uniformly ascribed. Nevertheless, some of them bear so much resemblance to some cases of facial palsy, as seen in adults, that the question of local and not central origin may, I think, occasionally be entertained. There is no class of nerve cases more uniformly associated with a definite onset than Bell's palsy, as it is called — pa- ralysis of the portio dura on either side — and its history is this : the patient, a little below par, perhaps, is exposed to wet or cold ; very frequently it can be stated that, at a de- finite time, he sat in a draught, with a stream of cool air playing on his cheek. The history is so constantly one of this kind, that it seems to be impossible to associate the symptoms with any central lesion, hardly possible to believe otherwise than that some local change must have been wrought in the nerve, as it lies in its somewhat exposed situa- tion on the side of the face or crossing the roof of the tym- panum. And what are the symptoms ? They are emphati- cally sudden onset, rapid loss of Faradic contractility, and more or less complete recovery in the space of a few weeks or less. And if it be true that such a cause can produce such a result in adults, there is no improbability in supposing the existence of some similar, affection in children. It is curiously seldom that facial paralysis is found in childhood, except under other circumstances presently to be mentioned. But in this perhaps we may see in part an illustration of the rule, that those parts most subject to use or strain are most liable to break down ; in part, perhaps, it is explained by the relative degree of liability to exposure and injury which various parts suffer at differing periods of existence. The limbs in children are all movement, uncontrolled movement, and exposed in many cases constantly ; as yet the facial nerve, though it is no doubt exposed now as it is later on, has not become subject to the constant strain involved in 505 THE DISEASES OF CHILDREN. the ever-varying phases of expression. Thus, I think, is explained the fact, that children are liable to suffer from local paralysis of limb rather than of face ; and it seems pos- sible that, even though the nerves involved be mixed ones, yet the sensory function, suffering less, might be difficult of detection at this age, and the entire trouble thus pass for motor. The deformities that ensue will depend in great measure upon the muscles that are affected ; the leg muscles being prone to suffer, and frequently those of the front of the tibia, talipes equinus and equino varus are the more common. Diagnosis. — Perhaps it may be thought that there are not many diseases for which an anterior polio-myelitis is apt to be mistaken, and to a careful examiner this is true; but there are several disorders of movement in childhood which have to be considered and eliminated in making a diagnosis ; and first of all may be mentioned paralysis due to pressure and nerve-stretching. I have several times been in doubt between infantile paralysis and an affection of this kind. A young child is left playing, perhaps on the hard floor, with but little power of changing its position, and with its nerves unpro- tected by the ossified prominences which seem made to shield them in later years. There is, at any rate, nothing improbable in the assertion that it was left in health and taken up paralyzed. In the upper extremity, nerve-stretch- ing, taking the place of direct pressure, may readily lead to similar results. Supposing there is a doubt about the case, the points to be attended to are alterations of sensa- tion, incompleteness of paralysis, and little, if any, disturb- ance of the normal electric actions. The previous history must also be taken into account, although this is liable to mislead in any case. Other cases come as paralysis, particularly of the arm, which turn out to be due either to injury or disease of the DISORDERS OF MOVEMENT. 507 joint. Injury is very common at the shoulder-joint; acute disease of the head of the bone and cartilage is common at the hip ; and for elbow and knee there is a local periostitis, not at all uncommon and generally syphilitic, which may lead to immobility of the limb. To remember the possi- bility of these is to avoid any error, for all these lesions are prominently painful. An examination of the joint generally indicates a difference between the two sides, and for the syphilitic affection there is generally a considerable amount of swelling just above the joint ; and, of course, if we have to go farther, and apply electrical tests, the presence of un- diminished electrical excitability should settle any occasional difficulty there might be. Rachitic paralysis is of the same nature. There are few things more common than to have infants brought for par- alysis of the legs, and to find that they are rickety. Rachitic children have very tender bones. They are not only soft, but they are actually tender, and such children constantly cry when they are handled hurriedly or roughly. But here, again, the existence of rickets should be a diagnostic safe- guard, and the persistence of pain makes the solution of the case easy. Infantile paralysis will sometimes need to be distinguished from many other paralyses as they occur in children, and perhaps chief of these is the paraplegic form — from paralysis due to compression of the spinal cord. In this the para- plegia is often very incomplete ; it may be associated with rigidity, and the reflexes, in place of being abolished, are manifestly exaggerated, whilst the muscular atrophy is re- placed by mere flabbiness. Some affections of the bladder may also help one to a conclusion, although the irregulari- ties of infants in this way tend to obscure an otherwise help- ful symptom. The spinal column should, however, in all cases be carefully examined, as spinal caries and curvature may occur in babies of but a few months old. 508 THE DISEASES OF CHILDREN. Hemorrhage into the cord (haemato-myelia) appears some- times to occur, and a diagnosis might indeed be exceedingly difficult in some cases. It might be expected to be less local- ized in its effects, and thus rather to produce the symptoms of central softening, with its anaesthesia, its tendency to bed- sores, paralysis of sphincters, and exaggerated reflexes, Late cases may also be confounded with the atrophic stage of pseudo-hypertrophic paralysis, or progressive muscular atrophy. The latter, however, is rare. In late cases of infantile paralysis the atrophied muscles may be replaced by fat, and pseudo-hypertrophic paralysis is followed by ex- treme wasting of the muscles. The history must, in these cases, be relied upon. The slow progress of the pseudo- hypertrophy, the characteristic walk, and slow atrophy with long-retained electrical reactions, must serve in most cases to distinguish them. Before quitting this part of the subject, and as I have already alluded to the occasional occurrence in adults of a similar affection, and now again to the occasional appear- ance of progressive muscular atrophy in children, it seems worth while, from a diagnostic point of view, to draw atten- tion to the interesting contrast that exists between infancy and adult age as regards the diseases of the spinal cord to which the two epochs are liable. Acute spinal paralysis is common in children, it is most rare in adults; chronic spinal paralysis is common in adults, and very rare in childhood. Looking a little further into the matter we can see that this is just what might be ex- pected. Children are subject to sudden and violent febrile attacks, and their tissues are constantly in a state of change and development. Adults are far less liable to the exciting cause, and their tissues have reached such a condition of stability that they do not take offence so readily, but when they are disturbed they recover more tardily. On the other DISORDERS OF MOVEMENT. 509 hand, the conditions which lead to chronic spinal paralysis and its consequent muscular atrophy are probably quite dif- ferent ; they are in great measure degenerative, or entailed by various local diseases of bloodvessels, capillary hemor- rhages, and so forth, which are not likely to be found in young people at the time of life with which we are now deal- ing. At the same time we must be prepared occasionally to find such a case even in childhood. Prognosis. — Infantile paralysis but rarely threatens life, although complete recovery is the exception. Ross states that if the Faradic contractility of some muscles and nerves be diminished at the end of five days, and abolished during the course of the second week, these will remain perma- nently paralyzed. The loss of power will, at any rate, be in proportion to the completeness of the loss of Faradic irrita- bility ; but so long as there is any reaction to either current, so long some restoration of motor power may be expected. After many months have elapsed of complete paralysis, a fortiori, after a year or two — as often happens in hospital cases — any hope of recovery is out of place. We can then only look for such amelioration as accompanies the better nutrition of the limb which sedulous attention may still procure. • Treatment. — The only question that arises is when to commence the application of electricity — that is to say, what should be done in the very early stages. It is not often that the disease comes under notice at this time, but if it should, some advocate resorting at once to electrical treatment, whilst others urge that any acute disturbance should be allowed time to subside, There is no doubt that treatment has to be steered between Scylla and Charybdis — those on the one side, seeing the dangers of adding to a process they suppose to be inflammatory, advocate rest; those on the other insist on the early and hopeless degener- 43 5IO THE DISEASES OF CHILDREN. ation of muscle if electricity be not resorted to. Now, assuming the observations to be correct which have been made, and that the early stage of infantile paralysis is one of vascularity and cell proliferation in the spinal cord, I think there can be no question that we should not be too ready to worry the cord into action. I can conceive that great harm may be done in such a case. But we must also remember that the initial process, in all probability, rapidly subsides, and much of the original affection clears up, and when this happens — in the course of five or six days after the onset — we may begin to pay attention to local treatment. Till then I should certainly administer such things as con- trol the circulation — aconite, ergot, digitalis, and iodide of potassium being the chief. I should probably give half a grain of iodide of potassium with a drop of tinct. digitalis every two or three hours, or if the fever were severe, half a drop of tincture of aconite every hour for a few hours at a time. The iodide may be replaced by a grain of hyd. c. cret. administered night and morning, or a local inunction of mercurial ointment may be adopted over that region of the cord which corresponds to the paralysis. Cold baths, ice compresses to the spine, and so on, would also be advis- able, in such cases as they might respectively seem suited to. In the later stages two results may be aimed at — get- ting some repair in the spinal cord, and keeping the muscles in a good state of nutrition. For the first object electricity is usually advised, galvanism being applied either to the muscles or to the spine. Erb recommends that the poles of the battery be attached to large sponges, one of which is applied over the supposed seat of disease behind, and one on the abdomen in front, and thus a gentle current is trans- mitted through the cord. He thinks little of the value of the peripheral application, but it is the one more usually adopted. There could hardly be any objection to applying DISORDERS OF MOVEMENT. 5" both methods. In the application of electricity to young children, however, there is a great difficulty. The sensation is a strange one, and frightens them ; it must therefore be administered with great caution and patience, the weakest currents being used at first and for some time, in the hope that the stronger may be more gradually applied. But in addition, or rather, I should say, before all things, plenty of bathing and rubbing to the muscles by the hand is quite as useful in its own way, and quite as essential as the applica- tion of electricity, and should be practiced frequently and patiently. For this the hand should be well oiled and the part rubbed and shampooed gently for a quarter of an hour twice a day, and when two or three weeks have passed by the child should be encouraged to make what use it can of the limb. Another important point is keeping the limb warm. A notable characteristic of such parts is their lividity and coldness. They should be enveloped in the warmest wraps and, in very young children, in cotton wool. In the various muscular failures, the antagonizing mus- cles, so far as is possible, should be controlled in some way by aiding the weaker muscles by strapping, or bandages, or india-rubber. But for details of this treatment the reader must be referred to works which specially treat of the subject. Hemiplegia. — When a child with loss of power in its arm or leg is brought for advice, there is a tendency in the mind of the beginner to assume that this is due to infantile paralysis. But, according to my experience, it is not un- likely to prove on examination to be some other form of paralysis than an anterior polio-myelitis, for hemiplegia or monoplegia of cerebral origin is not uncommon. Causes. — Hemiplegia in an adult is mostly due to apo- plexy from atheromatous vessels, to embolism, or to syph- 512 THE DISEASES OF CHILDREN. ilitic thrombosis. In childhood; however, we can exclude atheroma, and of syphilitic disease very little is known except as a cause of meningitis. I will not, however, go so far as to say that syphilitic disease of the vessels is not often present. More investigation is wanted in this direc- tion ; one of my own cases came on after snuffles. From notes of eighteen cases of hemiplegia, the common cause appears to be infantile convulsions, or some morbid condition associated with them. There was a history of an onset of this kind in seven cases. Heart disease will account for others — first, by embolism, as in adults ; and secondly, from the changes succeeding to some of the exanthemata, more particularly scarlatina and typhoid fever (one in eighteen). Some cases are no doubt rightly attributed to injury (three out of the eighteen), and others are due to the growth of tubercle. Tubercle may cause even sudden paralysis, but it more frequently produces hemiplegic or monoplegic tremors, and weakness of muscular force of any kind. Tubercular meningitis but seldom causes hemiplegia, it is more liable to cause local paralysis, the chief example of which in frequency and importance is squint. But, as yellow tubercle, the disease forms masses which, slowly and insidiously, undermine parts of vital importance which sud- denly give way. They more often occur in the cerebellum, but by no means always ; sometimes the cortex cerebri is attacked ; sometimes a large mass may be situated in the centre of the corpus striatum. Therefore, if there be any history of previous wasting ; any of discharge from the ear, or ill-health of scrofulous type, it will be wise to be on the watch for disease of tubercular nature. Three of the eighteen cases before referred to are attributed to tubercle in the brain. Tumors other than tubercular are also causes of paretic conditions, but since these receive separate consider- ation there is no need of their further mention here. DISORDERS OF MOVEMENT. 5 I 3 One other cause of hemiplegia, though not a common one, still remains — viz., cerebral abscess. Aural discharge, with suppuration in the middle ear, may lead to cerebral abscess with or without disease of the petrous portion of the temporal bone, and abscess may cause hemiplegia (once only in the eighteen). It does not usually do so, because the white matter allows of its gradual enlargement without symptoms till it gets to the surface, which, when it reaches, it inflames and causes death by acute meningitis. In three out of eighteen cases no cause could be assigned for the attack. Lastly, there is hemichorea. To remember its existence, as I have so often said, is to detect it, and thus to eliminate it from hemiplegia in ordinary. But it is quite a common thing for a girl or boy to be brought for paralysis of one side or one arm. The child, it may be, has an idiotic ex- pression, and the restless twitch of a finger, a shoulder, or some of the muscles of face or neck, reveal the disease in a moment. With the caution that chorea is a condition in which definite embolic paralysis sometimes occurs, we may refer the reader to the chapter devoted to chorea for any further information concerning that disease. Functional hemiplegia is not often found in children, but I have seen two well-marked cases in boys — of which a few details will be given in the section devoted to functional affections. Morbid Anatomy. — Very little is actually known about many of these cases, but the subject is one of particular interest, because, apoplexy of the substance of the brain being excluded, one frequent cause in adult life of severance of the continuity of the motor tracts is absent; whilst an adequate cause of extensive cortical lesion is present in the fact that so many cases appear to originate in consequence of convulsions. One cannot but suppose that infantile con- 514 THE DISEASES OF CHILDREN. vulsions are not unlikely to produce intense cortical conges- tion of the brain, and then to lead to meningeal hemorrhage, and to produce hemiplegia. If not this, yet they may initiate chronic changes in the membranes, which will not only thicken them, but will also compress and lead to atrophy of the entire half of the brain. Thus, years afterwards, it may happen that a unilateral atrophy of the brain is found, or perhaps a large cyst full of serum or chocolate-colored fluid and cholesterin. When we find such changes, there is generally, from the lapse of time, great obscurity about their origin; but we know, from recorded cases, that such dis- eases as pertussis, which produce sudden and extreme tur- gidity of the vessels of the brain, occasionally cause meningeal apoplexy and death. It is, then, a reasonable hypothesis, that surface hemorrhages of similiar origin sometimes also start more chronic evils. Further, although syphilis but seldom leads to gummata, there is evidence in favor of its power to produce meningitis, and if this is allowed, it would follow as at any rate not improbable that pachymeningitis would sometimes be found ; and, besides these causes, there are all the slow processes, partly hemorrhagic, partly inflam- matory, set in action by injuries and by unhealthy inflam- mations about the floor of the skull, chiefly about the internal ear. As regards embolism, one may wonder that it is not more common than it appears to be. Heart disease is common enough ; but it is to be remembered that whenever apoplexy of the substance of the brain is found in young people, a careful search is to be made for an aneurism on some branch of the cerebral vessels, and for heart disease, which, through embolism, is the common cause of the hemorrhage. The hemiplegia, which sometimes occurs after the exanthemata, is probably embolic, and due either to some endocardial inflammation, or possibly to the detachment of clot which DISORDERS OF MOVEMENT. 5*3 has formed in some pouch of a dilated ventricle, owing to the deterioration of the muscular substance resulting from the fever. I ought not to omit to add that cerebral besides originating, as already mentioned, is a recognized sequel of pleuritic effusion, and of chronic disease of the lung, associated with dilated bronchial tubes — a sequel due, it must be supposed, to the formation of thrombi in the pulmonary veins, to their detachment, and thus to embolism of the brain. Symptoms. — In my own cases the paralysis was right- sided in twelve, left-sided in six. I have never noticed any association with aphasia, although such a condition is described by Gerhardt. Once or twice I have a note that the child had spoken less well since the attack. If it be the fact that in most cases of right-sided paralysis aphasia is not present, it is a point of great interest — though it is what might be expected — that in early life the word-memory on both sides receives some cultivation, and it is only in later life that that on the left side becomes the main one. Of the right-sided cases, all were under six. In one or two of the cases some rigidity was associated with the hemi- plegia, and this is not an uncommon occurrence; it is men- tioned by Gerhardt and other writers. In some cases the face is temporarily paralyzed, as in adults : in five this was so; in three questionably so ; in eight not; in one there was ptosis also, the child dying with a yellow tubercle in its brain ; once there was paralysis of the tongue. Prognosis. — Many of these cases are not complete, and either slowly recover or result in some curious anomalies of muscular movement, which may, perhaps, be grouped together under one term, athetosis, or post-hemiplegic chorea. But in some cases the loss of power is complete and per- manent ; late rigidity and wasting of the affected extremities 5 l6 THE DISEASES OF CHILDREN. occur, as in adults ; and the development of the entire half of the body may be more or less arrested. Treatment. — As in other forms of paralysis, when there is no reason to suppose that life is in danger from tubercle or other causes, every attempt must be made to keep up the nutrition of the muscles by massage, bathing, warm cloth- ing, etc. Electricity should also be regularly applied to the muscles when possible. In the earlier cases, for many there is not much to be done, save to keep the child quiet, and see that it is fed properly and kept clean. Supposing that there is any rea- son for suspecting a syphilitic influence, this must of course be treated. The ear should also be examined, in case some disease may have originated there and an abscess be existing inside the skull which might probably be reached by a trephining operation. MOTOR DISORDERS. 5 i7 CHAPTER XXXVIII. MOTOR DISORDERS— (Cbnthtued), Pseudo-hypertrophic Paralysis is a disease which attacks children almost exclusively, and appears to run in families, affecting several members of the same stock. Those affected are nearly all boys (190 out of 220, Gowers), and as with haemophilia, it descends to the males by the females. Many of them stammer, and are of feeble intellect, and Chwostek has described an enlargement of the tongue in some cases. The essential features are enormous buttocks and calves, associated with great muscular feebleness, so that the gait is peculiar. The other muscles of the body are usually feeble, or even wasted, but they seldom show enlargement compa- rable to that of the calf and buttock. The disease is of such slow progress that few seem to have been able to watch its onset, and, lasting as it does for years, not many cases of death are recorded. It appears, however, to lead slowly to a fatal issue, either by general muscular atrophy and diffi- culty of respiration, or general marasmus. Morbid Anatomy. — In all cases where an examination has been made, the affected muscles have been found to be — if in an early stage — separated by abnormal growths of fat in the interstitial tissues ; if the stage be late they are replaced, or rather crowded out, by fat. The evidence as regards the state of the spinal cord is contradictory. The examinations of the cord in such cases have not been many, and it has once or twice been found diseased ; but the gen- eral opinion at present held seems to be that the affection is a local one of muscular origin. 44 5 l8 THE DISEASES OF CHILDREN. The distinctive features of the disease are the slow prog- ress and the very gradual loss of electrical power — a loss corresponding to but following the wasting ; differing thus from that of infantile paralysis, or anterior polio-myelitis, which precedes and is out of proportion to the wasting. But a time may come in this disease when the muscles being in a state of complete atrophy, it is impossible to recognize its characteristics, and in which it is difficult to distinguish be- tween it and progressive muscular atrophy. To my mind this is an important point in the disease. The elephantine buttocks and calves and the feeble intellect form a clinical picture which perhaps no one could well mis- take ; but when we say that the pseudo- hypertrophy may be little, the muscular atrophy very general, and that in any case of muscular atrophy a growth of fat may appear and replace the muscles, the distinction is by no means always easy. My own experience has been singularly meagre in typical cases, but it has supplied me with several of the more doubtful kind, and, inasmuch as they certainly form an in- structive group, short notes of them are appended. Ernest M., set. 12. His father is a very drowsy man, and suffers from intense headache. His mother has had rheu- matism twice, and three years ago some nervous affection, for which she consulted Dr. YVilks. One of her children died of " water on the brain," and another of " cleft palate." This boy, when he first began to walk, at fifteen months, was noticed to do so in a strange way, walking from his hips, swaying from side to side, and not bending his knees. When four or five, he improved slightly, and could walk for short distances without the aid of sticks. This continued till he was about nine, he being able to walk and play in a manner, but never like, or with, other boys. At nine years old his powers of locomotion again deteriorated ; he refused to go out, and when walking would help himself by means MOTOR DISORDERS. 5*9 of chairs, etc. For the last twelve months he has been car- ried about. It was also noticed that while he was becoming thin and emaciated, his calves and gluteal regions were well developed, in walking about he protruded his buttocks and his back was arched. His parents think that for four or five years his arms have become thin and wasted. His mental condition has always been good. He is a pale boy, with stammering speech, but sharp and intelligent. He lies in bed, and experiences the greatest difficulty in turning over. After much effort, he can manage to raise himself on his knees ; but he has to support himself with his arms. His legs are spare, and there is talipes equinus of both feet. His calf muscles are not large, but they are remarkably hard ; and when he lies in bed there is an unusual gap betw r een the thighs, which makes it appear that there must be something wrong in the setting of his hips ; but this is probably due to wasting of his adductor muscles. His lower limbs are capable of every variety of movement, but in a very feeble way. He takes his hands to help his legs when he wishes to cross one over the other. Tendon reflexes are all absent. Skin reflexes are all present. When he is placed on his feet his buttocks protrude and his spine becomes much arched, but probably only because in this way alone can he compensate for the talipes, and put his feet flat to the ground. With electricity, all the muscles, legs, and arms, and trunk, fail to respond to a weak Faradic current, to a strong one the left arm and leg act more than the right, and the trunk muscles act rather better. To a galvanic current applied to the muscles there is some response to fifteen cells. Electrical sensation is much diminished below the knees. Ordinary sensation is undiminished. This case was seen by several physicians and surgeons, and various views were entertained of its nature, but I ulti- 520 THE DISEASES OF CHILDREN. mately came round to the opinion originally entertained, I believe, by Dr. Moxon, that the case was one of the atrophic forms of psuedo-hypertrophic paralysis. Case 2. — A boy of nine, whom I only saw once as an out-patient. He had not been known to be ill, but when he ought to have walked it was found that he could not do so. He did not walk till he was six years old, and then but badly. He was better than he had been. He walked in a most decrepit manner, with his knees bent and the feet dragging. There was no incoordination or jerking. When lying down the limbs were still flexed at the knees, and the muscles of the hams were spasmodically taut. The limbs were spare without decided wasting, and without disease of the joints. He had been treated with electricity and cod-liver oil without decided benefit. This case seemed in some respects very like that already detailed, though its nature must be considered very doubtful. Case 3. — A boy of three and a half years. Had good health until five months before his admission. He was then languid and ill, and if he attempted to walk would fall down. He retched in the morning for a week or two. When seen by Dr. Willcocks, five or six weeks after this onset, he could walk in a tottering manner, with his legs much apart, but if laid on his back he could not get up again. About this time internal strabismus appeared. Now he can roll over, but cannot walk at all. The superficial reflexes are normal ; the deep are absent, save slight clonus at the right ankle. His limbs are plump, and there is moderate hypertrophy of the calf and gluteal muscles. The lumbar muscles stand out considerably when he sits up in bed, which he can do with a forward lean. He is unable to stand alone, falling forward if unsupported. In walking with support he throws his legs helplessly about, and keeps them wide apart. In attempting to raise himself from the ground he rolls over, MOTOR DISORDERS. 521 and rests his arms on his knees, but without effect so far as getting up is concerned. There is no lordosis. The elec- trical reactions are normal with both currents. Case 4. — A boy of nine. Began to walk at the age of twenty months, but he had always been weak and never able to get about like other children. He had gradually im- proved without any treatment, and was stated to walk much better than he could two years ago. He could walk about the ward quite well, but, like Case 5, he had great difficulty in mounting the stairs. He could only accomplish this by hanging on to the balustrades, and pulling himself up with his hands. Further, he could not rise from a sitting pos- ture. He would get on his hands and knees and blunder about, and, when he would seem almost to have accom- plished his purpose, would roll over again. He was a spare boy, of average intelligence, and without anything that could be called hypertrophy of the muscles, but to very careful examination the muscles of his thigh, and particularly the extensor cruris, had a hardened feeling which was suspi- cious. His thigh muscles failed to act to Faradism in any way, but they acted to tw r enty-four cells of a constant cur- rent. There was no patellar reflex on either side. He was galvanized and shampooed with much regularity for four and a half months, but very little improvement resulted. Case 5 was a boy of six or seven years, much like the last-mentioned case, who was brought to me because he could not walk upstairs, or pick himself up from a sitting posture. If sitting on the floor, he would turn over on to his hands and knees, but the weakness of his glutei and the extensors of his legs and thighs was such that he could not get himself into the erect posture without assistance. When he was erect he had no trouble in walking or running about, though I believe he was apt to tumble occasionally. He was a very spare boy, but the muscles were not definitely wasted, and I supposed his case to be one of this group. 522 THE DISEASES OF CHILDREN. The disorders of movement of patients affected with pseudo- hypertrophic paralysis are chiefly dependent upon weakness of the muscles of the lower extremities. Feebleness of gait is first noticed, and frequent falling; the legs are kept wide apart for the sake of steadying the badly-balanced trunk ; as they walk there is a half-rotatory, half-shuffling, movement to enable the forward step to be taken. Next there is the difficulty of getting up from a recumbent posture, the move- ment being accomplished by the hands, which, placed upon the knees and thighs, push the trunk upwards to supply the action of the paralyzed extensors. As the result of the paralysis of the extensors of the pelvis on the thighs lordosis follows, and later there is talipes equinus, and the patient cannot get his heels to the ground. The calf muscles are usually the first affected, then follow the glutei, and ulti- mately other muscles of the thigh, pelvis, trunk, and upper extremities. The pseudo-hypertrophy is a very variable element, but in most cases a great deal of quiet atrophy may be going on in various parts, obscured by the seeming attrac- tion of the parts which are enlarged.* Diagnosis. — It needs chiefly to be distinguished from infantile paralysis and progressive muscular atrophy. As a general rule the history will allow of its distinction from infantile paralysis, which comes on suddenly. The latter is rare. Prognosis. — It does not appear to have any tendency to ameliorate. Its course is very chronic, and may last from * There is at the present time a boy, aged eight, under my care in the Evelina Hospital, who very well illustrates this point ; for, while his calves are decidedly prominent, the muscles of his arms and shoulders are v This case also emphasizes a point I have observed in others, that it is at as important to pay attention to the indication as to the enlargement of the muscles. There are muscles of the arm which would pass for normal, or possibly as wasted, but which, from their peculiar hardness, are no doubt undergoing the changes which in the calves have produced the enlargement. MOTOR DISORDERS. 523 childhood to puberty. Death usually comes at last from exhaustion. Progressive Muscular Atrophy is not a disease of child- hood, but it occurs occasionally. The following notes are perhaps from a case of this kind : A boy of nine came for wasting of his right hand. It began three years before he came, and went on progress- ively for two and a half years, but had been stationary for six months. The hand ached much at first when he at- tempted to write; and latterly he had had pain and weak- ness in the outer side of the arm. He had never had any fit. He appeared healthy ; but there was extreme wasting of the muscles of the right hand and of the forearm. The fore- arm near the elbow measured f inch less than its fellow. There are many other curious forms of paralysis met with in childhood. I cannot say that they are common, but they are met with occasionally. In looking over my notes, and attempting to arrange the cases in some order, it seemed to me that they would be most instructive if they were simply enumerated with such notes of the cases as might seem desirable. A large group of cases, for example, may fall under the denomination of ataxia, using that term in a wide sense to indicate imperfect muscular control. In some cases it takes the form of rhythmical or irregular movement of the head. In infants this is often associated with nystagmus, and then is denominated the nodding spasm. Very little is known about this affection. There is no suspicion of blindness with nystagmus in this association ; and we can only say that it appears to be some anomalous play of nerve force ; that it is a disorder of dentition more particularly ; and as such is liable to come and go with the occasion. Sometimes, how- ever, the movements are by no means regular, but are re- placed by a decided jerking action, much more at some times 524 . THE DISEASES OF CHILDREN. than others. It is not only confined to infants ; I have seen on two or three occasions, in older children, a peculiar jac- titating movement of the body, trunk, and extremities, which has closely simulated the movements of insular sclerosis in the adult. I suspect that cases of this kind have passed for such in the few recorded cases of insular sclerosis in child- hood ; I do not think that any autopsy has yet confirmed the diagnosis. These cases may be found at any age. I have notes of such at three and a half, six, and nine years. In one case (set. nine) the disease was said to have existed from birth. In another case it was apparently hereditary, for the father was so unsteady in his fingers that he could never button his shirt-collar; whilst his son, a boy of six, wrote his name in a series of unintelligible zigzags, and in attempting to steady himself to put a glass of water to his mouth, the muscular movements became violent. This affec- tion had been noticed ever since he first began to play with blocks ; but he had never had any fits or any illness. He was a sharp, nervous child, and easily frightened by sudden noises, and then lost his self-control and stammered. In another case a child of six had had a fit, and was idiotic, though sensible enough to express his satisfaction that he had " done with the doctors " after we had finished examining him. He used his hands in an ataxic way ; got at a button of his waistcoat with difficulty; and only after many efforts, in which the arms made wide excursions, did he succeed in unbuttoning. This child spoke slowly and laboriously, and walked in a tottering way, and would fall quickly if not held up. All these were boys. In a girl of four the disease came on after " brain fever; " probably the initial fever of measles and whooping-cough which she had at that time. It is very difficult indeed to refer these cases to any actual lesion ; and some would get over the difficulty by calling MOTOR DISORDERS. 525 them congenital chorea. So far as treatment is concerned, it is useful to consider them — like the cases of some of the imbeciles with spastic paralysis — as instances of faulty con- trol and training, which will be bettered by a laborious and patient practice. The same thing happens under other cir- cumstances. After diphtheria, for example, and in many a case of tumor of the pons, the movements are very similar, and here there appear to be exactly the conditions required for the necessities of the hypothesis that cerebral control being stopped, or rather impeded, tremor and jactitation result. This, indeed, is often the question for diagnosis. A child, with tottering gait and jactitating arms, comes for treatment. The first thing that occurs to one is the possible existence of tumor of the pons or cerebellum. As a mere question of muscular disorder, such a case might readily pass for one of tumor. The decision must rest upon the existence or not of other evidences of tumor, such as optic neuritis, headache, vomiting, and the like. Facial Paralysis, of any persistence and completeness, is, in adults, far more commonly due to peripheral causes, such as exposure, than to any known central lesion. In children, the reverse happens, and it is but seldom due to the like cause. I have seen it once only in a girl of about eight years. Henoch and Steiner have, however, recorded cases of this kind. It occurs sometimes in infants soon after birth, and is due to injury in delivery. It usually passes off within a short time ; but the affection sometimes remains throughout life. A congenital and irremediable form is described by Henoch, the cause of which is un- known. Abscesses and enlarged glands behind the angle of the jaw also produce facial paralysis ; and it has been known to result from congenital syphilis (Barlow) ; but, more usually, 526 THE DISEASES OF CHILDREN. it connotes aural discharge and disease of the middle ear. Such cases are prone to die from tuberculosis. Disease of the ear may cause abscess of the brain and suppurative meningitis, as in later life ; but my own experience quite coincides with that of others, that tuberculosis, in one part or another, is liable to supervene when aural discharge and facial paralysis are co-existent. There is usually extensive disease of the temporal bone in such cases, and perhaps it is thus that it is an evidence of the tubercular tendency. Facial paralysis is, therefore, of very sinister omen in infants and young children. Hemiatrophia Facialis is a very rare condition, but some forty or fifty cases have been recorded. Latterly, two very striking cases, with photographs, have been published by Messrs, Jessop and Brown, from Dr. Gee's wards, in the " St Bartholomew's Hospital Reports." The disease is not jsively infantile; but Gerhardt has collected ten or twelve cases in children, and Jessop states that thirty-five began before the age of twent It is characterized by wasting of the muscles of one- half of the face, generally the left. The palpebral fissure narrows, the eye sinks in. the cornea becomes ulcerated, and the eye destroyed. In many of the cases there is neuralgic pain and some early pigmentation of the skin. Three other spasmodic affections may be mentioned in one group — viz., internal strabismus, nystagmus and retrac- tion of the neck. Internal strabismus is the common form of squint. It may be either concomitant or paralytic ; the former is due to excessive development or excessive use of the internal, the latter to paralysis of the external, recti. Concomitant squint is much the more common and is mostly due to hypermetropia. My colleague, Dr. Braiiey, tells me that some error in refraction is present in at least 70 per cent, of MOTOR DISORDERS. all cases, although in, perhaps, a third of this number the hypermetropia is so low that it would be difficult to accept it as the real cause of the squint. But by this prevalence of hypermetropia sufficient to produce it, a difficult introduced because the squint is frequently stated to have followed upon a convulsion. A history of this kind must be received with great caution, nevertheless it is probably true for som- ind one can then only suppose that the central disturbance has upset a muscular balance, hitherto only maintained with difficulty, and which, once disturbed, is unable to recover itself. For such cases as are not due to hypermetropia, some are thought to be dependent upon some congenital want of balance in the ocular muscles; others upon some defect in vision ; others, perhaps, upon defect in the centres for the movements of the eyeballs either of congenital origin or arising out of the disturbance of acute meningitis and so forth. Paralytic squint is most often a symptom of tubercular meningitis ; occasionally, perhaps, one of the results of a by-gone basal meningitis. The treatment of squint belongs to ophthalmic sur:; Nystagmus (oscillation of the eyeballs), when not a symptom of the nodding spasm,* is usually associated with amaurosis, or defective sight. Of six cases, four were blind ; it is usually met with in infants a few weeks or months old, and is liable to be associated with blindness of any form. Thus it is found with cataract, as well as with congenital defects at the fundus oculi. The nature of this muscular anomaly is obscure, but the fact that many cases occur when blindness has prevented the acquirement of the power of fixation seems to suggest that the faulty movement, if sometimes due to a central lesion, may at others be the re- sult of the want of training which the ocular muscles suffer --'■-■: 528 THE DISEASES .OF CHILDREN. when faulty vision is congenital or dates from very early infancy. The lens and the fundus oculi should be carefully examined for local disease. The presence either of cataract or possibly some local distribution of retinitis or choroiditis might allow us to hold out some hopes of relief by opera- tion ; for probably it can be said of this as of other muscular aberrations, that, no matter what the primary disease may be," some improvement may be expected by allowing educa- tion of the muscles to come into play. Cervical Opisthotonos is a symptom only, but it is of such importance as to demand a paragraph to itself. Dr. Gee and Dr. T. Barlow, in the St. Bartholomew's Hospital Reports, give notes of twenty-five cases of this affection in infants, varying from birth up to nineteen months. It is sometimes of gradual, sometimes of sudden, onset. It is often chronic, tends to remit in severity, is associated with rigidity of the limbs, convulsions, and hydrocephalus, and, in the majority of cases, terminates fatally. In all the cases (six) in which an examination was made after death, a basal meningitis of a non-tubercular nature was found. These authors note recoveries in a somewhat cautious manner, from the known tendency to remission which the disease exhibits ; but there can be no doubt that retraction of the neck does subside in some cases, and that even a meningitis of the base with retraction occasionally gets well. The case must be gone into completely, as sometimes the opisthotonos has appeared to me to be like torticollis, either of rheumatic origin or due to some temporary gastric dis- turbance. All these three affections — strabismus, nystagmus, and cervical opisthotonos — are worthy of investigation, from the interest which attaches to them with respect to the observa- tions of recent years as regards the localization of cerebral functions. Ferrier has shown that retraction of the head is MOTOR DISORDERS. 529 associated with destruction of the posterior part of the middle lobe of the cerebellum, and that disturbed movements of the eyeballs are found with other cerebellar lesions. It seems, therefore, not at all unlikely that what has been shown to be true for retraction of the head, both experimentally and clinically, may also be sometimes true for nystagmus and some forms of squint, and that a case may occasionally find its explanation in some bygone basal meningitis. Torticollis, or stiff neck, might perhaps be made the text for dwelling upon the question of the existence of muscular spasm from local causes. But, of late years, this latter group of cases has been by common consent much reduced by en- larging the area of central or nerve spasm. Wry neck, however, does seem still to remain more local or functional than general. Although in ignorance of its cause, perhaps it may be introduced here as related, I think, to occasional cases of retracted neck. Torticollis is a frequent affection of childhood ; it occurs in rheumatic families, in children who are anaemic and out of sorts ; it may also occur as a result of reflex irritation from enlarged glands, decayed teeth, etc. It is a disease of childhood, not of infancy, and cannot, therefore, be easily confounded with the spasm and contrac- tion due to the sterno-mastoid tumor, sometimes found within a short time of birth, and supposed by many to be the result of injury to the neck in delivery. Treatment. — Any local cause must be looked for, and, if possible, remedied. If none can be found it is advisable to give some gentle laxative and saline, such as the effervescing citrate of magnesium, pyretic saline, or some such mild aperient, one drachm three or four times a day, and, after a day or two to give Easton syrup or Parrish's food or a like tonic. Spastic Paralysis is, no doubt, best known in adults as 530 THE DISEASES OF CHILDREN. spastic paraplegia, or spasmodic spinal paralysis, and its symptoms are tolerably constant. They are gradually devel- oping motor paraplegia, associated with muscular twitch- ings and rigidity, sometimes contractures, and a great in- crease of the reflex activity of the tendons. The paralysis appears to be in great measure due to the excessive reflex excitability and the muscular rigidity which exist, and which lead to the characteristic gait ; the rigid limbs being dragged along with difficulty and the toes clearing the ground badly. Certain negative symptoms are not less important as regards the diagnosis. There is no affection of sensibility, no wasting of the muscles, and no disturbance of the functions of the bladder. But §pasm is by no means uncommon in the pa- ralysis of children. It is said more often to take on a one- sided pattern, and has received the name of spastic hemi- plegia ; but whether hemiplegic or paraplegic chiefly, certain peculiarities attach to it. First of these is the frequency with which it goes with idiocy and also with fits. Of ten cases, six boys and four girls, of which I have notes, eight were imbecile ; two only are noted to be intelligent. It sometimes occurs in the youngest infants with small brains (microcephalus) ; but more often it happens that the child has been quite well up to a certain time, and has suddenly been taken with severe brain symptoms and fits. The in- ability to walk has closely followed, and the idiocy has slowly supervened. These points are perhaps better illus- trated by short notes of cases : Case i. — A boy of two and a half has squinted since birth, has never been intelligent, and never walked ; has never had a fit of any kind ; he is quite imbecile ; there is internal strabismus and nystagmus ; the optic discs are bluish-white and atrophied; both legs move badly; they are spasmodically flexed at the knees, and can only be kept straight with difficulty. He is quite unable to stand for this reason. MOTOR DISORDERS. Case 2. — A boy of seven had a fit at the age of three years, remained well for twelve months, and gradually after this lost power of walking and talking; at first he walked on his toes. When lying down, his legs are rigidly extended, with pointed toes, resisting attempts at flexion. Case 3. — A girl, aged four. The original notes are 1 She is imbecile ; has fits ; there is internal strabismus, and the fundus oculi is hazy and swollen ; her legs and arms become quite rigid on slight stimulation ; the legs are so rigid that she is quite unable to stand alone. Case 4. — A boy of six and three-quarters. His paternal aunt became idiotic after fits ; a great-aunt died in an asylum with brain disease ; three other children died with convul- sions. The present patient was suddenly taken with vomit- ing while in bed five weeks before. A fit followed quickly, in which he had deviation of head and eyes to left, and loss of power in the right leg. He had many fits afterwards, ex- tending over a fortnight, and since then has lost his memory and power of speech. He does not now recognize his rela- tions. He is idiotic, but does as he is told. The right arm is rigid, jerking in its movement, and tremulous when ex- tended. The leg is in a similar state, although he manages to walk in a clumsy and unsteady manner. Sensation is normal. He is said to have been quite blind when he had the fits, and quite without sensation on the right side, even to the pricking of a pin. The fundus oculi is normal. Bridge of nose rather sunken, but no evidence of congenital syphilis. Case 5. — Girl, eight and a half years. Quite well and intelligent a year ago. Had a bad feverish attack, and was in bed a fortnight. When up again, was unable to use her legs well, but crawled about with a chair for six months, and now cannot walk at all. Has been getting babyish and mischievous for some months ; is now more like a child of 532 THE DISEASES OF CHILDREN. four in her manner. Both legs very wasted; slight contrac- tion of the flexors of the knee, so that she is unable to straighten them or put the sole to the ground. Pupils equal but sluggish ; hearing good, no otorrhcea ; teeth peggy, and crammed into the jaw very irregularly. Case 6. — Boy, aged three and a half. Early history want- ing. He cannot talk, and if he tries to walk, all his muscles become stiff. His hands and arms are spasmodically con- tracted, the wrists being strongly flexed, and the fingers over-extended, so as to be bent backwards towards the dor- sum. Muscles flabby, but not wasted. Expression imbecile. No note of fits. Case 7. — Boy, four and a half. Never had any illness, but never able to sit or walk ; head large ; high arched palate ; moves his legs irregularly, with much rigidity of muscles when attempting to walk, and temporary talipes equinus when put on feet. When lying on his back the legs and thighs become rigidly flexed ; arms, when attempt- ing to grasp, are shot out in a rigid extended manner ; but there is some control of left arm ; constant tremor of right arm, and athetosis of fingers. Case 8. — Girl, aged five. Convulsions a week after birth ; has never crawled or walked, and talks badly. Intelligent ; sight and hearing good ; picks up things clumsily — the ulnar side of hand and fingers being extended in a spas- modic manner — right side most marked ; in walking there is much initial rigidity of the muscles, which subsequently subsides. Some talipes equinus at first ; right leg more flabby and smaller than left ; both legs become rigid irregu- larly, apparently from irregular muscular action, partly reflex and partly voluntary; knee reflex absent on both sides. Case 9. — A girl, aged two years. Early history wanting. The parents are healthy ; but one other child has had "fits." MOTOR DISORDERS. 533 This child has a markedly contracted narrow forehead, with a microcephalic appearance and manner. The fontanelle is closed: there are no protuberances on the skull, and no evidence of rickets ; the face is well developed ; the arms and forearms are flexed and rigid; the thumbs inturned upon the palms, and the fingers clasped; the legs also are rigidly flexed. Directly she is touched the whole body passes into a state of rigid spasm, lasting for a few seconds. The sight is deficient in certain directions, and there are large patches of choroidal atrophy with central pigmenta- tion. Both of the discs are white, with pigmented borders, and on the right side one of the atrophic patches occupies the place of the yellow spot. In a tenth case, a boy aged three years, the distribution is paraplegic, and there is internal strabismus, with a skull of microcephalic type. But the child is rather precocious, and no cause of any kind could be elicited. The child had never walked. The disease, as it is found in children, is more general than in adults, and in many cases the rigidity is to be noticed in all parts of the body, or, at any rate, in all four extremi- ties. One side may be more markedly affected than the other. The cause of the spasm would in many cases appear to be due to uncontrolled reflex action, for directly the child is touched or startled in any way, all the muscles of the body start into a tonic spasm for a few seconds, and gradu- ally relax, the process being repeated over and over again, till the centre becomes temporarily exhausted, and the same stimulus fails to act so completely. These cases are sometimes, probably always, due to some central lesion. They are rightly called hemiplegic, in the sense that one side is often worse than the other, and the evidence is in favor of some one-sided lesion of the brain. In this respect they are evidently of the same class as the 45 534 THE DISEASES OF CHILDREN. post-hemiplegic disorders of later life, but these are uni- lateral ; in young children they tend to be bilateral. This difference probably finds its explanation in the time of life at which the lesion occurs. Now as at later dates, injury to the brain causes loss of control over the opposite side of the cord, and that half thus becomes more dominantly reflex than it should. The nerve-cells thus acquire a habit of quick discharge, and the blood supply necessarily becomes altered to meet the altered physiological needs. In the state of development such as now exists, it is impos- sible but that the fellow half of the cord should feel the influence of this uncontrolled action, and it also becomes timed to act in a similar way, although to a less extent. Thus the diseased action becomes more or less general. In the fully trained adult cord there would, at any rate, be less risk of such perverted action occurring, and, as a fact, it is not common. But in adults we associate this action on the one side with a degenerative change in the antero-lateral tract of the cord corresponding. Whether this is present in children is not known, but it seems hardly likely, at any rate in those cases in which it is associated with a microce- phalic brain. Perhaps it is, as Erb suggests, that the normal strands in these cases are never properly developed. It does not appear to me, however, that any hypothesis of this kind is necessary ; we have already a sufficient explanation in the damaged condition of the cerebral cortex, with its consequent deficiency of intelligence and control ; given this, and the functional development of the cord becomes arrested at the primitive stage of reflex action. The muscles are in consequence improperly controlled, irregularly exer- cised ; there is no harmony between the groups of muscles for complex action, they lapse into a state of spasm or con- tracture, and we have the very conditions with which we are concerned. Moreover there is one important fact about MOTOR DISORDERS. 535 these cases which seems to point in this direction — viz., that some of them improve very much as they grow in years. Case I is now ten-and-a-half years of age. He is much more intelligent, has learnt his letters, and can walk about very fairly, though he is clumsy with his feet. And I have watched an almost exact counterpart in another boy from infancy, till now when he is nine years old. I should add that the other symptoms are somewhat variable in these cases — in some there is muscular atrophy, in others none; in one or two the muscles have seemed to be replaced by fat, as in the pseudo-hypertrophic paralysis; and in some the eyes may be affected with cataract, retinitis pigmentosa, or choroiditis with atrophy. Prognosis. — This cannot be very hopeful; nevertheless, with much patience and attention, children may and do improve considerably. There is not, however, so far as I know, much chance of their being other than imbecile, and, even if at first the disease is not associated with epilepsy, there is a strong probability of its developing as puberty approaches. Treatment. — But little can be done medicinally. If there is any definite lesion, iodide of potassium or iodide of iron might possibly prove useful, and bromide of potassium and sodium, or one of these combined with the iodide, may be given to control the fits. All possible practice should be given to walking, and to as many definite muscular move- ments as possible. Regular daily shampooing is also of service. Electricity has not seemed to me to be of much benefit. 536 THE DISEASES OF CHILDREN. CHAPTER XXXIX. INFANTILE CONVULSIONS— EPILEPSY— NIGHT TERRORS. Infantile Convulsions include, besides severe and general convulsions, many cases* of local convulsive spasm or rigidity, such as strabismus, laryngismus, and that rigid inturning of the thumbs upon the palms and rigid flexion of the feet which have received the name of tetany, or carpo-pedal contractions. There is no essential distinction between infantile convulsions and epilepsy, so far as the fit is concerned ; the difference lies in the temporary character of the one and the chronicity or tendency to recurrence of the other. Nor will it do to push this difference too closely, for infantile convulsions may last, if not treated, for months. On looking over my notes, I find a tendency to class all convulsions under two years of age as " infantile," and all over that age as epilepsy, but in the epileptic cases are sev- eral in which the fits have continued since infancy. Per- haps this fact may have its instruction for us. The chronic tendency to convulsions which we call epilepsy unquestion- ably has much of habit in it ; each additional fit that comes makes the brain more prone to another, and it may well be that the convulsions of dentition, unchecked at their first onset, may in some cases become a confirmed habit, and thus chronic or epileptic. Eight out of twenty-six cases of epilepsy had suffered from infantile convulsions at an earlier date, and Dr. Gowers, working with much larger numbers, still makes the proportion as high as seven per cent, of all cases investigated, and he adds, it seems reasonable to ascribe to these convulsions of infancy a share in predisposing to INFANTILE CONVULSIONS, ETC. 537 the convulsions of later life. Neurotic heredity, according to the same observer, is found in thirty-four per cent., the same as for the whole of life. The convulsions of dentition, no doubt in part influenced by hereditary tendencies, are yet, it is now generally ad- mitted — following the observations of Sir William Jenner, and later of Dr. Gee — largely associated with rickets ; and it is believed that the impaired nutrition of which rickets is the expression is productive of an irritable or unstable con- dition of brain, causing it to discharge itself spontaneously, or on what would otherwise be an inadequate stimulus. A certain proportion of cases is due to actual brain disease. Of 102 cases recorded by Dr. Gee, one-fourth were due to local disease, and the remainder to general causes. These include various conditions, but only one of any numerical consequence apart from rickets — viz., some acute exanthem. Reducing the number from these causes, fifty-six cases re- main, and every one of them was rickety. Convulsion, then, during dentition, if it be not due to the onset of an acute febrile disturbance — and even in such case it is still possible that the same condition may sometimes be at work — is one of the modes of expression of rachitic malnutrition, and this is really the important factor in the causation of the disease. It is quite unnecessary to take up space by enumerating all the secondary conditions which in this state will induce a fit. I would say, with Dr. Gee, that the convulsive diathesis affords an opportunity to a thousand irritants, natural and unnatural. The reader can readily fill in for himself some of these numerous local fac- tors — the dentition, the worms, the indigestible food, the excited play, the febrile state, and so on. Symptoms. — These are not quite the same in infants as in older children and adults. Infants are said to turn pale, to turn up their eyes, to get black in the face, to catch their 538 THE DISEASES OF CHILDREN. breath, to become livid about the lips. Sometimes even babies will scream violently or give a cry before becoming convulsed. Sometimes they lose consciousness only, and wake up with a start. Once I noted insensibility, with a clonic convulsion of head and upper part of chest ; the chin on the sternum, and inspiration snoring. Laryngismus is common : sometimes there is tremor in sleep ; sometimes the whole body becomes stiff, and the breathing impeded, in a half-tetanic state ; sometimes even in infants the char- acter of the adult fit is maintained; there is the initial pallor, followed by lividity and convulsions — the fit commencing with a cry, and succeeded by somnolence. Lastly, may be mentioned twitching of the lips, half-closed and winking eyes, startings, and the condition of carpo-pedal contraction — the tetanie of Trousseau. In this condition the thumbs are bent rigidily across the palms of the hands, the sole of the foot is arched and the toes flexed. This state may last for many days, and remit and recur. Its importance is as an indication of the convulsive diathesis. It is a disease which occurs at all ages, but is far more frequent in infancy — according to Gowers, in the second decade of life also — than at any other period. In infancy it is more common in males than in females, and, as with convulsions, it keeps close company with rickets. Diagnosis, — The first point must be to search carefully for indications of rachitis ; their presence will tend to make one examine more critically the evidences of local disease which may present themselves. It will also be necessary, as far as possible, to assure ourselves of the absence of any acute exanthem. Very likely this will be impossible, for, in infants, pyrexia is quickly induced from numberless causes ; and the local factor which produces the convulsion will be liable to provoke febrile disturbance also. If an exanthem can be excluded, then there are the various local factors to INFANTILE CONVULSIONS, ETC. 539 be sought, chief of importance being brain disease, such as meningitis from disease of the ear, hydrocephalus, and so on. Excluding these, as we probably may do, in the absence of any evidence of cerebral disease save the con- vulsions — and, perhaps, a bulging fontanelle, to which I have already alluded, as having but little significance neces- sarily attaching to it — we next examine into the question of teething, food, state of bowels, etc. ; and we shall by that time probably be in a position to form some idea of the cause of the convulsion in the case before us. Results. — Hemiplegia may follow an attack of convulsion, as I have several times seen. It should be only of tem- porary duration ; but should it not pass off, or should any rigidity come on, some local disease of the brain in all pro- bability exists. Children sometimes stammer and are stupid after a fit. In several cases of idiocy the history of a fit is the first note of evil. Strabismus appears to be one of the common results of convulsion, the pre-existence of hyper- metropia notwithstanding. Lastly, I may note the curious and interesting observa- tion of Mr. Hutchinson, that zonular cataract is a frequent associate of infantile convulsions and rickets. It may be congenital, therefore the accuracy of calling it a result may be questioned ; but it may also form after birth, and it usu- ally affects both eyes. Prognosis. — Many children die from convulsions at this early period of life; and frequent and violent convulsions must necessarily constitute a serious danger. This will be the more especially the case when dependent upon such conditions as the onset of scarlatina or measles, or the ex- istence of whooping-cough. In the case of local disease of the brain, including, as it does, meningitis of all kinds, tubercle, tumors, chronic hydrocephalus, etc., the disease can hardly be increased in gravity by the onset of convul- 540 THE DISEASES OF CHILDREN. sions. But where it is associated with rickets, and the initial convulsions do not cause death, there is every hope that treatment will be successful in warding off their repeti- tion. Treatment. — In the actual convulsion what can be done should be done to stop it. This is not much ; but it is probable that the old-fashioned treatment, often called deri- vative, is of use, by lessening the turgid state of the brain which the fit produced, but which probably tends to prevent the restoration of equilibrium. To this end a warm or mus- tard bath is advisable, and an aperient should be given at once. Calomel is easy to administer, and is effective, and a couple of grains may be given to a child of a year old. When the child comes round, five grains of bromide of potassium maybe given immediately in some syrup; or if there is much somnolence after the fit, ten grains in solution may be given by enema. If this is unsuccessful, bromide of sodium may be substituted, or chloral combined with the bromide. As I have several times had occasion to remark, young children take both bromide and chloral well. Five grains of each may be given in combination to a child a few months old. If the convulsions be due to blood-poisoning of any kind, it is better to wait after the convulsions have subsided to see what course the case threatens to take. It need not necessarily be of greater severity because it has commenced by convulsions. Should it threaten to be so, quinine should be given at once. Epilepsy. — From the tables published by Dr. Gowers some very important facts are learnt concerning the disease as met with in children. Out of 1450 cases, 12J per cent, com- menced during the first three years of life; 5 J per cent, of the whole occurred in the first year; from then to five years the numbers fall, till at five the minimum Tor the early period of life occurs, only 1.7 per cent, beginning at that time. At INFANTILE CONVULSIONS, ETC. 541 seven, the commencement of the second dentition, the num- bers rise again, then fall, and rise again, until at fifteen or sixteen the maximum for this period of life is attained with 5| per cent, of the total numbers. Of those cases which occurred in the first three years of life, ascarides, sunstroke, falls, injuries at birth, are given as causes in a few cases; but the far larger proportion occurred during the first den- tition, and were attributed to teething; and the total num- ber of cases so caused may be put at 7 per cent, of the whole. If we further allow, as we can hardly escape doing, that rickets plays a large part in the occurrence of convulsions, and add other cases to those given in which rickets was probably present in early life, although the epileptic recur- rence did not occur till later, we have rickets playing the part of a predisposing cause in 10 per cent, of the whole num- ber. The neurotic heredity was in great measure transmit- ted from actual epilepsy (three-fourths of the inherited cases) ; but insanity was combined with it in a considerable number of cases. Of other diseases, chorea existed in other members of the family in numbers not far short of those of cases of insanity. Epilepsy is sometimes associated with malformation of the brain ; sometimes it comes on after hemiplegia, or blows, or a fall upon the head. Symptoms. — The chief feature of epilepsy is loss of con- sciousness, and this takes place in very varying degrees. Children will sometimes have a violent convulsion with bit- ten tongue, and insensibility, succeeded by stupor, as is so commonly seen in adults ; but a large number only faint or lose consciousness for an instant,* and -no more, but with a recurrence many times in the twenty- four hours. There is a sudden pallor, perhaps a momentary drop of the head, * Petit mal. — Ed. 46 542 THE DISEASES OF CHILDREN. while anything in the hand falls as from one momentarily overcome by sleep. The fits in children have a special ten- dency to occur by night. The nocturnal fits may consist of mere tremors, or the child may appear to be awake but with fixed gaze. It is perhaps convulsed, or laughs and talks in an idiotic manner. Observations as regards an aura are perhaps hardly reliable ; but I have several times elicited descriptions of giddiness and of disturbed sensations in the arm or in the fingers, and once in a girl of nine the fit regu- larly began by a complaint of abdominal pain. Diagnosis. — The paragraph relating to the diagnosis of infantile convulsions may be referred to. Prognosis. — This is neither better nor worse than it is in adults. A great many children improve under proper treat- ment, and the frequent recurrence of the fits is kept in abey- ance. When the fits are of recent origin, or have occurred but seldom, there is always a hope, to be encouraged in every possible way, that they may never recur; but, as in adults, there are also some very obstinate cases which resist all treatment. Some of the worst cases I have seen in this respect have been associated with confirmed hemiplegia, late rigidity, and so forth. If the fits are very frequent and in- tractable, there is a fear of imbecility following after. Treatment consists of attention to the child's hygienic condition, to see that his food is of proper quality, that his bowels are regular, sleep good, etc. For the arrest of the convulsions bromide of potassium is the most generally useful remedy. It may be given without risk (save with one exception) to the youngest children. At a year old we may begin at five grains three times a day, and even increase the dose if necessary. For older children, of ten and twelve, ten, fifteen, and twenty grains may be given three times a day. If this should not be successful, very likely the bro- mide of sodium will be so. I have sometimes thought that INFANTILE CONVULSIONS, ETC. 543 the latter is more useful with children than the former. Sometimes the iodide combined with the bromide is useful. Bromide and digitalis, or bromide and belladonna, are good combinations when a neurotic heart is associated with the fits. Oxide of zinc is a good remedy for children, in three- or five- grain doses, and borax is recommended by Dr. Gowers. A child that has had epilepsy will require careful watch- ing at particular periods. The figures already quoted from Dr. Gowers show that both the second dentition and also puberty are times at which the disease is likely to show itself. Therefore the bromide should be resorted to if any threatenings occur. Mental study should never be allowed to proceed to the extent of exhaustion. Exercise should be abundant, and food nutritious ; while all things that make for a too continuous or excessive, and therefore morbid, nervous erethism, must be avoided or controlled. The one risk attaching to the administration of the bro- mide is its liability to produce lumps, or indurated, soft, ,granuloma-like swellings over the body. The risk of this may be considerably lessened by combining some liq. arseni- calis, or liq. sod. arseniatis with it — this drug is very readily borne by children ; the bromide should never be continued for long periods continuously. Nightmare, or Night Terror, is a nervous affection of young children, and is allied to the much rarer phenomena of sleep-walking. It is also akin, I doubt not, to one form of nocturnal incontinence. All these conditions may be described as sleep disorders where cerebral under-currents seethe below a placid surface. Nightmare is usually sup- posed to have much to do with dyspepsia.* Henoch, how- * In mucous disease, although as a rule the nervous irritability is lessened, night terror is a very common feature in my experience; in chronic indiges- tion, too, nightmare and dreamy sleep, modifications of the same Symptom, 544 THE DISEASES OF CHILDREN. ever, will not allow that food has anything to do with it, and I agree with him for the most part. The children in whom it occurs are usually quick, excitable, nervous children, and it runs in rheumatic and choreic families. It would be in- teresting to follow it up in relation to epilepsy and other nervous disorders. Of thirty-seven cases, there were twenty- one boys and sixteen girls, and nineteen of these had a family history of rheumatism ; some others came of a nervous or neuralgic stock. It is to be treated with bromide of potassium, or that and syrup of chloral, and in this way always subsides. It is a malady of little detriment in itself; but, as an indication of a nervous organization, it is most valuable. It is the " slacken speed " to the engine-driver which must never pass unheeded. are constant. I have also seen them rapidly disappear under a treatment directed to the removal of the catarrhal condition of the gastro-intestinal canal. — Ed. FUNCTIONAL NERVOUS DISORDERS — HEADACHE. 545 CHAPTER XL. FUNCTIONAL NERVOUS DISORDERS— HEADACHE. Of other functional nerve disturbances in any marked form, such as are met with in adult life, childhood is not prodigal of examples. I have, however, seen functional vomiting and an extreme case, of functional hiccough, each in girls about twelve years ; and moderate hystero-epilepsy in girls of ten and twelve. In another girl of twelve there was functional paralysis of the abductors of the vocal cords. She had a fit in the out-patient room, and became insensible and rigid, but was not convulsed. She had also a croupy cough ; but on examining the larynx, which she very readily suffered, there was an entire absence of any morbid appear- ance, except in the position of the vocal cords. These played about somewhat close together during expiration, and during inspiration the anterior parts completely closed, the left over- lapping the right, and leaving only a chink posteriorly for the entrance of air to the lungs. The paretic state of the abductors was clear, and the functional character of the malady was equally so, for it quickly improved, so that in the course of half an hour it had almost disappeared. This patient had been in the hospital under Dr. Taylor for cata- leptic attacks, and, in one of her fits/ her eyes were first turned strongly to one side, and then she squinted. Twice I have seen hemi-anaesthesia with hemiplegia in boys of eleven or twelve. In the case under my own care I was at first disposed to think that there might be some actual lesion, notwithstanding the strong probability which experience teaches that, with complete hemi-anaesthesia and 546 . THE DISEASES OF CHILDREN. hemiplegia, the condition is a functional disturbance only. But we subsequently learnt that the child was a regular vagabond, and his previous history, his habits, and the va- riability of the paralysis, made it conform to rule rather than to exception. The boy was twelve years old, with a neurotic family his- tory. The paralysis came on in a night, four months before. He had been a sharp boy, and had reached the highest class in the school ; but he had become dull and odd in manner, staying out all night, and being dirty in his habits. He had a markedly neurotic aspect — very dark, with deep-set eyes and small cranial development. He had a cunning appear- ance, yet had no air of imposture about him. His face was paralyzed on the right side, and the tongue deviated to the right side. The right arm was paralyzed, the extensors of the forearm most markedly so, and the wrist dropped as in lead-poisoning. He made evident effort to move it when told, but was obliged to call in the aid of the opposite hand. There was less decided failure in the leg, but when he walked his toes caught the ground in putting the foot forward — the knee was flexed, the heel drawn up, and the limb moved clumsily, as from want of harmony between the co-acting muscles rather than from actual paralysis, but the extensors obviously had the worst of it. The loss of sensation was complete, and thoroughly distributed to the right half of the body, mucous membrane as well as skin. The knee reflex on the paralyzed side was markedly exag- gerated. He was partially undressed for examination, and as I watched him in attempting to re-dress, whilst we went to the other children in the ward, he was evidently quite help- less as regards the right arm. The paralysis both of sensa- tion and motion — but the former far more than the latter — varied much from day to day ; and sometimes his special senses suffered, and he would become completely deaf on FUNCTIONAL NERVOUS DISORDERS — HEADACHE. 547 the right side, unable to smell with the right nostril, and wholly blind with the right eye. He could not then tell light from darkness, nor did he flinch when the finger was brought close to his eye. There were no morbid ophthal- moscopic appearances. Unfortunately he became so unruly and dirty that it became necessary to discharge him, and he was thus lost sight of, not much better than when admitted. Hysterical contracture will also be found sometimes in girls of eleven or twelve. Quite lately, a case of this kind has been under my care. It was speedily cured by keeping the affected arm firmly bound to the side, and compelling the use of the other. Headache is very common in children, from six years old and upward, and it arises from all sorts of causes. It is usually frontal and associated with sickness ; sometimes it is one-sided, over one or other frontal eminence, and occasion- ally disturbance of vision accompanies it, as in the megrim of older patients. Causes and Diagnosis. — It is not easy to distinguish be- tween the different forms of headache. Most commonly the child is said to be subject to sick-headache ; but, when the case is investigated — in one the ailment may be due to anaemia ; in another to indigestion or constipation ; in another it is the trait of a child of rheumatic parentage; in another, the result of hypermetropia. To arrive at an opin- ion in any case, it is well first of all to examine the eyes by the ophthalmoscope so as to eliminate the last-named con- dition. A large number of children are hypermetropic, and when they begin to tax their eyes for reading the strain upon the power of accommodation becomes excessive, and frontal headache arises, which may or may not be associated with internal strabismus. The headache is usually a supra- orbital one, and the letters run one into the other as the child reads. It is not unimportant to add that these cases :_lS THE DISEASES IF CHILD?/ are often distinctly worse when the health is deteriorated from any cause. The strabismus may, indeed, only be no- ticeable at such times — like the decayed tooth, which, though ed, aches only now and again, in response to impairment of the general health. In another large group of cases, the children are badly nourished and anaemic. The relation of gastric disturbances to headache is more open to question ; for it is certain that in many, perhaps most, cases of megrim, the stomach and brain react upon each other, and food will unquestionably excite an attack of head- ache, as a worm or other intestinal irritant will excite a con- vulsion. Headache is sometimes troublesome in girls at puberty, and tfa catamenial irregularity and backwardness. The headache of brain disease is likely to be occipital, unless it be cue to meningitis, when it is general. Symptoms. — Sick-headaches usually manifest some peri- odicity, though it may be but an irregular one. They are oftentimes attributed to food, and they are associated with vomiting. The headache is frontal, often of throbbing char- acter about the temples. The head is hot. and there is often some intolerance of light, or some hyper-sensitiv hearing. The victim is the subject of a terrible malaise, and for the time being only wishes to be let alone, and longs for sleep. The tongue is usually clean, the temperature nor- mal, and the pulse not quickened. The duration of sick- headache is variable. It generally subsides in sleep, and lasts but a few hours. Occasionally the vomiting is severe and repeated, and the child is out of sorts for some days. anaemic headache is less localized, more continuous, and perhaps less often associated with sickness. In most cases of headache the bowels are irregular. Diagnosis. — The ailment being a common one, there is some overlooking the headache of organic disease. FUNCTIONAL NERVOUS DISORDERS — HEADACHE. 549 It will be well, therefore, to remember that bad headache sometimes ushers in typhoid fever — one of the common dis- eases of childhood — and that the headache of meningitis is usually associated with pyrexia and constipation, as well as its own more special symptoms. The hypermetrophic head- ache may be suspected if there be hypermetropia, and the anaemic, rheumatic, and other forms must be diagnosed by reference to the appearance of the child, its past history, its family history, etc. Treatment. — Headaches are usually troublesome, for several reasons. They are common, are not thought much of, and their excitants are not therefore avoided as they might be ; moreover, they are not immediately amenable to rem- edies — in many cases they hardly appear to be influenced at all — and the child slowly " grows out of them." The hyper- metropic headache must be treated by the ophthalmic sur- geon (not by the spectacle-maker), who will see that any anomalies of refraction or in the shape of the eyeball are properly corrected by carefully adjusted spectacles. Apart from this special form, all headaches are likely to be ren- dered less frequent by the prolonged use of such drugs as arsenic and iron, but they must be given for some weeks continuously if they are to produce much effect. In the headache of girls at puberty, perhaps iron, permanganate of potassium, and bromide of ammonium are most useful. For the attack itself, bromide of potassium may be given ; it is sometimes successful in relieving the throbbing forms of sick-headache. Guarana and tonga are sometimes useful, although not easily administered. Guarana may be admin- istered as an elixir (Martindale), the tincture of guarana being mixed with equal parts of simple elixir (F. 44), and half a tea- spoonful or a teaspoonful given, in water, for a dose. But, upon the whole, sleep is the best restorative, and arsenic the most reliable tonic for keeping the attacks at bay. y : D THE DISEASES OF CHILDREN. CHAPTER XL I. IDIOCY AND CRETINISM. Idiocy is met with at any age, from a few weeks after birth onwards. Imbecility is a condition of many grades. In some there is but slight departure from the healthy con- dition ; some are for long unable to walk or talk ; the worst cases have no natural sense of any kind. Twice only have I seen anything in the nature of cretinism amongst my own cases. Of nineteen cases, five were uncomplicated. In one there was a peculiar condition, which I could only denominate :h idiocy. The child, aged five, seemed fairly intelli- gent, although mischievous. She appeared to understand in a measure what was said to her, but her utterances in return were quite unintelligible. Two were deaf mutes ; five were more or less amaurotic (only one of these had had fits) ; one had white optic discs ; one retinitis pigmentosa ; one a peculiar stippled condition of choroid (? choroiditis); and the other two were amaurotic, without visible change in the fundus oculi ; four others had had fits ; and two were cretins. Idiocy may be either congenital or acquired. The con- genital cases are likely to be microcephalic. Acquired idiocy is common after convulsions. It is in many c impossible to say whether the two forms are alike due to some cerebral lesion or whether the one is dependent upon brmation rather than disease; but in some cases the history of sudden convulsion, one or many, is precise, as also that progressive impairment of intellect has followed. Idiocy may be compassed in a variety of ways at this early IDIOCY AND CRETINISM. 55 I age, in some by lesions which deprive the child of impor- tant channels for the acquisition of knowledge and experi- ence, such as sight and hearing, in others by damage to the cerebral cortex ; but the frequency with which convul- sions are spoken of as an initial symptom seems not unlikely to point to meningeal or inter-arachnoid hemorrhage, and subsequent pachymeningitic changes, as a common method of causation. Other cases there are, called by Dr. Langdon Down " developmental," where the disease comes to chil- dren who have at first evidenced an average intelligence, at the period of the first or second dentition or at puberty. Such children develop up to a point, and as a result, perhaps, of a fit, or some greatly impaired nutrition, such as may show itself by chorea, they become imbecile, and the brain undergoes no further development. Cases of this kind, and congenital idiocy probably, find a predisposing cause in consanguineous marriages and in alcoholic excess in either parent. The developmental form is possibly sometimes to be attributed to masturbation. Cretinism, as commonly seen, is a disease which is endemic in certain parts of certain countries. In Europe, it abounds in Styria and the Tyrol, and it is not uncommon in the Swiss valleys, Savoy, and Piedmont. It is occasion- ally seen in England, in the dales of Derbyshire and York- shire; but in this country it is more generally known as a sporadic affection. Happily it is not common. Those who have charge of large asylums for idiots see most of it, and Dr. Fletcher Beach, of Darenth Asylum, has published some interesting cases. Dr. Hilton Fagge was the first in this country to call attention to sporadic cretinism, in a very valuable paper in the " Transactions of the Royal Medico- Chirurgical Society." It is a curious and interesting disease, so strangely con- tradictory is it in its external form ; for in many respects 552 THE DISEASES OF CHILDREN. age comes to the features in babyhood, while the blight of babyhood, in its weakness, imbecility, and puniness, settles upon the corporeal form, and withers the opening mind. The appearance of these cases is very characteristic. They cease to grow in very early infancy, and year after year they change so little, that the child of two or three remains much the same at eight or ten. In my own two cases, a girl of nine and a boy of fourteen have hardly altered, the girl since she was four, the boy since three. They have a yellowish chlorotic aspect, their skin is thick, harsh, and wrinkled, and the subcutaneous tissues in some parts seem almost cedematous, the eyelids being particularly puffy. The scalp is also noticeable for its harsh, scaly condition, and the scanty growth of coarse hair upon it. The head is flat, the forehead small, the face large. The limbs are large, the hands and feet flattened out, the abdomen large and pendulous, the tongue seems often too large for the mouth, and lolls from the open lips and teeth ; the teeth are irregular, deficient, stunted, and decayed. The thyroid has usually been said to be enlarged, but in some cases of sporadic cretinism it has certainly been wanting, and in others it has probably undergone atrophic or destructive changes. Attention, too, has been called to the existence of pads of adipose tissue in the triangles of the neck. They are often of considerable size, but I do not know that they have any further significance than as a part of the general tendency which exists in these cases for the development of an excess of subcutaneous tissue. Causes. — Consanguinity in the parents and alcoholism have been thought to predispose to a degenerate state of nervous system which may develop into cretinism, as into other forms of idiocy. But from the fact that it is a disease which attaches to particular regions, it seems clear that geological conditions play an important part in its produc- IDIOCY AND CRETINISM. 553 tion, and of these the existence of magnesian limestone in the soil is generally considered to be the most important. It is said that infants are liable to become cretins if taken to reside in districts in which cretinism is endemic. The tendency which the same geological conditions have to produce goitre, and the frequent co-existence of the two diseases, have long been a matter of interest, and the re- lation between the two a subject of speculative inquiry. A further point was made when Dr. Hilton Fagge showed from dissections that in some cretinous children the thyroid body is absent. We do not yet know the full bearing of these facts ; but of late it has been asserted by Kocher that cretinism has supervened in adult life upon extirpation of the thyroid ; and in one or two cases of myxcedema, which is a cretinoid state supervening in adult life, the thyroid body has also been found to be atrophied. These observa- tions go to show that the perfect functions (not alone devel- opment, for the disease may apparently be produced after the brain has developed) of the brain are in some way dependent upon the integrity of the thyroid — a most impor- tant fact if it can be shown to be true. It is probable, how- ever, that cretinism owns many causes, hereditary, environ- ing, and possibly personal, and at present we are not in a position to speak very positively about it. Morbid Anatomy. — The bones of the skull are thick, the sutures abnormally obliterated, and the various foramina are liable to narrowing. Great importance is attached by some to premature union of the basal sutures, by which it is not unreasonably supposed that the growth of the skull, and, therefore, of the brain, would be seriously interfered with. The condition of the long bones is also peculiar; their car- tilaginous ends being enormously out of proportion to the stunted shafts. The Diagnosis of cretinism, or of idiocy, can give but little trouble. 554 THE DISEASES OF CHILDREN. Prognosis is bad in cretinism. In idiocy it will depend somewhat upon its degree. Dr. Langdon Down states that the worst cases are those of accidental origin. More is to be expected to result from training in congenital cases, and which are prima facie worse looking, than in the possibly- more hopeful appearance of the child who is imbecile from disease. Treatment, — With the exception that cretins must be removed from any place in which the malady is endemic, and taken to dry and porous soil, the treatment of all forms of idiocy is much the same. A diminished brain capacity is the malady ; to make the most of the little that is left is the aim of treatment. The individual is less highly endowed than ourselves ; he is in a lower grade ; he needs to be studied. He has to be educated, and it becomes the busi- ness of his instructor to instil habits of order, cleanliness, and obedience ; to discover his likes and dislikes ; his most sensitive nerve strands and centres, and generally to work along the lines of such senses as retain the most perception. Idiots must be educated objectively. They are to be made happy by every possible means. And to this end their surroundings must be pleasant ; they must have a teacher whom they love ; and their eyes, ears, and hands must be taught to carry instruction. A knowledge of color and form can be brought home to them through the eye, and thus some of the fond memories and instant pleasures with which the beauties of Nature are associated ; music may be made to charm the ear, and, making resonance amid the trembling strands, tone into life some pulses of thought ; while the hand, by judicious exercise, may be made apt for various arts. It is by the application of means like these, backed by indomitable perseverance, and a capacity for see- ing in the but slow progress of the day or of the year a comparatively bright future, that a success that must be IDIOCY AND CRETINISM. 555 called wonderful has been achieved at such institutions as Earlswood and Darenth. The education of the weak- minded must necessarily for the most part fall to such as have specially qualified themselves and who are specially apt. Patience, perseverance, and ingenuity in the opening up of fresh channels of instruction are the great requisites, and a somewhat uncommon combination of mental endow- ments in the instructor is necessary to command success. Nevertheless, these cases will, under favorable circumstances, and with the requisite attention, improve much even in home life ; and this hope is to be strongly impressed upon the parents, or those who have the charge of such children, as the motive for that continuous training which alone can enable the child to make the most of its diminished capital of brain power. Medically, there is not much to say, but that littler is important. Mens sana in corpore* sano is old and true ; but here the converse is the more important truth, that the mind being feeble, the bodily nutrition and reparative power are feeble. Imbeciles require warmth, they require to live on a dry porous soil, to be guarded against sudden atmospheric changes, and to be fed well. Except in so far as idiocy is occasionally seen in an early condition, dependent upon brain disease, syphilitic or other, or upon some neurotic state, such as chorea, it does not call for any special treatment in the matter of drugs. It is in one or other of these two conditions, idiocy and cretinism, that pronounced mental disease comes perhaps most frequently under notice ; but there are other less defi- nite conditions which are far more common — children not idiots, yet low, cunning, mischievous, and tiresome. Moral insanity West calls such aberrations, and a very good name it is. Others are stupid above measure with books, but sharp with tiheir fingers, or with some sense or other. All these require to be carefully studied, for there are few who 556 THE DISEASES OF CHILDREN. have not some doors open by which their moral culture may be raised if we will but carefully search for them. Another common form of neurosis is passion. A little excitement sends such children into a fury, so that they become dangerous to their playmates. More or less this is a very common form of mental disorder, and it is very closely associated with bodily disorders. The child is worse when it is poorly, and the outbursts of excitement tend to react upon the bodily functions, and thus to make their disorder worse. Some children are melancholic. I have seen marked cases of this sort in boys and girls, the latter more often. Melancholic children are usually anaemic and haggard look- ing, and decidedly improved by good feeding and absolute rest of mind and body. If there be any difficulty in their taking a requisite quantity of food, they must be dieted strictly, and made to take what is ordered. Such are fit cases for Weir Mitchell's plan of treatment, which has been so successfully advocated in this country by Dr. W. S. Playfair for neurotic women. Chorea Magna, so-called, is also a mental disorder. It is not one that English physicians see much of. It has many resemblances to some of the more frenzied states of hystero-epilepsy that are happily but seldom seen in this country. The affected child becomes quite maniacal, and performs all sorts of antics; dances, sings, declaims, or falls into a state of epileptiform convulsion, or of cataleptic rigid- ity. It is a disease which is likely to come on as puberty approaches, but sometimes occurs in precocious girls from ten years old and upwards. It must be treated by the administration of such drugs as iron, bromide of ammo- nium, oxide or sulphate of zinc, and arsenic, the patient being under judicious management away from her friends. CHOREA. 557 CHAPTER XLII. CHOREA. I shall commence my description of chorea by what may be considered a typical case, which was not long ago under my care in Guy's Hospital, and which has the advantage of an exceedingly good report by the clinical clerk, Mr. Braddon. It is that of a girl aged eleven years, a thin anaemic child, with thick red hair and vacant expression. She had never been ill, but was always considered delicate. Her father was killed by an accident eighteen months before her admission ; twelve months later her brother died ; and eight weeks before her present illness, she, a girl of eleven only, had to " nurse " her mother through an attack of rheumatic fever. During this time she had complained of pains in her limbs and back, was feverish, and took to her bed for two or three days ; and from that time she grew duller, apathetic, and lost her cheerful manner. A month ago she was scolded by her mother for clumsily upsetting a cup, and it was then first particularly noticed that the move- ments of her right hand were ill-conducted, and that she was always twitching the right side of her face. Her right foot next became unsteady, and these irregularities pro- ceeded gradually to constant convulsive jerks and twitches of either, but more particularly of the right side of the body. Five days before her admission, a game-cock flew at her, and frightened her so that she moped by herself and was speechless ; and, till her admission, her spasmodic per- formances had increased in violence, and her talking and gestures had become unintelligible to her mother. 47 558 THE DISEASES OF CHILDREN. She lies in bed with her head twisted on one side, and rapidly changing in position if she is observed. She opens and shuts her mouth, twitches up its corners, jerks her head, and snatches the eyes irregularly from side to side. Her arms are thrown constantly before her on the counterpane, with a tendency to place her fingers in any position but apposition, the forearm being mostly in a position of over-pronation. The left arm is less distorted in movement than the right. When asked to pick up a pin, an irregular series of muscular actions takes place, tending ultimately to the desired result, but in which there is a noticeable tendency to the use of the adductors in excess of the abductors, and the pronators before the supinators. When asked to sit up in bed, she does so by an alternating use of opposite muscles, working upwards spirally like an eel, her legs gen- erally crossed, but not much subjected to the irregular move- ments ; the abdominal muscles take a fair share in the gen- eral jactitation of the body. When spoken to, she first cried and then laughed ; she generally laughs, and at the same time the movements increase. She takes some time to gather head to answer r which she generally does with stuttering articulation and explosive manner. There was slight clonic response in the calf muscles on stretching the tendons, and the extensor tendon reflex was good, the superficial epigastric reflex being exaggerated. The heart sounds were sharp- sounding and unduly pronounced, but quite clear ; the pulse irregular, soft, ninety-six per minute ; a bruit de diable over the veins of the neck ; the bowels were rather confined, the tongue flabby and rather furred. She was treated by ten- minim doses of liq. arsenicalis, and kept in bed and fed well, and under this routine she soon became much quieter, and a fortnight after admission she was allowed to get up. On the sixteenth day she was still considerably choreic in both arms, and her heart was still irregular ; a decided but remit- CHOREA. 559 ting short systolic whiff had come at the apex, and another in the third left interspace near the sternum and over the third rib. The second sound was very accentuated, and the closure of the valves could be felt in the second space. If the student studies this report, he will find not only a truthful account of a case of chorea, but also in every fea- ture that is described one of the common occurrences of chorea, whether it be the family history, the antecedents, the appearance of the child, or the distribution of the movement, the posture assumed, the state of the-mind, the behavior of the heart, or any other of the many small deviations from normal behavior of the viscera, which together make up the disease. He may learn from it that chorea is associated with rheumatism (a fact, however, which is disputed by one of the first authorities upon the subject), both by heredity and by the patient having suffered herself from that disease (the mother had had rheumatic fever, and in all probability the child herself). It is typical in the sex — chorea being far more common in females. Next it illustrates the rela- tion of the disease to fright, worry, and overwork. All these things are powerful immediate provocatives of choreic movements, but they are, in all probability, not by them- selves sufficient, in the absence of rheumatic strain or other predisposing nervous weakness. Next it may be noticed that the onset is slow. She is first dull and apathetic, next she becomes clumsy with her right hand, and the right side of her face is twitched, and so on, till the whole right side is affected, and her speech grows unintelligible. Her posture in bed is characteristic. Over and over again a choreic child will lie in bed, with head, and perhaps body, twisted to one side, in the condition of pleurosthotonos, and then change suddenly to an exactly opposite curve. How often, too, does a choreic child lie extended in bed, making all sorts of grimaces, with " its arms stretched out 560 THE DISEASES OF CHILDREN. on the counterpane," with its fingers pointing in all direc- tions but the natural one of " setting " towards each other, and the forearms and arms so rotated inwards as to make the palms look outwards. The crying and laughing when spoken to, the attempts to protrude the tongue, ending in its sudden appearance and as quick retraction, a flash of suc- cessful effort, an accidentally conducted message amid the disturbance of the storm ; and lastly, to conclude this pre- liminary sketch, he may learn from it the not uncommon condition of the heart- — that its action is irregular, and that, in the course of the disease, there is likely to appear a soft systolic apex murmur, the characteristics of which are not sufficiently pronounced to enable one to say whether there is any organic disease of the valves or not. To define chorea is impossible; but Dr. Sturges has hit upon a definition which is picturesque and sufficiently true to the purpose when he says that " chorea consists in an exaggerated fidgetiness." This description is a valuable one, because it will serve to convey the fact that chorea is a disease of varied degree. Sometimes it is so slight that all that can be said is that this or that child is an unusually restless one. It makes grimaces, or has peculiar finger move- ments, or it can never sit still, and so on. Fidgety children require watching; more violent movements may come on at any time under favoring circumstances, and then they have chorea ; but it is merely a question of degree. As re- gards the movements, they are excessively irregular; they are as though the nervous current played about amongst the nerve-wires, and only now and again, by some determined flash of the sensorium, does the correct message find its way. But the disease tells most upon such muscles or groups of muscles as are most varied in their action — most under the influence of emotion, some say — and thus the muscles of the face and arms are those which suffer the most marked con- tortions. CHOREA. 561 Chorea often affects one side more than the other, when it is called hemichorea. The left side, some affirm, because the left arm and hand are less under control than the right ; the right side, others say, for reasons presently to be men- tioned. When the disease is one-sided, it not uncommonly assumes the form of paralysis, and choreic children are often brought for treatment because one arm is paralyzed. The twitching finger, the shrug of shoulder, or the grimace usu- ally reveals the nature of the disease without trouble. But although chorea, more marked on one side than the other, is very common, hemichorea, in the sense of the movement being entirely confined to one side, is very rare, and I agree with Dr. Sturges that such a condition is almost unknown. Chorea is essentially a general disease, an exaggeration of a faulty habit of control, and, although most decided here and there, is present to some extent everywhere. In fifty-four cases I have particularly noted the distribution. In thirty- four it was general ; in thirteen more on the right side ; and in seven only more on the left. But there is no doubt that the one side or the other are less often prominently affected than this, for while most of the unilateral cases are noted, no doubt no definite statement has been thought necessary in many that have been generally distributed, and it is probable that as regards the total number of my own cases (141) those in which the disease is mostly confined to one side would not have to be materially altered. It will be noticed that it does not coincide with my experience that the left side is the more prone to suffer unduly. The evidence of cerebral disturbance varies much. Not uncommonly choreics look completely imbecile, and they mostly laugh and cry from trivial causes and in a peculiarly explosive manner. But it does not appear that the chorea is dependent upon any definite cerebral disease, for it often goes with a brain which gives but little evidence of disturb- 562 THE DISEASES OF CHILDREN. ance, and in others imbecility and movements improve together rather as the bodily health improves. In a girl, set, eleven, lately under notice, it was remarkable how the disease seemed to resist all treatment for some weeks, when sud- denly, almost in a day, the child improved in appearance, the movements ceased, she began to get fat in the face, and then progressed uninterruptedly to recovery. The history of chorea as regards its course is often one of much monotony, and for this reason perhaps in general practice it often fails to obtain the requisite medical super- vision. It is difficult to say when chorea ends, and, conse- quently, to fix its duration. To be once choreic is to be always so to some slight extent, and, therefore, when the more violent movements are controlled, there is still a lesser range which is still choreic, and which must make one cautious in affirming a cure. It is no uncommon his- tory for such cases to run on for two or three months, although when they are taken into hospital they almost always rapidly improve. But this is only up to a certain point ; they then remain stationary, and the lesser move- ments 'of the choreic are often exceedingly troublesome. Six to ten weeks is usually given as the duration of the disease. Lingering, however, as chorea is, in childhood it very usually gets well. It is more liable to be fatal as puberty commences. Nevertheless, death-tables do not show this very well, because the disease is so much more one of child- hood than of adolescence, and although relatively the death- rate is small under fifteen, the aggregate equals that of the chorea of adolescence. By the records of Guy's Hospital, it appears that twenty-eight fatal cases of chorea have oc- curred in the last thirty years, the respective ages of the cases being as follows : CHOREA. 563 Years . 5 . . 7 . . 8 . . 11 . . 12 . . 13 . . 14 No. .. I . . 5 . . . I . . 3 . . 1.. 2 . . 1 Years . 15 . . 16 . . 17 . . 18 . . 19 . . 40-50 No. .. 1..1..1!'. 5-. 2.. 2 I pregnant woman exact age not stated. I younger not stated. I have had two fatal cases in young children, of which I give the notes. They very well illustrate the fact that when a fatal event ensues it is usually by the supervention of high temperature, rapid emaciation, and exhaustion — sometimes by coma. And, at any time, if the disease is complicated with much peri- or endo-carditis. A boy, aged five, was apparently in perfect health till eight days before his admission, when he slipped downstairs. He did not appear to be much hurt, and had a good night afterwards. But the next morning there was some loss of power in his hands and difficulty in swallowing. Soon after he began to scream at intervals during the day and occa- sionally at night. He had had pertussis and measles, but not acute rheumatism, nor was there any history of rheu- matism, so far as could be ascertained, in his family. He was in an irritable condition, resisting examination, but quite sensible and answering questions. He stared about in a vacant way, and his face, arms, and legs moved in a choreic manner. He swallowed without difficulty, and there was no paralysis of the ocular or other muscles. His left knee was a little swollen and painful, and a loud systolic bruit was audible at the apex, and another, less marked, at the base. No subcutaneous nodules could be found. He was kept at perfect rest in bed, and fed well, an ounce of brandy being ordered likewise. But the temperature gradually rose to 103 , the movements became more marked, and deglutition was very much impaired. He was then ordered salicin gr. v. three times a day, and he was 564 THE DISEASES OF CHILDREN. sponged occasionally; but he continued to sink rapidly, notwithstanding the administration of nutrient enemata, and subsequently of strong liquid nutriment, administered by catheter passed into the oesophagus through the nose. At the inspection there were general early pericarditis, a large fringe of vegetation round the mitral orifice, and smaller fringes on the aortic cusps. There was some bron- cho-pneumonia at both bases. The brain and spinal cord were apparently quite healthy. The other case was a girl of seven ; in some important particulars very similiar; there was the same, but more marked, rise of temperature ; the same inability to swallow as the case progressed. Rosa L., set. seven, was admitted on October 14, 188 1, and died on November 8, 1 88 1. The parents are healthy. They have never had rheumatism, but the maternal grand- father was rheumatic. Of three other children, one has had acute rheumatism twice. During the last six months she has complained of pains in her knees, which have never been swollen, and also of occipital headache. Fourteen days ago she became very excitable, and her hands began to twitch. She became gradually worse, and now the move- ments are universal and she cannot stand. There is no history of fright, but she passed a w 7 orm a foot long ten days ago. When admitted, she had severe general chorea — not marked on one side more than the other — without fever, and with normal heart sounds. She was ordered a tea- spoonful of aq. chloroformi ter die, broth diet, and was kept in bed. She did not improve, and, eight days after, her diet was increased by two pints of milk, and six drops of liq. sodii arseniatis in glycerine and water were ordered. Her milk was increased to three pints on the 28th, or two days later. CHOREA. 565 The temperature, till now normal, began to rise, and on the 30th reached 102. 8°. She became very restless, the movements almost continuous, and she became unable to swallow. Nov. 3. — Decidedly worse. She is emaciating. Temp. 1 03. 8°. The movements have eroded the skin of the back, and she was slung in a hammock. Subsequently some purpuric blotches appeared on her legs, she became coma- tose, and died on Nov. 8th, with a temperature of 105.4 . She was bathed before death to reduce the temperature, but without any appreciable result. Medicinally, succus hyoscyami and chloral were adminis- tered towards the later days of the illness. The inspection showed no morbid appearances, except in the heart and kidneys. There were subserous petechias all over the former, especially on the posterior surface of the left ventricle. The edges of the mitral valve were roughened, and to these were attached fibrinous warty vegetations the size of a pea. The kidneys contained infarctions. Of the thirty fatal cases, twenty-five were in females. Pathology and its Relations to Etiology. — With one ex- ception, chorea has no morbid anatomy. There is no one lesion of constant standing, save the fringes of vegetations which occupy the edges of the aortic and mitral valves ; but endocarditis, in the form of vegetations, is present in the greater number of cases. Of the fatal cases already recorded (thirty in all), these were present in twenty-eight, doubtful in one, and absent certainly only once. Their absence is quite the exception. The mitral was affected alone fifteen times ; both aortic and mitral valves nine times ; the aortic valves alone four times; and pericarditis occurred with the endocarditis six times. The constancy of these little growths upon the edges of the valves has led to a very direct, simple, and fascinating 566 THE DISEASES OF CHILDREN. pathology for chorea, in the suggestion that it is due to embolism. The vegetations are, it is supposed, washed off the valves and carried into the smaller branches of the cere- bral arteries, and thus produce local anaemia, mal-nutrition, and degeneration of the cerebral cortex and ganglia, which lead to the loss of control over the muscles. In favor of this view it is said that the disease is often one-sided, and most often right-sided, as is the case in hemiplegia due to embolism, and due, it is thought, to the straighter course the arterial passage offers to the transit of emboli to the left side of the brain than to the right. Secondly, in capil- lary embolism lies a rational explanation of the imbecility which so often accompanies the disease ; and lastly, that the smaller vessels have actually been found to be plugged in chorea by several competent observers. But these various arguments are traversed in several ways. The preponderance of a right-sided affection, for instance, is denied by many; a strict limitation of the disease is un- doubtedly rare. Supposing that one or other side suffers more severely, the affection is, nevertheless, present in other parts to a less marked degree. And as to the unilateral intensity, Dr. Sturges, whose experience is very large, and whose observation has been so careful and candid that it may well outweigh much that might otherwise point to a conclusion opposed to his, gives the seat of onset as thirty- six for each side. Dr. Pye-Smith, in an analysis of the cases in the clinical records of Guy's Hospital, 1870-72,* gives thirty-three cases of tolerably limited hemichorea, fifteen right and eighteen left. Out of fifty-four of my own cases, in which the distribution was carefully noticed, it was right- sided in thirteen, and left-sided in seven ; and I think it prob- able that larger numbers would make it still more evident * Guy's Hospital Reports, ser. iii., vol. xix. CHOREA. 567 that it has but little tendency to attack one side more than the other. Take, next, the fact that choreic children are, almost invariably, peculiarly and recognizably fidgety or nervous — physiologically unstable — and that the exagger- ated or pathological condition may be followed up step by step in association with excess of wear and tear, or in re- sponse to some sudden nervous shock. Next, if chorea be due to embolism, why is the heart-murmur produced late in the disease ? And, lastly, it may be asked, Why is chorea so uncommon in adults? Why is it relatively infrequent in children when compared with the frequency of endocar- ditis ? It can hardly be doubted that acute endocarditis, from whatever cause arising, leads not unfrequently to capil- lary embolism, though not, it would appear, to chorea. Con- siderations such as these make one feel sure that the theory of capillary embolism is quite inadequate to explain the larger number of cases of chorea, and we are quite prepared for what is found to be the case, that, opposed to such facts in favor of embolism as exist, is a large body of negative evidence, where the vessels have been examined without result. It seems to me that a study of this disease leads to the conclusion that it is one unassociated with any recog- nizable structural change in the nervous system — that it is, in fact, a functional disease. We see this in the antecedents of the child, both parental and individual — we see it in the disease itself, in the want of control, the emotional excite- ment, in some cases its relationship to hysteria, and its all but certain tendency towards cure. During the course of chorea, rheumatism sometimes super- venes, but in what proportion of cases I find it difficult to say, probably not a large one. I have already made men- tion of a case where the chorea was succeeded by rheuma- tism, and as the latter subsided the chorea returned. This subsidence of chorea at the onset of rheumatism has been noticed by many observers. 563 THE DISEASES OF CHILDREN. Fibrinous subcutaneous nodules, described by Drs. Bar- low and Warner, are likewise found in some cases of chorea, as in acute rheumatism. I have only met with them occa- sionally. Dr. Hillier* records a very remarkable case of this kind, certainly one of the most extreme that has ever been recorded. Etiology. — Although its pathology can only be clothed in somewhat vague language, yet that hypothesis accords best with the facts of the case, which supposes the existence of some depressed state of nutrition of the intellectual or governing centres. What the relation of rheumatism to chorea maybe we do not know ; but, for my own part, I believe that rheumatism is an evidence, perhaps a cause, of an im- poverished cerebral texture — a texture which is inherently bad, or easily exhausted, and which then discharges inter- mittingly, erratically, and feebly. Chorea is far more common in girls than in boys — ninety- eight girls to forty-three boys, or close upon, but rather in excess of two to one. If we take the statistics given by Hillier, M. See, Pye-Smith, Sturges, and my own, 1374 cases in all, the proportion is as much as five to two. That it should be more common in females is only what was to be expected, seeing that it is a disease very closely associated with emotional disturbances, which are at all times so much more rife in the female sex. The age at which chorea is most prevalent is between seven and twelve, and there is no decided difference between boys and girls as to this. But above twelve it would seem, as has been pointed out by others, that the disproportion between girls and boys, already two to one, increases to three or four to one. The table annexed shows this at a glance : * Diseases of Children, p. 238, Case V. CHOREA. 569 Age 3 4 5 6 7 8 9 10 11 12 13 14 Over. Total. Girls, 1 2 7 6 15 7 13 13 8 12 5 3 6 98 Boys, 042246784131 I 43 Total, . . . 1 6 9 8 19 13 20 2i 12 13 8 4 7 141 The same facts also come out fairly well in the heart dis- ease of the choreic, as seen in fifty-nine cases. 3 4 5 6 7 8 9 10 11 12 13 14 Over 3 3 13 3 2 5 4 7 3 3 13 [The season of greatest prevalence is the spring. It occurs with extreme rarity in negroes.] Chorea is very apt to recur again and again in the same individual. In nineteen of my cases it is noted as having recurred, and in several three or four times. I have several times had the same child under treatment on more than one occasion. There is a tradition abroad that chorea is likely to be set up in healthy children when they are associated with the choreic ; and in the familiar fact that when one person yawns others in his company are likely to follow, we have an ex- ample of unconscious imitation, such as the communication of chorea might be supposed to be. But there is no paral- lelism between the two. For whereas yawning is a perfectly orderly sensori-motor action, chorea is an irregular combi- nation of involuntary movements on the part of muscles which are for the most part habituated to perform move- ments entirely under the control of the will. One cannot conceive of the choreic movements being elicited by any mere sensori-motor disturbance such as starts a yawn, be- cause the movements are of parts which are specialized, and as such want the control of any one centre. Thus, although choreic children in some numbers are admitted into the gen- eral wards of children's hospitals, instances of contagion are 570 THE DISEASES OF CHILDREN. rare indeed. I have never seen such a case. Dr. West and others have recorded instances, and no doubt they occur occasionally, but the risk is not great ; and when they arise, they do so probably because some choreically disposed child has become startled by the sight of the contortions of its associate. This is illustrated by the history of a case in the Evelina Hospital but a short time ago, a girl aged nine years. Her mother had chorea twice, once when ten years old, and again at seventeen, and seven years before she had had rheumatic fever. The child's father had had rheumatic fever. The first child had had rheumatic fever, followed by chorea, a year ago. The patient is the fifth child, and in February, 1 88 1, had rheumatic fever. In June, 1882, and February, 1883, she had chorea; the first attack was caused by fright, and now from this last attack a younger child has " taken " it. Chorea is not prone to occur in several of a family (I have noted this only three or four times in my series of cases), nor is chorea, as chorea, transmitted in any large number of cases. In three cases only of 140 had it existed in one of the parents in former years. It is well known to be very liable to recur when once it has existed. In fifteen out of the 140 it was a second, in two a third, in one a fourth attack, and in one there had been many. As regards the heart disease of chorea, somewhat contra- dictory statements are made. The balance of opinion seems to turn in favor of the larger part of it being due not to organic but to functional disease. I cannot agree with this: making all due allowance for muscular irregularities, and a consequent temporary valvular (mitral) incompetence — a condition which undoubtedly exists in some cases — we have still other facts to consider: e.g., that in fatal cases a fringe of vegetations, either upon mitral or aortic valves or upon both, is present in the majority of cases; and that a considerable number of cases of heart disease have pre- CHOREA. 571 viously had no other disease than chorea, so far as is known (of 248 cases of heart disease in children, fifty-nine were attributed to chorea, fifteen, however, being due to disease the exact nature of which was somewhat doubtful); and that of choreic cases many in the long run suffer from defi- nite valvular disease. Moreover, the non-existence of a bruit is no proof of the non-existence of disease. I have several times seen the mitral valve fringed with vegetations in chorea, when no bruit has been audible during life; more than once I have seen fatal embolism under like circum- stances. It is most necessary to impress upon the student that the disappearance of a bruit is no proof whatever of the absence of organic disease ; for if such cases are watched, they will many of them show subsequent signs, by disturbed rhythm and altered quality of sounds, that the changes in the valves are slowly progressing, and I have no doubt whatever that here is one of the sources of some of the many cases of mitral constriction that come under our notice. Nevertheless, I would not altogether discard the notion of a functional affection of the cardiac muscle ; on the con- trary, I have no doubt whatever of its reality. Irregularity of action is a very common feature of acute chorea, and by this I do not mean a necessarily violent chorea; for it is well pointed out by Dr. Sturges, in his very masterly and philo- sophical essay on this disease, that the violence of the mus- cular movements has no correspondence with the frequency of the heart affection, and, as I say, it is well known that in chorea there is frequently an altered quality of sounds, or an alteration in the rhythm. The existence of such a con- dition has, indeed, not been without dispute, but I think there can be no doubt about it. The cause has also been the source of much discussion. We cannot go far wrong in considering it as due to choreic disturbances of the heart 572 THE DISEASES OF CHILDREN. muscle, and to be essentially the same as chorea of any other muscle. It is of little moment whether the effect be a paresis of papillary muscle alone, as some have contended, or a more general affection. It is only necessary to re- member that the younger the child, and the more recent the case, the more likely is it to be present. It chiefly con- sists in a want of keeping time, the beats following each other at irregular intervals, or in an excited, or sharp, or sudden systole, which is less sustained than natural. The chief interest of this condition in a practical way is, how- ever, the bearing that it has upon the previous question, that of the existence of organic disease ; and it must be admitted that, given muscular irregularity, valvular incom- petence — particularly, of course, of the mitral or tricuspid — is likely to follow. Some have even suggested that, if we allow this, then the vegetations found upon the mitral valve in cases of chorea are the result of such regurgitation, and a sequence such as this, as an occasional thing, is by no means improbable ; but allowing all this, and important as it all is as regards the question of the relation between rheumatism and chorea; I still think it conclusively estab- lished that the issue of chorea, as regards the heart, is in no small number of cases organic disease. The figures are as follow : * — thirty-eight had permanent cardiac disease ; nearly all of them mitral disease; thirteen others had evi- dence of disease, but whether permanent or not is uncertain. I may add that of seventy-eight cases in which the heart is noted as being normal, thirteen had certainly had rheu- matism. Exciting Causes. — In five-and-twenty cases of the 141 there was a distinct history of fright, and in six others the * I am not here including any case of heart disease attributed to chorea such as are some of the fifty-nine above quoted, but only such as I have my- self seen in chorea. CHOREA. 573 child was noticed to be unusually timid ; in other cases the disease commenced after a fit, some exanthem, over-work, etc. Taking the figures of Drs. Sturges, See, Hillier, and Peacock with these, we have 670 cases, with 224 of them due to fright or some nervous shock or strain. This, prob- ably, is too low an estimate of mental shock, for of 126 cases taken from the collective investigation records, sixty- six cases were attributed to causes of this kind. It is worth remark that, although there is in so many cases a definite history of fright, the onset of such cases is usually slow, and thus it happens that it is difficult in many cases to see any relation between the supposed cause and the effect ; and doubtless, for the same reason, it happens that a cause such as this is at times entirely overlooked. I am disposed to think that one frequent cause of fright or nervous shock in children which is liable to be overlooked in this relation, is nightmare. Nervous children are very prone to this affec- tion, and nothing is thought of it; but those who have ex- perienced its horrors — the palpitating heart of the awaken- ing, and the ecstatic relief which is then experienced, and remains with some for some time' afterwards — will know that, to an unstable nervous system, few things are more fitted to upset its balance and to induce chorea. And here, perhaps, I may introduce the question of the relation of chorea to rheumatism, because, although in the majority of cases, perhaps, the latter stands to chorea rather as a consti- tutional element which predisposes, yet in some it precedes the chorea and introduces it, so to speak, and may thus be said to cause it. The facts I have collected in relation to these matters are these : 574 THE DISEASES OF CHILDREN. Auto-rheumatic only .... 14 Auto-rheumatic with family history 25 Rheumatic family history only 50 Gouty " » « . 2 Choreic " " " • 2 Xo history of rheumatism known . 37 Xot stated ...... 11 141 Thus, thirty-nine had had rheumatic fever, and fifty more had a history of rheumatism in some of their near relatives. There has been much discussion as to what the relation between these two diseases may be — whether, even when Ave take into account the average of rheumatism which belongs to every family, there is any abnormal frequency of rheumatism in choreic families. I cannot enter into this here. It will be sufficient to say that, after having gone carefully into the question, I believe some thirty per cent, of families taken indiscriminately are rheumatic, while for chorea the percentage is about sixty. I do not think chorea is always rheumatic — it is a common method of nervous breakdown in nervous systems of unstable build, however produced ; and a choreic child may as well be the offspring of the epileptic, neuralgic, gouty, hysterical, or passionate, as of the rheumatic. Choreic children are often anaemic, often spare, as if they had been living badly, though this is bv no means ahvavs the case. Sturges gives it as his opinion that the choreic child is not uncommonly healthy- looking. Prognosis. — This is, as a rule, favorable. The disease is troublesome rather than dangerous. Nevertheless, if the movements be very violent, if the temperature is high or slowly rises, if there be much peri- or endo-carditis, or if the disease assumes the form of general paralysis rather than CHOREA. 575 that of jactitation, the case must be regarded with anxiety. Certainly such cases as show much imbecility, with inability to swallow food, are dangerous, and require the most careful nursing. Treatment. — Choreic children are some of the most fre- quent attendants at the out-patient rooms of hospitals. In- quiry generally elicits the fact that they have been under treatment for some time, rather getting worse than better, and the parents have become tired of the want of improve- ment. This is not because chorea is not bettered by treat- ment. Take any or all these cases into hospital, and in a very few days a marked improvement will be manifest. It is often said there is no treatment for chorea— it gets well by itself. It does nothing of the kind. Many a child will drag on and on in a most miserable state at its own home for weeks and weeks, getting worse rather than better, which, when taken into a hospital, rapidly improves ; and I believe that this is because many are content to give a choreic child this remedy or that of the many that have been recommended as valuable drugs, and there the treatment ends. Where lies the difference in the result ? Simply in this, that in hospital the child is kept in bed. Here is the first principle of treat- ment for all cases of acute chorea, the rest and quiet which bed offers. Other subsidiary details are by no means unim- portant ; regularity in the administration, suitability in the quality, of the food, and attention to the action of the bowels, are not to be neglected, but rest and quiet come before all things. The child should be placed in bed, and, if the move- ments are violent, it must be carefully protected by padding the adjacent sides of the cot, or in very bad cases the child may be slung in a hammock. The bowels may be cleared out with some compound decoction of aloes — some glycerine being added, as recommended by Mr. Squire, to make it more palatable — or by some jalapine (one or two grains) ; 5/6 THE DISEASES OF CHILDREN. and, if the sleep is bad, some Dover's powder, chloral, or succus hyoscyami may be given at night-time. A full milk diet is ordered, and some malt extract. As regards drugs, if the case is in any way acute or violent, I order nothing, but the child is regularly shampooed twice a day for a quar- ter of an hour. This generally procures sleep ; and by means of it, the good dieting, and the regular method of a hospital, great improvement is soon manifest. When, under this treatment, the more violent movements are quieted, then is the time to commence with drugs. I think there can be no question that no one can claim any great advantage over another. Sulphate of zinc, gradually increased up to ten or fifteen grains three times a day, is, I think, a most useful remedy, though very old fashioned. Arsenic, gradually in- creased from seven or ten drops up to fifteen, or even more, is another ; and with these, and iron and cod-liver oil, it is best to content oneself. The more sedative drugs, such as the bromides, chloral, hyoscyamus, conium, are of little real value, save as occasional draughts for sleeplessness, etc., in the early days. Veratrum viride has been recommended as useful in chorea. I have tried it, but seen no benefit from its use. In the last three years all the cases of chorea that have come under my notice in hospital have been treated as follows : They have been put to bed and allowed simply to rest, with good feeding, for two days. At the end of that time massage has been commenced, and special diet ordered, as given in the appendix of formulae. This treatment is car- ried out for a fortnight or so, when they are allowed to sit up in bed, well supported by pillows, and perhaps play with toys. I am never in a hurry to get them up, if the case has been in any way a severe one. The muscular strength ap- pears to me to be recovered much better in bed, while it is remarkable how too early exertion will throw a case back. When up and about again, the arsenic or zinc and cod-liver CHOREA. 577 oil should be continued for sometime, and the child guarded from any great excitement in its play. A quiet convalescent home or change of air is often advisable, and the parents must be instructed to be careful of the child for a long time, as the remaining choreic movements are liable to become aggravated, under even trivial excitement. [The value of arsenic is unmistakable. My plan, when the patient can be watched, is to begin, from the first visit, with a small dose of Fowler's solution, three drops three times daily for a child of seven years, and gradually increase the amount by the addition of one drop a day until puffing of the eyelids or vomiting and gastric pain show that the limit of toleration has been reached. It should then be discon- tinued for a day, and afterwards resumed, the quantity being continuously kept a little below the maximum dose, until convalescence is established. Subsequently small doses of arsenic with iron must be given for a length of time to ward off a return. This method with attention to diet and the functions of the body has always proved most satisfactory, and often acted with wonderful rapidity.] For choreic children, as a preventive, there is nothing like regular exercise, always short of fatigue. Gymnastics of all kinds are excellent, as are also exercises of any kind which tend to increase the voluntary control of the muscular sys- tem. Thus drawing, piano playing, or for younger children various kindergarten appliances, etc., are all useful, some for one case, some for another. 57§ THE DISEASES OF CHILDREN. CHAPTER XLIII. RHEUMATISM. " The fundamental difficulty in discussing rheumatism consists in defining what we mean by it," writes Dr. Thomas Barlow, and, true as this is as regards adults, it is still more true of children, who comparatively seldom suffer from acute rheumatism in such a pronounced form as is met with in older people. Children, indeed, suffer from typical acute rheumatism, with its fever, its pain, its swelling of the joints, its sweating; but to circumscribe it by these limits only, would be to ignore the larger part of the field of its work- ings, and to form a most inadequate conception of what rheumatism is capable of doing in childhood, or what I shall venture to call the " composite " of that disease. Acute rheumatism in the adult we all know well. It is a disease which sends the patient to his bed for three weeks; which is attended with fever, with profuse sour sweating and miliaria; with swelling and redness of the larger joints of metastatic development ; with much pain ; and with, in many cases, acute peri- or endo-carditis and pleurisy, or pneu- monia. And the disease is found in children in like manner; the older the child, the more likely is it to be typical; but a classical attack of acute rheumatism may be found at any age. I have seen it as early as two years, and more doubt- ful cases even in children of two and three months only. The age at which the individual cases occurred is stated in the following table : RHEUMATISM. 579 34567 4 . . . 6 . . . 4 ... 11 ... 6 10 11 12 Over But, speaking generally, children's rheumatism is want- ing in the severity of any one symptom, and its existence is often revealed by no more than one of many. There is but little fever — but, stay, we must hardly say that, for it is a common thing in young children to have a temperature of 101 , or so, which, if not tested, would have passed for nothing for all the history that the doctor could obtain. It is probable, however, that the temperature is not often ab- normally high for more than a day or two. The profuse sour-smelling perspiration so common in adults is almost absent in children. Of sweating there is but little, and of acidity of smell, none. The pain is less severe, and though the patients fret, they move about. The joint affection is less severe, the swelling has to be searched for, and often it happens that the puffiness of one ankle, or wrist, or knee, associated with pain, when pointed out to parents, has been recognized, but thought unimportant. Supposing the illness is sufficient to keep the child in bed, it may still happen that only one joint is affected, and that with the slightest swell- ing and the faintest blush. There can be no doubt that a large number of children suffer from rheumatism in this way, and never go to bed at all ; others, perhaps, who are kept in bed for a day or two, yet never see a doctor; and, in either case, when, years afterwards, some old valvular mischief needs explanation, there is no memory of the pre-existence of any disease. But what is true of these symptoms is not true of the heart. It is an old and thoroughly acknowledged maxim that in rheumatism the younger the patient the more the risk of heart disease ; but more than this, since the tout en- 580 THE DISEASES OF CHILDREN. semble of adult rheumatism fails in children, and this part or that is affected solely, so is it with the serous membranes of the thorax as well as with those of the joints. And though such cases are not common, an acute pericarditis or an acute pleurisy is sometimes the first and only evidence of rheu- matism. It is highly probable that an acute endocarditis may, in like manner, be the sole index of the rheumatic state. One might say that it certainly is so, but that from the nature of the evidence demonstration is less easy. Unless one has watched the onset of the murmur, it is often impossible to say what is its age. From this description it will be apparent that the rheuma- tism in children is apt to be expressed by very indefinite symptoms. If a child is suffering from acute pleurisy, for example, what is there in it which will warrant one calling it rheumatic ? Probably nothing. The significance of inde- terminate symptoms as indicating rheumatism has been shown by a careful study of life histories, and it is by this study in individual cases that a particular symptom will have to be judged. Acute rheumatism, therefore, is not common. It is represented in childhood by what are called growing pains, by a little transient swelling of one joint, by pleurisy, by pericarditis, by a progressive or persistent anaemia, which leads to a medical examination, when valvular disease is detected, and so on ; nothing pathognomonic of the disease, which is only to be correctly apprised by the most careful inquiries into the family history and the small ailments from which the child has previously suffered. It has been said that it is more common in girls than in boys, and in the sixty-nine cases just tabulated, forty-two were in girls, twenty-seven in boys. The attack appears most commonly as a general one — that is, localized to no one joint, and oftener by far in no joint at all, but being asso- RHEUMATISM. 58 1 ciatcd with general pain or soreness all over. Again, taking the same series, I find twenty-six thus generalized, fourteen others in which the knees were chiefly at fault, fourteen where the ankles were swollen, three only in which the wrists were alone affected. But there are other complaints which ought to be mentioned. Thus, four cases com- plained only of extreme pain in the side, which, in the absence of local inflammations of pleura or pericardium, must, I suppose, be attributed to a rheumatic muscular condition. The neck was alone affected once, the pericardium alone once. I have no note of anything that could have been called meningitis. At the same time I have occasionally seen cases of meningitis in children with rheumatic family histories, which have raised, though unfortunately not solved, the question of a rheumatic meningitis. The fever has generally been of the most moderate, or at any rate has easily been controlled by drugs. In the last ten cases taken from my note-books, which are a very fair sample of the usual run of such cases, the longest duration of any rheu- matic symptoms was four days, except in two cases, where bad peri- and endo-carditis complicated the disease. Con- trary to the opinion of some, I should say that relapses are uncommon; but again I must add that this statement is based upon cases treated almost invariably by salicylic acid or its compounds. In making this statement I am speaking of such recur- rences of the disease as have some definite time-relation to the primary attack — that is to say, which occur within a few days or a week or two of each other; and I must also ex- clude what might perhaps be considered of the nature of a relapse, the onset of chorea as the rheumatism subsides. Children, like adults, once they have had rheumatism, are liable to recurrent attacks of pain of no great severity. As I have already said, these are by no means to be made light 49 582 THE DISEASES OF CHILDREN. of, since they possess a well-known tendency to associate themselves with lesions of the heart and its valves; but they are to be looked upon as of the nature of fresh attacks, or of the persistence of a status rkeumaticus rather than as the recrudescence of a worn-out malady. As in adults, but more commonly than in them, acute pericarditis and endocarditis (the latter far more frequently) are often associates of acute rheumatism. But for the reason already given that the rheumatism so often escapes notice, it is almost impossible to say what proportion of cases occur as the direct outcome of the one attack, or how far it re- sults from some persistent state which slowly and surely damages the valves. Of my series of sixty-nine cases of acute rheumatism, fifteen had organic disease, one aortic disease, two pericarditis, and the remainder mitral disease ; and five more had sufficiently pronounced symptoms of cardiac disturbance, such as alteration in quality of the sounds, displacement of impulse, irregularity of action, as to make it probable that there was also actual disease. Acute rheumatism is strongly hereditary. Of the same sixty-nine cases, thirty-two had a good history of rheuma- tism in close relatives, father, mother, or brothers, or sisters; nine more had a moderate rheumatic strain, the disease having occurred in uncles, aunts, or grandparents ; in four the history was vague ; seventeen had no ascertainable rheumatic taint; and no statement was made upon the point in seven. The' remarkable power of transmission which rheumatism occasionally shows is well illustrated by a case I published in the " Guy's Hospital Reports," vol. xxv., where, with a rheumatic strain both in father and mother, five out of a family of six children under fifteen, all but a baby of fourteen months, had either had rheumatism or heart disease. A boy of fifteen had had rheumatic fever twice, and had mitral regurgitation ; a second boy, aged ten, RHEUMATISM. 583 was similarly affected ; the third, a girl, aged eight, died of mitral disease; the fourth, a girl, had rheumatic fever (after scarlatina), with subsequent progressive thickening of the mitral valve ; and the fifth, a boy, aged four, was laid by, all one winter, with rheumatism. Steiner gives a yet more striking case, where a rheumatic mother had twelve children, and eleven of them had had rheumatism before the age of twenty. But the larger part of the rheumatism of childhood con- sists of isolated, and, at first sight, disconnected, ailments, which must now be enumerated seriatim. Tonsillitis maybe mentioned first, because there is a grow- ing frequency of assertion that it is a rheumatic ailment, generally as preceding the attack. It is probably more com- mon in adults than in children. I have notes of only a few cases of the kmd. Next we may take chorea. This, as one of the most prominent of the diseases of childhood, has already received consideration on its own merits in the preceding chapter; but in relation to rheumatism it is important to bear in mind that it not uncommonly precedes, more often it succeeds, and occasionally it alternates, so to speak, with rheumatism. Cases occur where chorea is followed, and, in great measure, replaced, by acute rheumatism, and, as the latter subsides, the chorea comes back again. The actual figures have already been dealt with ; but I may say again that it appears to me that chorea has a relationship of some sort with rheu- matism in two-thirds of the cases ; but there is naturally a good deal of difference of opinion upon this point. Heart disease is another symptom of rheumatism. It hap- pens over and over again that a pale and emaciated child is brought for treatment. Mitral disease is detected, and yet there is no history of previous rheumatism. Inquiry reveals that one or other of the parents has had rheumatic fever, 584 THE DISEASES OF CHILDREN. perhaps some one or other of the brothers or sisters also. We are fairly justified in regarding such cases — always sup- posing that the rheumatic attack has not been overlooked — as cases where the rheumatism has localized itself in a par- ticular part. In a few cases I have seen even young infants with heart disease, which, had it not been that there was a rheumatic family history, would have been supposed without question to be due to malformation. Pericarditis, in like manner, may be the primary disease, and the joint affection develop later, or not at all. As illustrations of these points, I may mention the following cases : An infant, aged two and a half months, ailing for four weeks. It was extremely pallid, with a cantering action of the heart, and a loud systolic mitral bruit audible all over the prsecordia, and in the axilla and back. Its mother had suffered from what was probably rheumatic fev^er when twelve or thirteen years of age. A boy of fourteen, with pains all over him, and extreme anaemia, was admitted for irregularity of the heart, and de- veloped an acute pericarditis without any definite rheumatic attack. Another boy, about twelve, was admitted for pericarditis, and developed a rheumatic affection of the joints some three or four days later. A girl, aged eight, with a rheumatic father, and who had suffered nine months before with rheumatic fever, was ad- mitted with left pleuro-pneumonia, followed within a few hours by pericarditis. She was in the hospital seventeen days, and had no joint trouble at any time. Acute pleurisy and pleuro-pneumonia are sometimes the symptoms of rheumatism. They are very commonly part of acute rheumatism; but I am now more particularly allud- ing to the fact that just as a pericarditis may be the only indication of rheumatism, so also may pleurisy or pleuro- RHEUMATISM. 585 pneumonia. The case just mentioned is an illustration of this. As other features of a rheumatic attack may be mentioned, first of all, certain acute erythematous affections of the skin. Urticaria is one of these ; and for the rest, perhaps, erythema multiforme is the best general term, for the eruption is some- what diverse in appearance — now papular, now marginate, and occasionally associated with purpura. Next, there are the subcutaneous nodules, which have been described by Dr. Barlow and Dr. Warner. These are small inconspicuous masses, which occur mainly about joints. The back of the elbow, the malleoli, and the margins of the patellae are the commonest sites ; but search should also be made along the vertebral spines, the crista ilii, the clavicle, the extensor ten- dons of foot and hand, the pinna of the ear, the temporal ridge, the superior curved line of the occiput, and the fore- head. They may be solitary or in crops, are painless, and generally more palpable than visible. They appear and dis- appear in a few weeks, sometimes in a few days, and in rare cases persist for many months. They are fibrous, nucleated in structure, and some are possessed of considerable vascu- larity. These nodules are of considerable importance in two respects. In the first place, inasmuch as they undoubtedly occur in the course of, or as a sequel to, acute rheumatism, they may be of considerable use in establishing a diagnosis in doubtful cases ; and, in the next place, it has been shown by Drs. Barlow and Warner that they are almost invariably associated with disease of the heart, and more often than not with a progressive form of disease. There yet remain to be mentioned some few lesser ailments, which, whilst they do not appear to have any constant or even frequent relation with rheumatic fever, are nevertheless found in particular children, and sufficiently often, in those who have a rheumatic family history, to justify their inclu- sion in the composite of rheumatism. 586 THE DISEASES OF CHILDREN. Children of rheumatic parentage are often habitually anaemic and thin. As a matter of practice, if I have to do with a child who is anaemic, thin, and of dark with- out any particular transparenc ; f skin, I ah inqu carefully into the family history, and I think that rheumatism taints more than an average of such. The rheumatic diathesis is sa ft some to be expressed by a fair complexion amongst other things. My own experience would lead me to say that a dark complexion was more prevalent But this is a question which depends so much upon what individuals consider to be evidence of rheumat that I do not propose : attempt to upset the generally re- d statement. Nervousness is entitle term, perhaps, but it is one in common use with parents, and ; f con- ditions which are important to note. Of these, a sub-choreic conditio:: A child is constantly fidgeting, or mak- performing irregular movements of his fingers or hands, or he is clumsy in his movement other has an irritable or exhausted ner\ ifter what to healthy children is moderate play. The nervous c becomes unusually excited while playing, perhaps suddenly bursts into a cry, or becomes ill-tempered without cause, or, after the ga:r i out, and wanting to lie down ; or may be he is actually languid and ill for some ds. Sleep com^ if at play wares their bedtime. They wake up fitfully, talking or aming. 2v~htmare is another rheumatic a— It is v common — seventeen out of a series :: : :n owned a rheumatic parentage. Obstinate headache in children is frequently found in r; lilies. It is prone to be associated with the anaemia of which mention has already been made. Of thirty-three RHEUMATISM. 587 cases of headache, twenty-three were of rheumatic stock, five of epileptic, and five only showed no abnormal taint. Stiff neck is another ailment quite common in childhood, and for which, perhaps, lumbago is substituted in the adult. Whether this be so or not, however, I should wish to teach that stiff neck, an ailment of childhood, and lumbago, one almost confined to adult life, are both diseases of the rheu- matic strain. Barlow suggests that the isolated phenomena met with in the rheumatic, and of which stiff neck is one, are the acute rheumatism of the adult distributed, so to speak, and it may be so ; but I cannot say that I have no- ticed the condition in those who have actually suffered from joint troubles or heart disease at any former period. Amongst other troubles which may be said to be of this sort, I have noticed spasm of other muscles, causing sometimes retrac- tion of the head, the peculiar inturning of the thumb upon the palm, and the toes to the sole of the foot, which is called tetany ; also muscular tremors of various kinds, stammering, and nocturnal incontinence of urine — all these things re- duced to their cause, or to come as near to it as may be, are nerve discharges, excited by morbidly slight stimulation or irregularity in the discharging act. And there is another feature of the rheumatic child which is no doubt allied to these — viz., a frequent stomach-ache soon after the ingestion of food. A number of such children tell a tale of pain dur- ing or soon after a meal, and this is often associated with an action of the bowels. Their food is said by mother or nurse to run through them. Now what happens is surely this, that the nervous supply to stomach and intestine is morbidly irritable and responds to the introduction of fresh food by excessive vermicular action. I may perhaps add, as part of the argument, that at little opium in the form of Dover's powder, almost certainly cures the complaint. Of skin diseases, psoriasis and erythema nodosum occur 5 S3 THE DISEASES OF CHILDREN. in the rheumatic, and the latter in a peculiarly marked man- ner ; for of twenty-nine cases, nineteen were rheumatic, five only were certainly not so, five had not been interrogated upon the point. Allied, I suppose, to this affection is the purpura that occurs in the rheumatic, or the more definite .sis rheumatica which occurs in the form of crops of purpuric tingling papules. But this is more common in adults than in children, in whom I have but seldom seen it. Diagnosis. — There is less danger of rheumatism being mistaken than of its being overlooked ; but I have several times seen a rheumatic hip give rise, by the persistence of pain and absence of swelling, to the suspicion of early dis- ease of the joint ; and there are other affections of the bones and joints which sometimes lead to mistake. There^is an occasional acute suppurative disease of hip or knee in infants ; there is the acute inflammation at the epiphysial lines which takes place in infants with congenital syphilis ; there is the hemorrhagic periostitis which occurs in scurvy ; there is acute ostitis and necrosis with pyemia — that fatal disease which is so common in childhood and which is constantly mistaken at first for rheumatic fever ; there are the effusions into the joints which take place in bleeders (hemophi there is the pain and tenderness of rickets ; — all these, by the pain and immobility which they occasion in young children, may be thought to be rheumatic without much difficult}', if we are not on the look-out to discriminate between them. And again, as Barlow has pointed out, there is much in the early stages of infantile paralysis to liken it to acute rheu- matism. There is often fever and general tenderness in the affected limbs ; and Barlow records a case of a child in whom, for more than a fortnight, there was extreme tender- ness and a little redness and swelling of the dorsum of each foot. Having said this much, however, it mav also be su^ested, RHEUMATISM. 589 though I would not say positively that it is so, that the rheu- matic state may act upon different individuals in different ways, and thus may produce, in some, effects which we are wont to attribute to other causes. I might illustrate what I mean by this very disease — infantile paralysis. Here is a disease which suddenly attacks healthy children with fever, and which ends in paralysis. We know absolutely nothing of the disease, except that it produces certain results. To any one who should affirm that infantile paralysis is due to the rheumatic poison we could say nothing, as we have no evidence for or against such an opinion, and clearly there is no reason why it should not take its place as one of perhaps a number of possibilities, luowever unlikely or small its chance, so to speak, may be. But the point of this is equally true as regards joint disease and serous inflammations in the rheumatic. We generally assume, in dealing with any de- structive joint disease, that it is not rheumatic, because it is a generally accepted maxim that rheumatic inflammations are prone to resolve. But if, as soon as we see a chronic synovitis or destruction of a joint resulting from it, we at once exclude rheumatism because of the condition, what chance have we of ever ascertaining the natural history of the disease? I believe that permanent disease in various parts is no uncommon result of an attack of rheumatism which has been overlooked. We allow this much without question as conclusively established in the case of the heart, but for pleura or joint no such teaching is accepted. I should like to see a revision of statements on this point, based upon a careful inquiry into the life history of the individual, his family history and antecedents, in all such children as are affected with chronic joint disease and empyema. Of course, such common affections are due to a great variety of causes, many of them in no way rheumatic, but I doubt not that rheumatic inflammation adds its quota to the total. 50 590 THE DISEASES OF CHILDREN. Of scarlatinal rheumatism I have already said all that is necessary (p. 187). If it be a distinct disease, the counterfeit is at any rate so like the original as to be undistinguishable. There is the same metastatic affection of joints, the same tendency to the occurrence of an endocardial murmur, the same relief by salicylic acid treatment. It differs in one or two points, perhaps, if the type of disease be drawn from a large number of cases, for there is but little tendency to peri- carditis; the endocardial murmur is prone to disappear — though this must not be taken to indicate that the bruit has been of a " functional " nature, and unassociated with endo- carditis — and there is some, though judged by its variety but slight, tendency to the occurrence of acute suppuration in the joints. These, however, hardly to my mind constitute any essential differences, and I look upon the disease as prob- ably acute rheumatism. I am the more inclined to do this, as several cases which have occurred to me have been in rheumatic families, and I am therefore disposed to believe that it is a constitutional trait, which develops itself under the altered condition of health produced by the scarlatina. Rheumatism has no morbid anatomy, save such as at- taches to the heart, and to this belong no peculiarities. But it may be said, in short, that acute rheumatism is fatal by its pulmonary and cardiac complications ; and that, when it is so, it is usual to find acute pericarditis and endocarditis, the muscular wall of the heart being pale, softened, and dilated; the weight of the heart is increased, and usually very much so, probably in great measure by acute inflam- matory swelling, and the lungs are in that peculiar con- densed, solid, sodden condition of leaden color, which has usually been called oedematous. This condition is com- monly double-sided, and is associated with more or less pleural effusion. The treatment of acute rheumatism follows the same lines RHEUMATISM. 59 1 as the disease in adults. The child must be kept in bed, between the blankets or well covered in flannel, and any painful joints are to be swathed in cotton wool. The diet strictly farinaceous; milk and bread and butter, biscuit, etc., may be allowed. Since Dr. Maclagan first recommended sali- cin, all my cases have been treated either by it or salicylate of sodium, the latter far more often, on account of its cheapness. By its means the attack, if free from complications, has been a disease of comparative unimportance, and relapses have been almost unknown. Eight, ten, or fifteen grains may be given every three hours; ten grains is the usual dose for a child of eight or ten, and it is given with syrup and acetate of ammonium; this usually for three or four days, when it is reduced to three times a day, and then, after a week or so, combined with quinine. Should there be any pericarditis or acute endocarditis, the chest is to be covered with wool, or spongio-piline, or poultices, and small doses of opium, in the form of Dover's powder, given three or four times in the twenty-four hours. Three or four grains of the powder may be given to a child of six or eight, and belladonna or digitalis must be given if necessary, according to circum- stances. The salicylates are supposed to be inclined to dis- turb the hearts action, and are therefore sometimes discon- tinued when heart disease sets in ; it has also been stated that, after its onset, their continuance is unattended with good effects upon the rheumatism. I always give it with caution and careful supervision in such cases, but I am by no means disposed to withhold it, unless there should be distinct indications for doing so. But there is this to be said, that when the heart attack is severe, the joint affection is very slight, or none at all. The cardio-pulmonary condi- tion, which I have described above, is a most puzzling one to treat. The child lies propped up in bed, extremely pale, with dilating alas nasi and rapid breathing, the heart pump- 592 THE DISEASES OF CHILDREN. ing away at 120 to 160 per minute; there is acute pericar- ditis and mitral disease also, though this is often uncertain from the confusion of sound produced by the pericarditis and the rapid action. The chest shows considerable dulness and high-pitched tubular breathing, probably from the seventh or eighth rib downwards, at both bases. In such cases it is very difficult to say what drugs do good, and whether a case is to do well or badly. Undoubtedly the most essential requisites are careful nursing and judicious feeding; these, and opium given internally, will steer many cases through the pericarditis — the heart's action quieting down, and the pleuritic effusion and solidification of the lung slowly clear- ing off. But there are, unfortunately, many cases, hot differ- ing much in the physical conditions ascertainable, in which the child becomes more restless, vomiting supervenes (one of the worst symptoms possible in cases of this kind), and the child dies quite quickly. These are cases in which brandy must be administered freely. Ether is, no doubt, a useful drug under these circumstances, but it is not one that children take readily, and it is often vomited, in which case, however, it may be injected subcutaneously. Regarding the treatment of the rheumatic child — whether it be rheumatic by any attack of former acute rheumatism, or its tendencies shown by some of the lesser ailments in- cluded in rheumatism and associated with hereditary taint — there is much to be said. Such children require the most watchful medical care, and much more than is usually con- sidered necessary by their parents — uninstructed, as most of them are, as to the meaning of trivial ailments in such chil- dren. A tonsillitis, a headache, paleness, etc., do not neces- sarily suggest the advisability of an examination of the heart; but such conditions in these children are to be looked upon as part of the life-history of rheumatism, and unless the heart be examined — shall I say, supervised (as RHEUMATISM. 593 indicating the necessity for prolonged watchfulness") — disease may be creeping on where we least expect it. These are some of the cases where the doctor should be remunerated for keeping the child well, rather than called in to cure it when actually ill. His fee should be an annual retainer, irrespective of any illness, and there is no doubt that rheu- matism and its results would be diminished. The manage- ment of the rheumatic child requires discretion at all points. It is not only that its diet and its clothing require it, educa- tion and play alike call for advice in many instances, and the question of residence, although often quite beyond power of alteration, is one of vital importance. Of course, until we know what rheumatism is, we must deal to some extent in generalities, which may be very open to discussion; but with this admission, it may be said that warm flannel cloth- ing is essential ; the diet should be varied, and contain plenty of easily digested vegetables, in addition to the milk and ordinary food ; and both as regards work and play, the slightest indications of excess, in the way of exhaustion — whether this be temporary or continuous, any headache, tendency to nightmare, or what has been called nervousness — must lead to immediate moderation. For such children the greatest care should be exercised in the selection of a school, both as to a dry, warm climate, the home life therein, and the happiness of the child; and unless all these things are satisfactory, it is far safer to keep the child at home. The rheumatic child is one who requires drugs on occa- sion. Whenever it is below par, or getting anaemic, some good tonic should.be administered, such as Easton's syrup, with which I am in the habit of combining arsenic as one of the most useful of remedies for cases of this sort. Five drops of Fowler's solution, or seven, or ten, with half a tea- spoonful of Easton's syrup, taken continuously for a month 594 THE DISEASES OF CHILDREN. or six weeks, is a most valuable help in these cases, and cod-liver oil, stout, maltine, and such things, are also to be recommended. For the nervous or excitable condition, particularly in girls, the bromide of ammonium, bromide of potassium, hydrobromic acid, and manganese are of value ; and for the nightmare which occurs in younger children, bromide of potassium and hydrate of chloral combined, form almost a specific. Five grains of the bromide and five of chloral (half-drachm of the syrup), may be given to a child two years old, and continued as a draught at bedtime for a few days, with the almost certainty of success, care being at the same time exercised that the excitement of the day be re- duced to its minimum. Of the abdominal pains I have already spoken, and advised the administration of Dover's powder. Such children require attention to the bowels, which are liable to be irregular. If so, some gentle aperient in the shape of fluid magnesia, effervescing citrate, liquorice powder, syrup of senna, confection of senna, or the fluid ex- tract of cascara sagrada, in doses of ten to thirty minims, may be given, and a little tincture of nux vomica also is sometimes of advantage. The treatment of nocturnal in- continence is discussed in " Genito-urinary Diseases," page 452. HEART DISEASE. 595 CHAPTER XLIV. HEART DISEASE. In studying diseases of the heart in children, it is neces- sary to be aware of a few preliminaries. The heart's action is more rapid than in adults. It is not necessary to burden the memory with the precise data for particular periods, but it will suffice to remember that at birth it is about a hun- dred per minute, for the first two years it quickens up to one hundred and fifteen or one hundred and twenty, and that subsequently it gradually slows again. From two to six it remains about a hundred, and then gradually drops to seventy or eighty. In early childhood there is a good deal of difference — often as much as twenty beats per minute — between sleeping and waking ; the heart, of course, beating slow in sleep. This is naturally a matter of great impor- tance in disease, for if the heart's action can be thus reduced, as much sleep as possible will certainly be advisable in cases in which the heart is diseased, and needs all the rest that can be obtained for it. This difference is said only to apply to young children. One cannot, however, dogmatize on this matter, for it would appear, from some observations made for me by Dr. Newnham at the Evelina Hospital, that the amount of slowing is subject to some variability. In several cases it was noticed to be three or four beats quicker during sleep; although on the whole there was a well- marked reduction of four or six beats, and sometimes as much as thirty beats per minute ; and this not confined by any means to the youngest children, but to those of seven, eight, and nine years. The heart's action is also less regu- f:5 THE DISEASES OF CHILDREN. lar in its rhythm — one beat will t the next strong, and so on. The point of this is chiefly igs and Pepper Gpmark, that t be exercised in drawing conclu- sions in cases Q> doubtful meningitis, in which disease an irregular pulse is one of the most valuable diagnostic indi- cations. The heart's actic :; ; )ften more diffused upon the surface and visible than in adults ; the position and the im- pulse with regard to the nipple is more variable, and the im- pulse is Dften higher than normal in the fourth interspace. The precordial dulness is a little larger. Perhaps this would not be so in children of absolutely healthy -:::.::dard ; but so many suffer from moderal tortions, from bygone all, that the lung which should cover the heart more thoroughly is less expanded than natu- ral. The heart sounds are usually more tic-tac — that is, less si an in adults; althougl - an adequate cause — acute Bright's _-. for example — they will be- come thick and laboring as in an adult. This is well worth notice, for I have often had my attention called to the existence of albuminuria by the peculiar lengthening and laboring of the first sound. This is perhaps the : striking when one has to contess — at least, I should — that any corresponding changes in the pulse can but seldom be shown to exist. It is very difficult, indeed, to gain reliable information as regards volume and force, and the sphygmograph I have met with ut disappoint- ment in children. There is rhildhood in dis- : of the heart, excepting, of cour- ":rms of congenital disease : but there are one or two points which are worth remark, and even where the rs follow the same line of adults, the o of origin of many cases in grown-; le makes the various forms of heart disease in early life of considerable etiological value. HEART I : - Steiner makes the statement that a useful rule in diag- - is to consider all heart affections occurring under four s of age of congenital origin, and that only after that age do the acquired di ake their appearance, because their chief exciting cause, rheumatism, is seldom met with in children under four years of age. But this rule mu5t not be insisted upon too rigidly. Heart disease is, no doubt, much more common over four than under; but those - which occur in younger children must not be too hastily assumed to be of congenital origin, if by congenital nean such conditions as are due to malformation rather than to disease. Taking my own cases, the figures stand thus: Rheun:?.::: heart disease, . . . 134 cases. Non-rheumatic, or with no history. . 5 5 The heart disease of chore?, r no doubt, seldom occurs befor a;re is r.zzti in : 5; :?.se = ::":hes : . - i "_ z itz : - : : - : ; : : n : ; : : : : z - ? : : -; 12 :f -- :: :: II - 11 : : ' : Sixteen cases, therefore, occurred under four years of age. Of these, twelve, or three-fourths, it is true, are headed as congenital ; but of the twelve cases so-called, five were asso- ciated with a simple systolic bruit, which, in an adult, would certainly have been attributed either to mitral or tricuspid regurgitation ; and no doubt we are too apt to conclude that when cardiac murmurs are present in infancy, there is some malformation of the heart. The following case may point this remark : A male child, aet. two months, was admitted into the Evelina Hospital for cough and stomatitis. It was illegiti- 598 THE DISEASES OF CHILDREN. mate, brought by a woman in charge, who stated that it had been ill three weeks. It was in a moribund state, and very thin. Temperature io; c . Respiration and pulse not to be counted. There was a loud systolic bruit heard at the apex and all over the right side of the chest. It died in a convulsion within a short time of its admission. At the in- spection, the mitral edge was thick, and on its surface were abundant inflammatory granulations, uniformly distributed round the orifice, and quite sufficient to interfere with its efficient closure. I could give notes of several other cases of infants but a few months old in whom the physical signs were in favor of simple mitral regurgitation. I may also add that Mr. Bland Sutton, in a recent paper read before the Royal Medico-Chirurgical Society upon the value of the systematic examination of still-born children, has published a case of recent endocarditis in an eight months' foetus, the pulmo- nary and aortic valves showing soft vegetations, and the mitral being much puckered. This distinction between disease and malformation, though not always practicable, is clearly an important one. Causes. — Of two hundred and forty-eight cases of heart disease in early life which have passed under my notice, either at Guy's Hospital or the Evelina Hospital for Chil- dren, twenty occurred in the course of acute rheumatism ; one hundred and thirty-four are set down as rheumatic (occurring, that is to say, either as the sequel of actual rheu- matism, or in families with rheumatic history); fifty-nine gave a history of chorea, or were actually choreic, at the time they were under treatment ; and fifty-five could not be attributed to any definite cause, if we except s^vcn, or, at most, twelve, which may have been congenital. As regards causes of valvular disease other than rheuma- tism and chorea, of which there must surely be very many, HEART DISEASE. 599 though no one at all approaches either of these in impor- tance, scarlatina probably comes first ; but other exanthems occasionally lead to endocarditis, and diphtheria, pneumonia, pleurisy, typhoid fever, syphilis, and pyaemia are all occa- sionally to be found in its company. It is, moreover, interesting to note how valvular disease is more common in females than in males all along the line, not only in the rheumatic and choreic cases, but also in others : Females. Males. Total. After rheumatism, . 8 9 . . - 45 - • • 134 Choreic, • 45 • • . 14 . . • 59 Other, . 33 ' - . 22 . . 55 167 81 248 Next, as to the nature of the valvular disease : Rheumatic, Mitral, . . 79 Aortic, . . 3 Aortic and mitral, 8 Doubtful, . . 44 Congenital, . . — 134 Choreic. 39 7 11 2 59 Non- rheumatic 29 I 3 10 12 Total. 147 II 22 56 12 248 This table shows how large a proportion mitral disease bears to other forms. Eleven cases only out of the total were simple aortic disease, twenty-two others had both aortic and mitral disease. Doubtful cases form a large group. This heading is not intended to indicate that the existence of disease was doubtful, but only that its exact nature was not to be precisely determined. Under it are classed all cases of thick sounds, thumping action, displaced heaving impulse, in some of which no doubt the mitral was at fault, and in others I have suspected an adherent pericardium. But I do not doubt that if mitral disease had its due, many of this 600 THE DISEASES OF CHILDREN. group would fall to its share ; and this would raise the pro- portion which mitral disease bears, so overwhelmingly, as to reduce all other forms to a numerical insignificance. If, next, we inquire further into the form of mitral disease, in five cases a pre-systolic bruit existed, and ten others probably had a contracted mitral, whilst doubtful cases are included in the group devoted to them. Therefore, not only can it be said that mitral disease is the common form of heart disease in childhood, but that mitral incompetence, or mitral regurgitation, is by far the commonest form of mitral disease. I lay stress upon this, because it is said and taught that there are two different forms of mitral contraction, and one of them is of congenital origin. If so, it should show itself in childhood ; whereas, in very young children, mitral stenosis is almost unknown, whether we look for it at the bedside by auscultation or in the post-mortem room. I have long been looking for such a specimen in children under five years of age, and have never yet seen one. Mitral regurgi- tation is common enough, but mitral stenosis is not found until we come to deal with children of eight or nine years of age. It is not at all common at that age, but after that it becomes common as years advance, and, as we all know, it is one of the commonest affections of adult life. A girl of four years was in hospital from June to Novem- ber, 1882, with acute peri- and endo-carditis, and acute pleurisy, with consolidation of the base of the left lung. Her illness was attributed to cold caught six weeks before her admission, and neither personal nor family history of rheu- matism could be elicited. After she left the hospital no more was heard of her until thirteen months later she came in to die. There was still, as there had been when she left the hospital in the previous year, a loud systolic mitral bruit, and the impulse of the heart was inside the nipple. Convulsions were the immediate cause of death. HEART DISEASE. 6oi The inspection showed a large heart with an adherent pericardium. The mitral valve was considerably thickened, but the aperture admitted one finger. The aortic valves were thickened. I give this case because it is typical of the cardiac changes one may expect to find in young children, and of the condi- tions which lead to death. The pericardium was firmly ad- herent, and the heart large and no doubt dilated. The mitral valve was considerably thickened, but not yet substantially contracted, for it admitted one finger, which is a fair capacity for the heart of a child of five years old. Acute pericarditis occurred in twelve cases in all — in six associated with acute valvular changes in chorea, in six with acute rheumatism. In comparison, therefore, with endocar- ditis, it would seem to be uncommon.* But the student must remember that it is found in many other conditions than these, and, perhaps as commonly as in any, in those acute inflammations of bone which are not infrequent in childhood and adolescence, and which go by the name of infective osteo-myelitis. Such cases almost always suffer from abscesses in the heart, and, as a natural consequence, acute pericarditis follows, and should the patient live long enough, pus collects in the sac. Pericarditis may also be met with after scarlatina (when, perhaps, it is rheumatic) ; by extension of disease from the neighboring pleura ; and occasionally, but very rarely, though more often in children than in adults, with a tubercular affection of the serous membrane, and as a sequel of acute Bright's disease. Should there at any time be evidence of a large accumula- * I am now only dealing with my series of hospital cases. I have seen it more commonly than these figures indicate, but that is probably, as I have remarked for empyema, because outside the hospital, more than inside, the practice of the hospital physician lies amongst the worst cases, not those that are mild. 602 THE DISEASES OF CHILDREN. tion of fluid in the sac, the possibility of it being purulent must be considered, particularly if the inflammation have extended from a left-sided empyema, or be secondary to the existence of tubercle. A septic form oi pericarditis is de- scribed by most authors as occurring in the new-born infant, and originating in the umbilical sore. Acute peri- and endo -carditis are noteworthy in children as more liable than in adults to lead to a rapidly fatal termi- nation. Whether the inflammation is more severe in child- hood may perhaps be doubtful ; but at any rate the heart swells more quickly, its cavities dilate more readily, and a very few days' illness may determine a fatal issue. I once had a case of a young man, above the age, it is true, with which we are now concerned, who, to all appearance, had a healthy heart four weeks before his death. He was seized with acute pericarditis, and at the post-mortem the heart weighed 19 ounces. This looked at first like acute hyper- trophy, and no doubt in part it was ; but subsequent experi- ence has made me think that the criticism of Dr. Coupland, made at the time the case was recorded, was a just one, and that, as he suggested, something of the nature of acute swelling had taken place. In children an acute inflamma- tion of the heart of this kind takes place — pericardium, muscle, and endocardium, all are involved — the heart swells, rapidh' enlarges, and the ventricular cavities dilate, and then there follows that contracted leaden consolidation of the bases of the lungs, a condition very common in chil- dren, which is neither simple collapse, nor simple oedema, nor simple pneumonia, but probably something of all these, and which is an excessively anxious and dangerous condi- tion, because it is an indication of a sorely stricken heart. The physical signs in such a case are not without interest. The heart's action is generally of great rapidity, the anterior wall of the chest will enlarge rapidly in the praecordial HEART DISEASE. 603 region — protruding, in fact, before an enlarged heart — the pulmonary second sound will be loud, and the systolic sound at the apex will be replaced by a confused roar. Should there happen to be much effusion, the conditions will necessarily be modified thereby, and there will be in- crease of the precordial dulness, particularly upwards and to the right, and the impulse will become less violent and less diffused. It is but seldom that pericardial effusion causes either impulse or friction sounds to disappear al- together. But there is another form of heart affection than those I have mentioned, and probably one of no mean importance — viz., simple dilatation. Dr. West records several such in which no disease of the valves was found post mortem. I have myself seen it repeatedly ; more especially, however, in connection with post-scarlatinal nephritis. I do not, however, suppose that this is the sole cause of the condition. On the contrary, when we consider how liable the cardiac muscle is to suffer in its nutrition in prolonged anaemia — a common affection in children — how it has been shown to undergo dilatation, independently of nephritis, after scarla- tina, measles, typhoid fever, and septic conditions of all sorts — nay, how it has been many a time seen that after acute rheumatism the only change discoverable in the heart may be a simple dilatation of the left ventricle — we must always be alive to the possibility of the existence of this condition, and take it into consideration in endeavoring to unravel the nature of individual cases of mitral incompetence. As I have already said, the heart probably dilates in childhood with undue readiness. It is this which constitutes the fatal element in so many cases of acute heart disease, and yet, if on the watch to avert it, and prompt to recognize it on its first occurrence, no doubt much may be done towards saving life, and sometimes towards restoring a heart to a normal 6C4 THE DISEASES :? CHILDREN. condition,* which, were it not for this, would pass on into incurable disease. As regards symptoms, or the course of the disease, chil- dren are peculiar in one or tw :h are worth noting. They emaciate more than is customary with adults, and the younger the child the more markedly is this the case. Id very young children, the extreme emaciation and pallor of simple mitral regurgitation would often suggest a pulmonar rather than a cardiac affection, until a :scultation reveals the true condition; and I think it may be said, further, that physical examination reveals no other evidence of the cardiac affecti : the murmur, disturbed cardiac action, and increased precordial dulness. In young chil- dren, there is liable to be an absence of the hepatic enlarge- : which is common even in children a : rs older — of seven, eight, or nine years. Heart disease in very young children — of one, two, or three years old — is a wasting dis- ease. The reason for this is probably not far to seek: the cardiac defect at this time of life leads to impaired nutrition, as it does at any time ; but no :al, and rapid was results. The wasting so reduces the total blood supply that the circulation keeps within bounds, so to speak, and the mitral incompetence does not therefore produce those .me congestions of liver, spleen, and k hich are the common features of a later age. For a similar reason, probably, severe cardiac dro not common in older children. We see a child with all the local evidence of an enormous heart and with a large pulsating liver, perhaps without any ascites and generally without much anasarca, but such are always pale and always thin. I ?rhaps it is owing to some explanation of this kind that chronic heart disease of children is in many cases amenable to treatment, as regards relief to urgent ymptoms. The blood stream, diminishing, s, in proportion :: the emaciation, HEART DISEASE. 605 dammed back irremediably in the lungs, and a temporary rest, with tonic and aperient medicine and careful feeding, certainly enables many a case of permanent mitral disease to go on for years.* It is difficult to prove, but I have thought, after watching many of these cases for a long time, that here is the source of part of the number of cases of mitral stenosis that one meets with in adolescents and adults. May not the mitral regurgitation of infancy and early child- hood, when recognized and carefully tended, be kept going until, in the natural order of things, the mitral inflammation — which at its outset produced incompetence — contracts, and cicatrizes, so to speak, culminating in a cure in one sense — viz., a contraction of the orifice ? The natural ten- dency of all inflammatory conditions of the mitral valve is towards constriction of the valve, but, like its parallel, urethral stricture, in the presence of an active dilating force — in the one case in the passage of urine, in the other, of blood by muscular propulsion — years pass by before any serious amount of disease is produced. As regards the symptoms of both endocarditis and peri- carditis, it must further be said, that in children of any age they are liable to be very obscure. A short, dry cough, breathlessness on exertion, and palpitation, may be all that have been noticed, combined with a gradual loss of flesh. But when examined, there may be the rounded chest, the increased prsecordial dulness, the displaced, diffused, and heaving impulse, the roaring systolic bruit, which betoken not only old valvular disease but consecutive hypertrophy and dilatation also. Prognosis. — Acute peri- and endo-carditis, if they be attended with much turbulence and rapidity of action of the heart, or any evidence of consolidation of the lungs, require * West gives several cases of the kind, and refers to a passage in Dr. Latham's book of similar purport. 51 606 THE DISEASES OF CHILDREN. a guarded prognosis, based upon a careful study of the child and its surroundings. If, with the conditions just men- tioned, the child be restless, unable to lie down, takes food badly, sleeps badly, and, above all, vomits, the condition is one of great danger. At the same time, it is hardly possi- ble to avoid mistakes in forecasting the issue, seeing that some very bad cases rapidly improve, the consolidation of the lung and pleuritic effusion clearing up, and the heart's action quieting down ; while others no worse, perhaps not so bad as they, die off either quickly, or perhaps after hovering for some days without improvement. In chronic valvular disease, the opinion must be based upon the progress of the case. If the child takes food well, and the heart's action becomes quieter, the impulse less diffused, the separate sounds more distinct, and the con- gested viscera less hampered, whilst it is able to take the recumbent posture when asleep at night, further hopes may be entertained that it will ultimately reach a safe position — " safe but not sound," as Latham expresses it. In simple dilatation, the prognosis must also depend upon the extent of the dilatation and the evidence of impaired func- tion which may be present. With close watching, the strictest rest, and the careful administration of digitalis and such like remedies, some of these cases unquestionably recover. The treatment presents no special features in children, but one may again insist that in acute cases dilatation of the heart takes place with readiness, and this we must be on the watch to prevent or remedy. Opium is one of the most valuable remedies for this purpose, and with children of this age, six to fourteen, it may be used freely — three or four grains of Dover's powder every four hours may be given. Belladonna is useful, combined with bromide or iodide of potassium, according as there is need for soothing turbulent action, or for procuring the absorption of inflam- HEART DISEASE. 60J matory products. Then comes digitalis or the convallaria majalis, the former being much the more reliable in its action ; and last, but not least, I shall mention stimulants, which are very necessary in some of these cases. A child often may have three or four ounces of wine a day, if by careful watching the conditions seem to improve under its use. If there be much pericarditis, counter-irritation to the praecordia may be kept up by a mustard-leaf or lin. iodi,* and the chest wrapped round in a cotton-wool jacket. Absolute rest must be enforced for a long time, and, in the convalescing stage, iron and quinine should be administered for some weeks. Absolute rest must be continued for a long time. It may be well to emphasize this. There is no more important rule of practice, and none that is more often neglected. The case has been one of acute peri- and endo-carditis, and the heart is smothered in a thick jacket of lymph, its muscular wall is swollen and degenerated, its cavity in all probability dilated. The subject is a child of ten or twelve years of age. Is a two or three months' recumbency longer than is necessary under such circumstances for the repair of so damaged an organ ? Is it too much to insist upon, when the future of a just-opening life depends upon it? The surgeon with the diseased joint makes light of a year of rest; yet who has not seen a child after acute pericarditis skipping about at the end of a month or six weeks as if nothing had been amiss ? This ought not to be ; and in all cases, after rheumatic peri- and endo-carditis, the heart is to be rested in all possible ways for several months. There * Linimentum Iodi, Br. P., contains : Iodine, . . . . . • X X ounce Iodide of potassium, . . . y z " Camphor, . . . . . . j£ " Rectified spirit, 10 fluid ounces. — Ed. 608 THE DISEASES OF CHILDREN. are many ways of accomplishing this ; but chief of all, natu- rally, is the avoidance of all bodily exertion. Where it is possible, no walking, not even feet to the ground, should be allowed for three months. The child is to be carried everywhere ; and when at last it is allowed to walk about, the pulse and heart's action should be carefully watched. We may remember, too, that the heart is rested also by sleep. I have already remarked that the beats of the heart are sometimes considerably reduced in number at this time. It may be rested also by diet and general attention to bowels, etc. The food must never be allowed to overload the stomach, or stimulate the circulation too much. Rest is also to be obtained by tonics, which help the cardiac muscle to contract and slow the action of the heart. Here it is that iron acts — it restores the nutrition of the muscle, and thus slows the action. Digitalis, acting in another way, accomplishes the same purpose, and allows the heart more rest by prolonging the pause. Belladonna, convallaria, bromide of potassium, and hydrobromic acid are all use- ful, either in the same way or as sedatives in quieting the excessive action of the heart. Finally, as regards pericarditis, although purulent peri- carditis is by no means common, nevertheless, the student must remember that all serous inflammations in childhood have a greater tendency to the formation of pus than in adults. Therefore, supposing that in a case of pericarditis there is evidence of much effusion, and that evidence re- mains persistent — and still more so if the effusion has come on insidiously without any well-marked pericardial rub — the pericardial sac may possibly contain pus, and should it do so, the question of its removal ought to be discussed. In such cases the child is very anaemic and very ill, and any treatment is only too likely to be ineffectual to avert a fatal result. Nevertheless, what little evidence there is HEART DISEASE. ,609 points in favor of an exploration by a fine syringe, and, if pus should be found, of a free incision. Cases of this sort are no doubt very rare, and they usually pass away undiag- nosed (but this need not be). [Paracentesis of the Pericardium. — Whenever an effusion into the pericardium, whether it be serum, pus, or blood, accumulates so rapidly or in such quantity that it threatens life, or where it refuses to undergo absorption by ordinary treatment, it is the duty of the attendant to tap the dis- tended sac. This rule holds good even though there be such constitutional disease present as must, in all probability, soon bring about a fatal termination. Aspiration is the method preferred to all others. It does away with the danger of suppuration, of hemorrhage from the wounding of an artery, and of fluid dribbling into the pleural sac, should it be punctured. The entire amount of the fluid can be withdrawn, and little injury will be done should the fine needle pass through the edge of the lung or strike the ventricular wall itself. Fitch's trocar, attached to Potain's aspirator with a vacuum-jar should be used, the stopcock being turned to allow the atmospheric pressure to exert its force as soon as the trocar is buried beneath the integument. The operator is thus at once apprised of its entrance into the collection of fluid. The point of puncture preferred is the fifth intercostal space, close to and above the junction of the sixth rib with the corresponding cartilage. If there be evidence of point- ing, the tapping should be done at the most prominent point. Should the heart sounds be very loud at the point advocated for tapping, and adhesions be inferred, some other spot must be selected. In a monograph entitled " Para- centesis of the Pericardium," by John B. Roberts, M.D., from which this extract is taken, a table of sixty cases is given. Of these there were twenty-four recoveries and thirty- 6lO THE DISEASES OF CHILDREN. six deaths. Of those in the death column who survived the operation by a day, the average length of life was twenty- seven days. In other words, in those not already moribund, and who survived the shock of the operation, there was a probable prolongation of life of nearly four weeks.] Malformations. — There are many varieties of malfor- mation of the heart, or, as it is generally called, congenital disease. There is patency of the foramen ovale, patency of the ductus arteriosus, deficiency of the septum of the ventricles, and stenosis of the aorta where the ductus arte- riosus opens into it, just beyond the left subclavian artery. There are other anomalies, such as a single ventricle and auricle, one ventricle to the two auricles, or the viscera are transposed, the heart being placed on the right side of the chest and the liver and spleen transposing in correspondence, and lastly there are the various forms of adhesion and steno- sis of the various valvular orifices, chiefly of the pulmonary artery and of the aorta, and occasionally of the tricuspid and mitral also. But to give such a list as this is only to name the chief conditions. It will be quite unnecessary, however, to describe all these seriatim. Those malfor- mations consisting of reduction in the number of the cavities, are very rare, and generally destroy life quickly ; the only one, practically, which is in any way common — and this, of course, not so in the sense that its occurrence bears any proportion to that of other diseases of the heart — is stenosis of the pulmonary artery, with which is usually combined a deficient septum between the ventricles. Next after these in frequency comes a patent foramen ovale and patent ductus arteriosus. And all these, while they may, and frequently do, occur independently, more often are found in company. Malformations of the heart vary as, and are in great mea- sure to be explained by a knowledge of, the stages of devel- HEART DISEASE. 6ll opment of the foetal circulation. In the earliest embryonic days the heart has no separate cavities ; it subsequently divides into two, and later into the four of the mature foetus. So with malformations ; do they occur early, we meet with one auricle and ventricle, the pulmonary and systemic ves- sels coming off from the ventricle in common. A little later, and there is the heart of three cavities, two auricles, and a ventricle. Gradually, as the imperfections of later develop- ment remain persistent, so there is found a heart with four cavities more or less complete, usually with some deficiency in the septum, if not of the auricle, still of the ventricle. Now it is that the main vessels go wrong; the pulmonary artery fails to develop, or its valves form a perforated cupola, or the conus arteriosus becomes contracted ; the blood under these circumstances cannot pass easily to the ductus arte- riosus by means of the pulmonary artery, and the more ready route, by the interventricular septum, is kept open, the pul- monary artery contracts, and the aorta becomes twisted towards the right ventricle. This is by far the commonest malformation — the pulmonary artery contracted, the inter- ventricular septum open, and the aorta, arising, as it is said, either from the right ventricle or from both — and it is at once apparent why it should be so common ; for, in addi- tion to the complex process which necessarily takes place in the accurate adjustment of the valves and in the forma- tion of the vessels from the branchial arches, it is brought about by other conditions which interfere with the natural flow of the circulation at that time of life. For example, a premature closure of the ductus arteriosus will so ob- struct the circulation along the pulmonary artery, that the blood will tend, as in the contractions at the ostium, to find a more ready outlet by means of a still imperfect septum. The premature closure or permanent patency of the foramen ovale or ductus arteriosus are usually amongst 6l2 THE DISEASES OF CHILDREN. the malformations occurring during the later periods of foetal life. These are, perhaps, less easy of explanation — the former particularly so. Of permanent patency it may be said, in the words of the late Dr. Peacock, whose mas- terly thoroughness has well-nigh exhausted his subject, " Under all circumstances, it is very generally associated with some obstruction at or near the pulmonic orifice. " To make the subject, however-, more clear, let us with Pea- cock turn it round and trace the conditions of the heart from the more perfect to the rudimentary forms. He says :* " If, during foetal life, after the septum of the ventricles has been completely formed, the pulmonic orifice should become the seat of disease, rendering it incapable of transmitting the increased current of blood required to circulate through the lungs after birth, the foramen ovale may be prevented clos- ing; and, if the obstruction take place at an earlier period, when the septum cordis is incomplete, a communication may be maintained between the two ventricles. The same cause may also determine the permanent patency of the ductus arteriosus; for if, during foetal life, the pulmonary artery be much contracted or wholly obliterated, the blood must be transmitted to the lungs through the aorta; and, unless the ductus arteriosus be itself obstructed, that vessel will neces- sarily become the channel by which it is conveyed. Similar effects would result from obstruction in the course of the pulmonary artery or in the lungs, in the right ventricle, or at the right auriculo-ventricular aperture. So also, obstruc- tion at the left side of the heart, as at the left auriculo-ven- tricular aperture, or at the orifice or upper part of the aorta, would cause the current of blood to flow from the left auricle or ventricle into the right cavities, and thence, through the pulmonary artery and ductus arteriosus, into the aorta, and * On Malformation of the Human Heart, pp. 159-60. HEART DISEASE. 613 would equally determine the persistence of the foramen and duct or of an opening in the ventricular septum. The pul- monary artery and aorta would indeed appear to be either capable of maintaining for a time both the pulmonic and sys- temic circulations ; and the necessary effect of the one vessel having the twofold function to perform would be to give rise to hypertrophy and dilatation of the cavities of the heart more directly connected with it, and to the atrophy and contraction of those which are thrown out of the course of the circulation. " These effects of obstruction at the different apertures must vary, according to the period of foetal life at which the impediment occurs. If the pulmonary artery be obstructed before the complete division of the ventricles, the aorta may be connected with the right ventricle, and both the systemic and pulmonic circulation may be chiefly maintained by that cavity. If, on the other hand, the obstruction take place after the completion of the septum, the double circulation will be carried on by the left ventricle :— in the former case the left ventricle, in the latter the right, becoming atrophied. The degree of obstruction may also influence the course of the circulation, and so affect the development of the heart. A slight impediment at or near the pulmonic orifice, while the growth of the septum cordis is in progress, will proba- bly give rise to hypertrophy and dilatation of the right ven- tricle, and to the persistence of a small inter-ventricular communication. More aggravated obstruction, on the con- trary, may arrest the progress of development, and throw the maintenance of the circulation on the left ventricle. The influence of obstruction at or near the pulmonic orifice or in some other portion of the heart, in modifying or arresting the development of the organ, is thus far capable of demon- stration ; but it is probable that similar causes may equally give rise to the more extreme degrees of malformation, in 52 6 14 THE DISEASES OF CHILDREN. which one or other cavity retains its primitive undivided condition. For if obstruction taking place during the growth of the septum be capable of preventing its complete develop- ment, it may be inferred that impediments occurring at a still earlier period may entirely arrest the formation of the septa, so as to cause the ventricle, or auricle, or both, to re- main single, or to present only very rudimentary partitions. It cannot, indeed, be disputed that in some cases, more par- ticularly when the arrest of development is extreme, no source of obstruction exists to which the defect can be as- signed ; but it must be borne in mind that the absence of any obvious impediment to the circulation, after a lapse of a considerable period, as in persons dying several years after birth, does not afford any proof that some obstruction may not have existed when the deviation from the natural con- formation first commenced. On the contrary, as remarked by Dr. Chevers, the condition which at first sight appears least in accordance with the theory of obstruction — that in which the pulmonary orifice and artery are dilated — really affords evidence that some serious impediment must have existed in the lungs or elsewhere, though it may have en- tirely disappeared." There are yet other malformations to be considered, not, however, of so much importance as diseases incidental to childhood, as for the questions they raise as regards the eti- ology of valvular disease, and I shall, therefore, only mention them to awaken interest and watchfulness for their detection. The first and more important is slight congenital defect in the various valves, which, by making them work at a disad- vantage, or inefficiently under increased strain, becomes an important source of disease in later life. Peacock was a strenuous advocate for disease having this origin, and his reasoning was based upon a very full inquiry into the facts for himself, and a perusal of published cases. There is no HEART DISEASE. 615 doubt much to be said in its favor. Some intra-uterine en- docarditis occurs, and slightly thickens one or other of the valves. Adhesion between the flaps or cusps is thus pro- duced, and in the ordinary course of wear and tear such defects become subsequently accentuated, and disease gradually progresses as the subject advances in years. There can be no doubt of the occasional existence of mal- formations, which, though slight, are sufficient to lay the train of permanent disease, and to this extent it must be allowed that an argument exists for the occasional occur- rence of mitral stenosis of a congenital form. At the same time, it must be said that on the left side this condition is very uncommon, and on either side, in proportion as changes — other than the perfect fusion of the valves, chiefly of the pulmonary and aortic valves, in a dome-shaped cu- pola, which all allow to be of congenital origin — are called congenital, so it becomes difficult to be positive concerning the time at which they occur, mainly because a careful ex- amination of acquired valvular disease, rheumatic and other, aortic or mitral, shows that adhesion of the valves, matting, and the more moderate degrees of fusion, can be traced in all stages as the result of endocarditis of extra-uterine life. So much, indeed, is this the case, that it is very difficult to say what is certainly congenital. Nevertheless, the student should bear this question in mind, and endeavor, not only to satisfy himself on the matter, but, if possible, elucidate it by careful examination of such cases as endocarditis in very early life as come before him. I can only allude to one other condition — viz., the con- traction of the aorta beyond the left subclavian artery. The aorta at this spot is more or less constricted, as if a string had been tied around it. Sometimes it is completely oblit- erated at this spot. The ductus arteriosus is sometimes patent. The chief interest of the condition lies in bearing it 6l6 THE DISEASES OF CHILDREN. in remembrance and correctly diagnosing it. It is compat- ible with many years of existence. In the two cases which have come under my own notice, one was a man, aged twenty-seven, the other, a man of thirty-seven years. It almost necessarily leads to hypertrophy of the left heart, and very probably to dilatation also ; while, from the fact that the circulation has to be carried to the lower part of the trunk by the subclavian and other vessels at the root of the neck, the enlargement of the surface vessels may allow it to be recognized. I believe that I have once recognized it in this way in the case of a man in whom, with obscure cardiac symptoms, some large arteries could be traced coursing be- neath the skin in the scapular region. Symptoms. — The general symptoms of malformation of the heart are cyanosis, palpitation, and more or less impedi- ment to the respiration ; and they are generally present from birth onwards. But they may be altogether absent ; they may occur only in paroxysms, or they may be absent for some time, even years, and come on without any assignable reason as the child grows older. Such children, are, how- ever, usually ailing from birth; they are easily chilled, and subject to attacks of bronchitis. As regards the local symptoms, bruits, etc., by which the particular malformation may be recognized, it can hardly be said that any are diagnostic. There may be no murmur even though the cyanosis is extreme, and when a bruit does exist, it is often so loud and harsh over the entire praecordia, that it is a matter of the greatest difficulty to localize it de- finitely. In looking over fourteen cases of which I have notes, I find that two are cases of transposition of the heart; one of the heart only; a second of the heart and viscera. In both these a systolic bruit existed in the praecordial re- gion, and to the right side, which is not unlikely to have been developed in connection with disease of the pulmonary HEART DISEASE. 617 artery. In five others the bruit was pulmonary or septal in position. In five there was an apex bruit, one accompanied by a thrill, and in which it was hardly possible to arrive at any positive conclusion ; in one, with much cyanosis and disturbed action, there was no bruit at all. In one there was a persistent humming-top bruit, which suggested a patent ductus arteriosus ; and in one a loud systolic bruit, to the right of the spine more particularly, the nature of which was uncertain. The chief point to remember is that the larger proportion of cases by far are contracted conditions of the pulmonary artery, combined with a patent septum ventriculorum ; and, consequently, whatever the variations which the prsecordial bruit may present, unless other indications allow of its ex- clusion, this malformation is in all probability present. Its proper characteristics, however, are a systolic bruit along the left border of the sternum from third to fifth rib; most in- tense in the mammary line, and running upwards to the left clavicle, but not along the aorta or towards the axilla. There may sometimes be a thrill over some part of the area occu- pied by the bruit. The prsecordial dulness is usually ex- tended laterally to the right, by reason of the dilatation of the right side. A patent foramen ovale, although occasion- ally associated with cyanosis without other malformation, has so frequently been found without symptoms of any kind, that it can be seldom diagnosed. A patent ductus arteriosus can be but rarely capable of recognition. Walshe, from two published cases, thinks it " a matter of fair conjecture, that if a cyanotic adult (for which in this case we must read child) presented the signs of hypertrophy of the right heart, a negation of murmur at either apex of the heart, a single prolonged diastolic, or a double murmur, of maximum force at the pulmonary carti- lage, and not conducted downwards, the cause of these com- 6l8 THE DISEASES OF CHILDREN. bined conditions would be found in a patent state of the ductus arteriosus/' I venture to doubt even so cautious a conclusion as this, because, from a case which has lately- been under my observation, it is certain that a dilated pul- monary artery is by itself a sufficient cause of a bruit of this kind ; and both in Dr. Fagge's case, and that of Jaksch, from which Walshe draws his conclusion, the pulmonary artery- was dilated. In the particular case I refer to, and which came frequently under my notice, the peculiarity of the bruit (it was delayed systolic rather than diastolic, although it continued on beyond the systole into the diastole) consisted in its time and in a peculiar musical tone, and I went so far as to discuss not only the question of a patent ductus but also that of a communication between the aorta and pul- monary artery, as the result of aneurism, and also of simple aortic aneurism. All of these seemed possible. A mere dilatation of the pulmonary artery had not occurred to me, but such the post-mortem proved the condition to be. Now this may at first sight appear to be beside the ques- tion of congenital disease, because it is hardly a point which concerns the diseases of childhood ; a patent ductus being a recognized condition, a simple dilatation of the pulmonary- artery hardly so. But a little reflection will convince one that this view is a narrow one. It has always been a ques- tion of interest to those who have made a study of the dis- eases of the heart and lungs how far collapse of the lungs in early infancy and childhood may be conducive to actual dis- ease, and it is obvious that in atelectasis there is a sufficient cause, not only of dilatation of the pulmonary artery, but of patency of the ductus, dilatation of the right side of the heart, and patency of the foramen ovale, did it but occur a little prior to the time at which closure takes place in these aper- tures of communication between the two sides of the heart. We have, however, in atelectasis a cause of chronic valvular HEART DISEASE. 619 disease, if not of actual malformation, on the right side, which is probably of far more importance than that usually- ascribed to it; and for this reason the physical signs of dila- tation of the pulmonary artery are well worth the attention of the student. Simple stenosis of the aorta may be easily recognized by a loud systolic bruit along the aorta, by a systolic thrill, and by a slow pulse. It is not a condition which comes often under notice in childhood. It would appear that, if it be congenital, the disease goes on for a long time, the left ven- tricle undergoing hypertrophy, and compensation being complete. After a time, however, at two or three and twenty years of age, dilatation begins, and then it is that these cases come for treatment. Prognosis, — What is the duration of -life in these cases is another question, which can only be answered in the most general terms. As a rule, all serious malformations cut life short early. The slighter forms, such as slight apertures in the foramen ovale or in the septum, are compatible, at any rate, with many years of existence. The risk to life is natur- ally in proportion to the derangement of the circulation ; and according to Dr. Peacock, the commoner forms of malfor- mation rank in order as follows, commencing with the least dangerous : Moderate contraction of the pulmonary artery. Contraction of pulmonary artery and patent foramen ovale. Contraction of the pulmonary artery, with imperfect septum. Completely impervious pulmonary artery. A single ventricle to one or two auricles. While, however, all these bring life to a standstill within a few weeks or months in the great majority of cases, and 620 THE DISEASES OF CHILDREN. those at the bottom of the list more speedily than those at the top, nevertheless there is no one of them which is not compatible with a life of many years. Therefore, for indi- viduals, the prognosis must be somewhat guarded. The causes of death are usually cerebral disturbance due to cyanosis, or imperfect expansion and collapse of the lungs, with some intercurrent bronchitis. Treatment. — This resolves itself into a few common- sense rules, which any one can suggest to himself. These children suffer from cold; they must, therefore, be well clothed, and in cold weather be kept as much as possible in one uniform temperature. This is the more necessary, as the lungs are in a permanent state of engorgement and very liable to bronchitis, and sudden changes of temperature increase the risk. An attack of bronchial catarrh in any case of this kind may prove the last straw which brings the laboring circulation to a stop. Children with congenital heart disease are not uncommonly subject to outbursts of passion ; these must be guarded against as much as possible. The diet must be carefully regulated down to simples in small quantities, at somewhat more frequent intervals than is the usual habit of children : and if the emaciation makes way, they must be fed with tonics, cod-liver oil, and mal- tine. Cyanosis. — Two views have been held as to the cause of the extreme lividity that is so common a feature of con- genital disease — one that it is due to the mixture of arterial and venous blood in the course of the circulation ; the other that it is dependent upon the congestion which follows upon the obstruction of the pulmonary circulation. Of these two, the latter is without doubt the more generally correct, for these reasons chiefly, that it is not uncommon to find ex- treme cases of malformation with no cyanosis, or which are cyanotic only in paroxysms ; and also that simple pulmo- HEART DISEASE. 62 I nary disease has been known to cause as extreme cyanosis as any malformation of the heart ever does, and that with- out any abnormal communication between the two sides of the heart. It is now, therefore, very usually taught that the cyanosis is due to the extreme obstruction in the lungs, and the consequent retardation of venous blood in the cutaneous capillaries. But this is not the whole truth, for such a dis- coloration as is met with from congenital heart disease is very uncommon from any other cause. It is therefore prob- able that the dilatation of the cutaneous capillaries most commonly reaches a sufficient pitch only when the disease takes effect in earliest infancy ; and it is not unlikely, also, that a certain thinning or delicacy of the skin is requisite to its full exhibition. Certain it is that, where the cyanosis is well marked, the skin is of a remarkably silky, almost greasy, softness. Aneurism is not a common disease in childhood; but when it occurs, and it may do so even in any of the larger vessels, such as the carotid, or iliacs, or femorals, it is almost always associated with (many think due to) the plugging of the vessel from an embolus, dislodged from the valves of the heart and carried to the diseased spot. The history of such a case is probably this : an inflammatory clot from the valves is dislodged and catches across the fork of a vessel, leads to clotting there and, then, to inflammation of the clots of the artery ; the artery thereupon softens and allows of dilatation, under the pressure of the blood behind the plug, and an aneurism is formed. There is some doubt amongst pathologists about the exact mode of production of the aneurism, but of the fact, and of its association with embolism, there is no doubt. Aneurisms of this kind have been found in young people on the internal carotid, axillary, femoral, and popliteal vessels, not to mention the cerebral arteries, which have often been affected ; indeed, supposing 622 THE DISEASES OF CHILDREN. that a young person should die with apoplexy, death is probably due to such an aneurism, which has ruptured after its formation. Occasionally, aneurism produced in this way has come under surgical treatment for the cure of the dis- ease ; but it is well to remember that the condition is an indication of the existence of the worst possible form of disease of the valves of the heart, one usually associated with embolism in many of the organs, and with hectic fever. It is nearly always fatal within a few weeks ; and there is hardly scope for treatment other than palliative. PURPURA — HAEMOPHILIA — SCURVY — A'N/EMIA, ETC. 623 CHAPTER XLV. PURPURA— HEMOPHILIA— SCURVY— AN2EMIA, ETC. Certain other diseases may be noticed in connection with the heart, though, strictly speaking, they are probably blood diseases rather than diseases of the circulatory sys- tem. Purpura is one of these. It is by no means uncommon in children of the lower classes as the result of bad feeding or bad living. It may be met with in all degrees, from scattered petechise in the skin, of small size, and which might easily be mistaken for fleabites, or larger and more profusely spread, up to considerable extravasations into the subcutaneous tissue, or to bleeding from the nose, gums, stomach, bowels, and kidney. Purpura when confined to the skin is sometimes called simple ; when affecting mucous membranes also, purpura hemorrhagica, or morbus macu- losus. Purpura is a condition which is found associated with many diseases, such as rickets, rheumatism, blood-poison- ing of various septic kinds, or ulcerative forms of heart disease, and it is produced in some subjects artificially by the administration of drugs, such as iodide of potassium. Many of these forms, however, are allocated to the distinct disease, and we have thus purpura rheumatica, the petechiae of scarlatina and small-pox, and the purpura of heart dis- ease. These are not generally included in the term purpura, but only such cases as originate, often without fever, with- out any more definite cause than prolonged failure in nutri- tion, dietetic or other. Even extreme cases of this kind are not uncommon, and they usually speedily get well upon 624 THE DISEASES OF CHILDREN. proper diet. I have, however, met with one case which was associated with fever and severe intestinal lesions, which speedily proved fatal. The intestine was found in this case in a spongy, tufted condition, not unlike the gums as seen in bad cases of scurvy. Hemorrhage occasionally occurs about the fundus oculi in purpura. This lesion has of late been frequently de- scribed ; but, so far as I know, it has no special importance attaching to it. A girl, set. four, was admitted on July 31, 1877. She had been languid and fretful, suffering from stomatitis for three days, and two days before admission the body became covered with purple spots. The gums com- menced to bleed on the morning of admission, and blood had also came from the right ear, from which for two years there had been an occasional discharge of pus. The child by nature was of a dark, sallow complexion, but had en- joyed good health. It had been noticed that since her birth any scratch or cut would bleed freely. The child had been well fed, was fond of vegetables, and had had plenty. The mother was of dark complexion, and believed that she had had a similar attack when a child. The gums were much swollen, greyish looking, and fungating. All parts of the body were covered with small petechiae but no bruises. The child lay feeble and exhausted, with a temperature of 99.8°, pulse 134, respiration 20. The urine was normal. The thoracic and abdominal viscera also. Gallic acid, in six-grain doses, was administered three times daily, and green vegetables, milk, and beef-tea were ordered. The bleeding from the gums becoming serious, they were painted with tincture of perchloride of iron. She vomited blood twice only; passed none in the evacuations and none in the urine. The bleeding from the gums gradually ceased, and the spots faded from the skin, and she left the hospital well after about three weeks' stay. PURPURA — HEMOPHILIA — SCURVY — ANEMIA, ETC. 625 During her illness the fundus oculi was examined for hemorrhage, and on the right side, above and internal to the optic disc, and at some distance from its margin, a large dark round blotch was seen, with a haze over it, and a white margin surrounding it. Near it was a large vessel. The appearances were those of hemorrhage into the choroid, with either atrophy around it or the white margin of a dis- placed retina. Both discs were whitish, and the chorodial pigment was very unevenly distributed — some parts of the choroid looking white by contrast with others. The child was seen again some months later, and, the pupils being dilated with atropine, the fundus was fully ex- amined. No trace of the former hemorrhage existed, and the uneven distribution of pigment so marked before was now hardly noticeable. Five cases of purpura that have been under my care in the Evelina Hospital have all been of the female sex. Of the pathology* of purpura nothing is known; the blood has been examined, without result ; the bloodvessels also, with no decided bearing. All that is known is the practical fact that it depends often upon deprivation of particular kinds of food, and quickly disappears when these are sup- plied. It is indeed but seldom fatal, although, in severe cases, the amount of bleeding from the nose, the bowels, or the kidney, may give rise to some anxiety. Treatment. — Rest in bed is necessary if there be any severity about the attack ; and to stay the bleeding some gallic acid may be given in honey, or some turpentine in syrup. The body should be kept cool, and ice may be ap- plied if necessary to the head or spine, or even placed in the rectum. Plenty of good milk should be given, and orange, lemon, or lime-juice, with green vegetable diet and under- done meat or beef juice. 626 THE DISEASES OF CHILDREN. Haemophilia. — Purpura — the just detailed case in particu- lar — with its history of a tendency to bleed to excess on slight scratches, etc., leads naturally to the consideration of haemophilia, or the haemorrhagic diathesis. It is a disease which is strongly hereditary, and it is far more common in males than in females, the proportion being about eleven to one. As regards its transmission, there is this curious fact about it, that it passes to the males through the females, the mothers remaining quite healthy whilst passing on the dis- ease to their sons, and fathers who are bleeders but rarely transmitting it to their sons. The females in bleeder fami- lies, according to Dr. Wickham Legg, from whom I am con- densing this account, are, unfortunately, remarkably fertile. Symptoms. — The subjects of haemophilia differ in no ap- preciable respect from other people. They are usually healthy. The symptoms usually show themselves soon after birth, within the first year or two of life, and are character- ized either by bleeding from the nose or mouth or sponta- neous ecchymoses in the skin. In the extreme cases, found usually only in the males, the bleeding arises spontaneously, or from the most trivial causes, and occurs not only in the skin and from mucous surfaces, but large extravasations take place into the subcutaneous tissue and intermuscular septa, and into the cavities of the larger joints. To this escape of blood into the joints is due the obstinate swellings of the joints, particularly of the knee, which characterize this dis- ease. Of the few cases that have come under my own notice, one was a boy, aged four, who had persistent epistaxis after some slight injury. Another, a boy, aged nine, with epis- taxis to blanching, whose brother suffers also from frequent epistaxis. A third, a male, of eighteen months, I am uncer- tain about, from the possible existence of rickets. He had had convulsions, and his head was large ; but he looked in PURPURA — HAEMOPHILIA — SCURVY — AN/EMIA, ETC. 627 perfect health, except that he was covered with painless lumps, of bruise-like appearance. In some of these the amount of extravasated blood was large. The whole body was dotted over with petechias. One sister had passed blood per anum, and had been in Guy's Hospital for haematuria. And another boy, who died aged twelve, was said also to have had lumps much like those of this child. A fourth, a boy, aged five, bled profusely after the extraction of a tooth- Several others in the same family had suffered from the same thing, and there is a married sister who always loses severely at her confinements, and whose catamenial flow lasts a fort- night out of every month. Pathology. — Nothing is known of the cause of this con- dition. The various viscera have been examined, and the blood also, but mostly without result. Diagnosis. — This is not easy from purpura due to other causes. Attention must be paid to the history, and also to the family history and to the sex of the patient. Prognosis. — The disease appears to be persistent through- out life, and there is naturally a risk to life from the occur- rence of profuse hemorrhage at any time. Nevertheless, if all due care be taken to avoid injury, the extraction of teeth, etc., and to keep in as good a state of health as possible, there is no reason why old age should not be attained. As regards the local affection of the joints, it is slow to depart, and is often associated with pain and fever. Treatment. — The perchloride of iron appears to be the best remedy, though none can be said to materially influence the disease. Preventive treatment is the most effective — viz., the avoidance of injury in any shape, warm clothes, resi- dence in a warm climate, and good living. When hemor- rhage has been so severe as to threaten life, transfusion may be had recourse to. The joint affection must be treated upon general surgical principles, by rest, splints, etc., bearing 628 THE DISEASES OF CHILDREN. in mind that the fluid within is blood, and therefore that, after the inflammation has subsided, gentle movement of the joint is advisable, to prevent the formation of adhesions. Scurvy is not strictly a disease of childhood ; but, of late, attention has been called to a scorbutic affection of the bones, often associated with moderate rachitic changes, and which has hitherto passed as acute rickets, chiefly from the de- scriptions given of it by foreign writers who had no knowl- edge of its morbid anatomy. Dr. Cheadle, from cases which have come under his own care, propounded the doctrine that the disease was a compound of rickets and scurvy. Dr. Gee has published cases evidently of the same kind under the name of " osteal or periosteal cachexia;"* and Dr. Barlow, in the Medico- Chirnrgical Transactions^ has considerably extended our knowledge of the subject by eleven additional cases, two of which are of the greatest value, for the writer was able, by a post-mortem examination, to demonstrate the actual nature of the lesion that existed. From these two cases, and another already published in the Transactions of the Pathological Society of London, by Mr. Thomas Smith, it is shown that the clinical features of acute rickets are asso- ciated, it is true, with moderate rachitic changes, but much more with extensive sub-periosteal hemorrhage in the bones, chiefly the femora and tibiae, scapulae, ribs, and cranium, and with a tendency to fracture, and sometimes with separation of the shaft from the epiphysis, as occurs in syphilis, acute necrosis, and perhaps other conditions also. The clinical symptoms are given in the following case, which was sent to me by Mr. Oram, of Clapham, and the nature of which I at once recognized, being fresh from the perusal of Dr. Barlow's paper : A child of fifteen months. Its father is a dark man, and, * St. Bartholomew's Hospital Reports, vol. xvii., p. 9. f Vol. lxvi., p. 159. PURPURA — HEMOPHILIA — SCURVY — AN/EMIA, ETC. 629 Mr. Oram tells me, one of the most anaemic men he has ever seen. The mother is slim and small, but calls herself healthy. There is no rheumatic history. This is her first child. She nursed it for four months, and since then it has been fed on 11 milk food." "The child cannot take milk." For many weeks it has been subject to effusions of blood in the cellu- lar tissue of the orbits. The effusion takes place quite sud- denly, and perhaps before it is reabsorbed a fresh one occurs. For a month or two it has been quite unable to move its limbs. It was not an anaemic child in any marked degree. Its head was rather rachitic, the anterior fontanelle open ; no craniotabes ; no bosses on the skull. The two lower incisors only were cut; the gums were normal; no purpura. Both upper eyelids were swollen out by large effusions of blood, giving a black eye on each side, and the left eye was promi- nent in addition, apparently from effusion of blood into the orbit. The child shrieked most painfully whenever it was touched, so that there was much difficulty in ascertaining where the most pain lay, but it was chiefly in the lower limbs. The radial ends were nodular the ribs moderately beaded ; the thighs and spine normal ; the knees also. The lower half of each leg was swollen, brawny-looking and indurated; the dorsum of the foot was cedematous ; the skin was pale and without any undue heat. It was impos- sible to be quite certain of any thickening of the bones, as the child's shrieks were terrible directly its legs were handled ; but the indurated feeling of the integuments, and their peculiar adhesion to the bone, not unlike the sensation of scleroderma, made me think that the bones were affected. The optic discs were healthy ; the urine was not examined; the liver and spleen were normal. Raw beef juice was ordered, underdone pounded meat, orange juice, and milk — the diet to be varied as much as 53 63O THE DISEASES OF CHILDREN. possible — and opium was given in small doses three times a day. The child rapidly improved ; and a month later it was free from pain, took its bath with pleasure, and moved its legs freely. This case corresponds in all essentials with those that have been described by others. There was plenty of evi- dence of a moderate degree of rickets ; but the brawny tension of the lower limbs from the ankle upwards, and the extreme pain, were as certainly something more than rickets, and corresponded with what has been observed by Dr. Barlow to be associated with sub-periosteal hemorrhage. Then there was the fact that it was supposed not to be able to take milk, and its diet had been nearly confined to artificial food ; at the same time there was no evidence of syphilis ; the parents were moderately well-to-do ; and the child rapidly improved by a simple change of diet, and by quiet- ing its pain by the temporary administration of opium. Diagnosis. — It is, perhaps, most likely to be mistaken for syphilitic disease of the bones. This, as is well known, is liable to occur at the epiphysial junction, and to spread as a periostitis along the shaft of the bone, and it leads to ab- scess and to separation of epiphysis from shaft. The ab- sence of any definite signs of syphilis, and the existence of rickets, with the history of bad feeding, might in most cases make us suspect the real nature of the affection ; but it may be also added that the brawny induration running gradually up the shaft is not quite what we meet with in syphilis, nor is the extreme pain of these cases often found to such an extent in the syphilitic bone disease of infancy. Moreover, as Dr. Barlow points out, syphilitic disease occurs at an earlier Sge than does acute rickets. Prognosis. — If treated properly, and not already too ex- hausted, these cases will get well, though the process of recovery is sometimes tedious. PURPURA — HAEMOPHILIA — SCURVY — ANEMIA, ETC. 63 I Treatment. — This resolves itself into variety in diet — such things as raw beef-juice, underdone pounded meat, orange juice, cauliflower, julienne, or milk, etc., being par- ticularly useful. Anaemia is a very common ailment in childhood. Natur- ally, both bad blood and poor blood are associated with all sorts of diseases, and are, in fact, amongst the symptoms of many ; but besides these morbid states of the blood, due to definite disturbances and changes in the viscera, it is no un- common thing to find that a child is anaemic, and there is no definite cause for it. The child may have been working hard, or playing hard, or growing fast, or the pallor may be the remnant of some preceding illness ; but whatever may be given as the explanation, the most careful examination fails to show any organic disease. Anaemia is common to all ages, from infants a few months old and upwards; and in younger children, from babyhood up to three years, it is often, but not always, associated with some enlargement of the spleen. The microscope usually shows a very abnormal state of blood in these cases : the red corpuscles are much dimin- ished in number, the white corpuscles are in slight excess, a number of small corpuscles stud the field, and there is also more or less granular matter. Diagnosis. — This must only be arrived at by a careful exclusion of every other disease. The child must be thoroughly examined; and only in the absence of actual structural changes in the viscera, in the absence of syphilis and ague, rickets, etc., is simple anaemia to be diagnosed. Prognosis. — Simple anaemia is sometimes very intractable, and one cannot but feel that, in such cases, the condition is a serious one. It is impossible that the blood can be seri- ously at fault for any length of time during the period of growth and development without harm. The difficulty that 632 THE DISEASES OF CHILDREN. exists of gauging its exact influence upon this organ and on that does not make the risk any the less, and an anaemic child requires attentive treatment. Treatment. — The difficulty lies in getting at what is wrong; too often it is considered sufficient to give a tonic, chiefly iron, and this almost without inquiry. But, before resorting to drugs, investigation must be made of the per- sonal hygiene of the child — its disposition, its food, its sleep, its clothes, its habits, its play, its work, its home, and its environs, etc. Not till all these things have been considered can it be determined whether the requisite treatment should be by quinine, iron, arsenic, or cod-liver oil, or by more food, more air, less work, and so on. If careful inquiry be given to these matters, the treatment will generally suggest itself. RICKETS AND BONE SOFTENING. 633 CHAPTER XLVI. RICKETS AND BONE SOFTENING. Rickets is one of those diseases for which familiarity often breeds a certain amount of contempt in the student's mind. " Only a case of rickets " is not infrequently his mental atti- tude in regard to it. It occurs so often, under conditions of home life which it may well-nigh seem hopeless to combat, amongst the poor, the ill-fed, the badly housed of our large towns. Nevertheless, it is a disease of much interest. That it is called Englische Krankheit may well make us study it thoroughly, and to a motive of this sort may be added that it is a cause of heavy infant mortality through bronchitis and its allies, whilst yet it is one of the most preventable of diseases. Etiology. — As with many another disease, so soon as we come to discuss its causes, although the evidence on the main points is unmistakable, there are yet subsidiary ele- ments which, w T hilst they are less certain, have, sometimes, in the heat of controversy, been allowed to obscure the light we have. Rickets is a diet disease, due to the prolonged administration of indigestible, and for the most part of starchy, food. It has been said, indeed, that rickets can be produced at will by the copious admixture of starch with the milk at a time when the child is unable to digest it. It is hardly so. In the larger number of cases atrophy and the death of the child are brought about by bad feeding. In some, and these also very common, Nature, so to speak, saves the ship from wreck, and the child is left to drag along in the sadly deteriorated condition we know as rickets. This 634 THE DISEASES OF CHILDREN. much all will allow. It is only when we come to discuss the question as to what other influences are at work in the pro- duction of the disease that any uncertainty exists. But, for my own part, in matters so difficult of solution, I doubt the necessity of their discussion. It must be admitted that a deteriorated condition of health on the part of the mother, either during gestation, or while suckling the infant, is only too likely to conduce towards — perhaps actually to produce — rickets. I quite believe with Dr. Eustace Smith that un- duly prolonged suckling makes for rickets. One can as readily admit — the burden of proof surely lies on him who would not do so — that bad air, ill-ventilated rooms, want of cleanliness, are potent abettors of the disease. And syphilis also, in that it produces a much impaired state of nutrition, which often extends over many months, may surely help in the same direction. These are all questions which will have to be entertained in individual cases. These various elements of bad hygiene will then need to be very carefully appraised, and the direct- ness of success in treatment will no doubt depend much upon whether this be done well or ill. But the general question involved is untouched by them ; and rickets remains essen- tially a diet disease, unless, indeed, such a radical hypothesis be accepted as that of M. Parrot, that rickets is a manifesta- tion of infantile syphilis. *- I shall not discuss what may be the etiological formula for rickets in Paris or other large continental towns ; it will be sufficient for my purpose to say that in England rickets, as a disease, exists for the most part independently of syphilis, and it is not ameliorated in most cases by mercurials or iodide of potassium. The arguments in favor of its dietetic origin are, shortly, these. Changes in many respects like it are found in the lower animals kept in confinement and under artificial con- RICKETS AND BONE SOFTENING. 63 5 ditions as regards their food. It is a disease of all large towns, more or less — that is to say, in proportion as the population increases, over-crowding occurs and the means of subsistence become more costly; then hand-feeding, and cheaper, less troublesome, and less valuable foods are sub- stituted for milk, and so we have rickets. Although called the English disease, it is by no means confined to this coun- try. It may be seen in most of the large continental cities, and in some is as common as it is with us. Lastly, it is a disease found, to say the least, in overwhelmingly large pro- portions, in hand-fed infants. Dr. Buchanan Baxter made some most careful inquiries on this point amongst the out- patients at the Evelina Hospital, and the result was that no less than ninety-two per cent, of the whole number had been given farinaceous food before the age of twelve months. The time of life at which the disease is met with forms an im- portant element on this head, and I have analyzed 141 of my own cases, to show the time of life at which the disease occurs : k 7 8 9 10 11 12 18 m. 2 T/ x/ ■ _, , --p . , 1 2.V0. -3. 'vA 4^6 Total. m. m. m. m. m. m. m. under years /z ° 2/,i ^ D 3 i 3 2 5 6 11 36 26 19 13 2653 141 Sixty-eight w r ere boys, seventy-three girls. Dr. Gee* gives much larger numbers than these. Of 635 cases (365 boys, 270 girls) 32 were under six months, 144 from six to twelve months, 183 from twelve to eighteen months, 133 between eighteen months and two years, 116 in the third year, and 27 in the fourth year. And he further states that thirty per cent, of sick children under two years of age are rickety. This table only gives the age at which the child was brought for treatment. In most cases the onset of the dis- * On Rickets, "St. Bartholomew's Hospital Reports," vol. iv., p. 69. 636 THE DISEASES OF CHILDREN". ease must have ante-dated the attendance by a considerable period. But it shows well how large a proportion of cases occur from ten months to two and a half years — that is to say, from weaning onwards through the period of denti- tion. It may be added here that some authors have contended for the existence ii> of foetal rickets, ('2) of rickets at birth (congenital rickets) and (3) of the rickets at the time of life here spoken of. As to foetal rickets, most authors consider it to be a form of cretinism; and the existence of con- genital rickets is but doubtful, although, as I have said, if exceptional, its occurrence seems possible. All agree that rickets is rare during the first two or three months of life. I have stated the case thus far somewhat dogmatically ; but it must be borne in mind that there is no single fact in con- nection with rickets which has not been at some time or another, and which is now, disputed by this authority or that. There are some who think the disease a diathetic one — one, that is to say, passed on from parent to child, in large measure independent of and incapable of production by external agencies alone. And some observations of Ritter von Rittershain show that rickety children frequently come of mothers who still bear traces of having suffered from a similar disease. It is also said, and the same author, to some extent, countenances this view, that tubercle is asso- ciated with rickets. Trousseau held that the two were mu- tually exclusive. But there can be no doubt that tubercu- losis is not uncommon as a sequel to rickets, although, as Hillier says, the two conditions seldom go on actively at one time. Others hold, as I have done, that it is dietetic; others, still more rigorously, that it is not only dietetic in a general way, but due to the administration of starch in particular; others, again, lay stress on feeble health in the mother dur- RICKETS AND BONE SOFTENING. 637 ing gestation or lactation; others upon bad air, want of light, insufficient clothing, want of cleanliness, etc., and so on. Arguments quite worthy of consideration have been used for and against all these hypotheses by observers, of whom it will be enough to say that their names include some of the brightest ornaments of medicine and pathology in this and other countries. But upon a reflective study of much that has been written, the short summary I have given seems to me a fair and reasonable one; although I should not wish the student to suppose that it could not be dis- sected, and arguments advanced against some of the conclu- sions arrived at. Symptoms. — Rickets is, for the most part, a slowly progressing general change in the tissues and the viscera, which runs an insidious apyrexial course. In the earlier stages of the disease the symptoms are somewhat vague. Diarrhoea, restlessness during sleep and a tendency to throw off the bedclothes ; profuse sweating of the head, neck, and chest; causeless crying when the child is moved, and a flabby condition of the muscles of the arms and legs, com- bined often with an excessive amount of subcutaneous fat, are amongst those which at first are the most noticeable. Later on, the ribs become beaded, the wrists, knees, and ankles enlarge (Dr. Marshall has even noticed the knuckles to enlarge), the shape of the head becomes characteristic, the nervous system irritable, and, in the latest stage, the child wastes, the ribs fall in, the spine and long bones curve, the liver and spleen become enlarged, and death may happen from bronchitis, broncho-pneumonia, convulsions, etc. But the symptoms must be considered in rather more detail. The head in rickets is often characteristic ; the veins upon the forehead stand out full of blood ; the fontanelle bulges and is unduly open ; but the head is elongated from 54 638 THE DISEASES OF CHILDREN. back to front, and its posterior segment enlarged. The head appears flattened in the temporal region, and the fore- head, although overhanging, is not expanded. Thus, in several points, it differs from the hydrocephalic skull, which tends to assume a globular shape, the temporal fossae bulg- ing in place of flattening, the forehead being expanded, and the frontal bone opening gently upwards to the globu- lar and bulging anterior fontanelle. Rickets may be com- bined with hydrocephalus ; but apart from this, the rachitic skull is latterly compressed, with prominences in the region of each frontal and parietal eminence. The cause of this has been much discussed, some attribute it to the fact that the child lies much on its back. By thus subjecting, the occipital bone to pressure, the posterior part of the skull be- comes flattened, and the brain is pressed forward against the frontal bone. This may be in a measure true, but it is also to be remembered that rickets is a disease which begins comparatively late — not till some months after birth — and, therefore, not until the centres of ossification in the skull have had a fair start. The regions of the frontal and parietal eminences are then comparatively well protected, and the growth of the brain will go on with less difficulty by length- ening the skull from before backwards, and also by pushing outwards as a whole the lateral halves of the skull cap. Moreover, the interfrontal suture unites before the end of the first year, and, should the rickety condition supervene at a later date — as is probably not uncommon — the growth of the brain will then more readily proceed backwards, and, by widening out of the parietal eminences, a head with a small square forehead and large posterior segment would be produced — the shape, in fact, which is a characteristic of the skull in many a case of rickets. I cannot forebear to add that the brain is not exempt from laws which apply to other parts, and that — like the RICKETS AND BONE SOFTENING. 639 foot of the Chinese lady, which takes its shape from the appointed boot — it grows best along the lines of least re- sistance. Can anything of greater significance be suggested, where convulsions of varied kind form one of the chief fea- tures of the disease? It can hardly be a matter of indif- ference whether the growth of the brain is allowed to pro- ceed as it should do, or whether by an early closure, say of the frontal or sagittal suture, the posterior parts are made to develop in disproportion to the front, or some part of the latter is placed under disadvantage. The size of the skull has usually been said to be increased in rickets, but Ritter von Rittershain, on the ground of careful comparative measure- ments, denies that there is any enlargement. The head often appears to be large, but this is due to the peeky face, the stunted limbs, and bad nutrition. Trousseau taught that the large skull went with precocity ; but if the skull be not really enlarged, that contention falls to the ground ; and if it be, the precocity is of a very shallow kind in most cases — it is more true to hold, with Gee, that the brain is usually dwarfed. Sir W. Jenner ascribes the prominent forehead to infiltration of the anterior lobes of the brain with albuminoid material. This must, however, be a very rare condition, whereas the prominence of the forehead is a very common feature of the disease. I believe the explana- tion I have given, that the brain pushes the segments of the skull backwards and forwards, is more satisfactory for the majority of cases; while in some it is accounted for by an exuberant growth of soft bone on the frontal eminences. Hydrocephalus is said by some to be a frequent associate of rickets. I know of no facts which prove this. The fon- tanelle may remain widely open long after the period when its closure should be complete (this is given by Eustace Smith as the end of the second year, but in healthy children very little of a fontanelle should remain after the end of the 64O THE DISEASES OF CHILDREN. first year), and it may bulge unduly, and frequently does so in rickets, but these things do not necessarily mean hydro- cephalus. At the same time, the onset of this disease would seem to be likely enough, for any delayed ossification of the skull to some extent predisposes towards the occurrence of a congested brain, or of hydrocephalus. Craniotabes, first described by Elsasser in 1843, has till lately always been held to be a sign of rickets. M. Parrot and others have called this doctrine in question, and con- sider the complaint a sign, not of rickets, but of congenital syphilis. Craniotabes, or wasting of the skull, is a condi- tion of softening of the bones, particularly of the occipital, by which, under moderate pressure from the finger, the bone caves inwards with a crackle like that of stiff parchment. It is of two kinds: in very young infants the bones of the skull will yield under pressure and sometimes crackle, but this is not a diseased condition. The true disease generally exists in localized patches. It is said to occur in thirty to forty per cent, of all cases of rickets, and is found to perfec- tion from six months after birth onwards. It is an open question how far this condition is due to uncomplicated rickets, and how far to syphilis ; but it is a remarkable fact that, since the question was mooted, some very weighty evidence has been produced in favor of its association more with syphilis than with rickets. Dr. Thomas Barlow and Dr. Lees collected 100 cases of craniotabes, and have pub- lished* the results of a most careful inquiry upon its rela- tionship both to syphilis and rickets. From it they conclude that forty-seven per cent, of the total are almost certainly syphilitic ; and to thfs may be added the observation of Dr. Baxter,! that °f tne twenty-three per cent, of craniotabes in rachitic children, seventy-five per cent, were syphilitic. * " Path. Soc. Trans.," vol. xxxii., p. 323 et scq. f Op. cit.,?. 361. RICKETS AND BONE SOFTENING. 64I My own opinion inclines in the same direction. For a long time I examined for craniotabes amongst rachitic childr and, finding it so seldom, I was disposed to think it was far common than has been taught ; but then, bein^ en- gaged at the time on other obsen upon congenital syphilis, all cases that showed any traces or suspicion of that disease, even if associated with rickets, were, no doubt, - jd into the syphilitic group, and thus would have escaped notice. Certainly, in such cases as I have known in recent years, craniotabes has most often been, either in well-marked s of congenital syphilis, or in cases in which the suspi- cion of the existence of that dise? strong; but there A a proportion of cases in whic jch taint can be shown to exist, and I should suppose it to be one of those conditions for which a combination of circumstances, if not necessary, at least is most favorable to its production. In this regard it is important to remark that experienced obse tote that craniotabes is : invariably asso- ciated with laryngismus. Now laryngismus is univers: illy admitted to be almost always due to rickets. I do not know that anyone has asserted it to be due to syphilis; so that, if the two are thus closely :ed, the fact is clearly in favor of the rachitic nature of craniota:: The skull of a child affected with craniotabes shows shal- low depressions at the diseased pai ;:hiy bevelle into the surrounding bone. The depressed areas may be so numeroL: iner table a somewhat trabeculated appearance. The thin layer of bone which covers in the de- pression is that which gives the crackle as it bends inwards on pressure. In some cases the thinning is more genera'., in- volving, perhaps, the entire occipital bone ; in others, the local thinning is considerable, and may go on to the forma- tion of a number of membranous opercula. In other c again — and the real nature of such is still open to question 642 THE DISEASES OF CHILDREN. — there is much tendency, not only to thinning and soften- ing, but to the formation of new bone, in most cases leading to the production of a velvet-pile-like layer of osteophyte over the surface of the bones between the sutures and the centres of ossification. In this way the sutures come to form furrows, and the calvaria assumes the shape of a hot-cross bun — the natiform skull — and sometimes the bone formation may be so active that the skull may reach a thickness of half an inch or more. The new bone is very soft in all these cases, can be cut with a knife, and is of a peculiar claret color, from the amount of blood it contains. Many, as I have said, consider this condition of the bones of the skull to be a sign of congenital syphilis. It is certainly frequently found in syphilitic infants — in infants in whom other evi- dences of rickets, though not absent, perhaps are of the slightest. Nevertheless, I do not think one can altogether exclude rickets from at any rate an occasional share in its production. Epiphysial Lesions. — Other signs of rickets are found in the epiphysial extremities of the long bones and in the ribs. In these the ossifying layer of cartilage at the junction of the epiphysis with the shaft, or in the case of the ribs at the junction of the costal cartilage with the bone, becomes swollen — sometimes enormously so — and thus is produced a characteristic swelling of wrists and ankles and a beading of the ribs. These symptoms, although present in most cases, are by no means remarkable in many. A child may be very rachitic as regards its head, and perhaps show a distorted thorax, enlargement of the spleen, and even curvature of its bones, whilst yet there is but little enlargement either of the ends of the ribs or of radius or tibia. The bones are soft in rickets, and thus come sundry char- acteristic distortions of spine, thorax, pelvis, and long bones. In the thorax a double curve is assumed, the ribs fall in at RICKETS AND BONE SOFTENING. 643 their junction with the costal cartilages, and a vertical depres- sion of considerable extent is produced in such parts of the thorax as are not supported by the solid viscera. The abdom- inal viscera prevent the falling in of the lower part of the chest; the lateral parts of the upper segment fall in consider- ably; whilst the sternum becomes rounded and prominent, and the antero-posterior diameter of the chest becomes the dominant one. Some have distinguished between this, the chest of the rickety child, and the distortion due to other causes, such as atelectasis, or non-expansion of the lung. In the latter the ribs yield generally from their angles for- wards, and the chest becomes of a peg-top or angular shape, from the sternum becoming carinated. I must con- fess, however, to have had much difficulty in thus separat- ing two distinct classes of cases. On a priori grounds it may be argued that the softened bone curves, not only at the epiphyses, but also generally in its length ; there is ample evidence that it actually does so ; and there seems little reason why the ribs should not thus yield. The worse the rachitic condition, so much the more yielding will there be, and the lateral grooves will then be pronounced. In the less severe cases the recession of the chest-wall will be less, and the chest will approach the angular type. More- over, I am by no means sure that this shape does not repre- sent a partial obliteration of the more marked distortions. It is much more common in children of six, eight, or ten years. The grooved chest is the common type of infancy. It is certain that, as the child grows and the bones harden, the deeper dip of the ribs at the costo-chondral articulation gradually expands again ; while the antero-posterior expan- sion of the lung is in a measure permanent, and tends to perpetuate the prominence of the sternum. Of the pelvis I would speak in the same way. The pelvis of mollities is beaked, or Y-shaped, that of rickets is contracted in its 644 THE DISEASES OF CHILDREN. antero-posterior capacity by the sacral promontory being unduly prominent. But in extreme cases of rickets, when the body weight has been unduly thrown upon the pelvis, the acetabula may be forced backwards into the pelvis, and a beak be produced by the symphysis and pubic bones. The femora and tibiae bow outwards and forwards ; the radius and ulna curve outwards ; and in extreme cases the natural curves of the clavicles become much exaggerated. These conditions go with (sometimes they may be replaced by) an unnatural relaxation of the ligaments, particularly at the knees, and thus cause the knock-knees and bandy-legs that are so often seen in late cases of rickets. A good deal of discussion has been carried on as regards the cause of all these deformities. Some have contended for muscular force acting upon soft bones ; others for simple weight — the bones, not being strong enough, yielding under the weight they are called to support. Both these forces are probably entitled to some consideration ; but the theory which attributes the curvatures to undue weight is no doubt ' the more important, and most of the curvatures may be understood and explained by a consideration of the direc- tion in which the force has acted. In one case it may be the weight of the body in walking ; in another, that of one part of the limb upon the remainder, as in lying down. In the arms it is due to those parts being used as a help to progression, the child moving on all-fours. In the thorax some have attributed the distortion to a combination of softening of the bones, with collapse of the lung, which is a frequent associate and consequence of rickets; others to soft- ening of the bone, and a yielding under the inspiratory pull of the muscles. Of this, however, there can be no doubt, that the deformity of the thorax is almost constantly associ- ated with bronchitis and atelectasis, and that in the bones of the spine and extremities curvatures never reach any ex- RICKETS AND BONE SOFTENING. 645 treme form in such as have not been allowed to walk or sit up unduly. Another important point as regards the rachitic skeleton is that the bones are stunted in their growth, and in ex- treme cases the child may be greatly dwarfed by this means. Muscular Symptoms. — The muscles all over the body are often excessively painful ; not only the muscles of the extremities, but those also of the back and abdomen. Pres- sure is very painful to these children, and they will often cry bitterly whenever they are moved. This condition is often present even before the changes in the bones are at all pronounced. Some cases are described as screaming when- ever any attempt is made to move them ; but I am inclined to think that in such there is likely to be some periosteal lesion, such as is described on page 624 as a combination of rickets and scurvy. Nervous Symptoms. — Convulsions, tetany, and laryn- gismus are in a very 4arge number of cases associated with rickets. Indeed, so commonly is this the case, that laryn- gismus particularly is thought by many to be always rach- itic. All these affections are described elsewhere — convul- sions and tetany as diseases of the nervous system, p. 537, and laryngismus under the head of laryngeal spasm, p. 309. Zonular cataract, where some of the strata of the lens between the nucleus and the cortex become opaque, leaving the margin and the central part clear, is a liability which attaches to infantile convulsions, and therefore to rickets Why this is so, we know not. Glandular Symptoms. — The lymphatic glands all over the body become slightly enlarged and assume a shotty feeling in rickets, and, although- it cannot be said to be common if we compute the entire number of rachitic chil- dren, an enlarged spleen and anaemia should always direct our attention to rickets as one of their causes. 55 646 THE DISEASES OF CHILDREN. Dental Symptoms. — Dentition is much delayed in rickets. A child of two years old may perhaps have no more of the milk teeth than the incisors and a molar or two, and these all more or less decayed. Delayed dentition is a valuable sign of the more moderate forms of rickets, which might otherwise pass unnoticed. The enamel of rachitic teeth is bad or rocky or pitted in its disposition ; the teeth are notched, or have horizontal ridges, and break away down to the gum, where they appear as black jagged stumps. These conditions are not peculiar to rickets ; they in all probability occur as the result of any severe or prolonged state of ill- health in infancy. The urine is said to contain too little urea and uric acid, and an increase of the earthy phosphates ; though this statement has been called in question by Rehn and See- mann. Complications. — These are chiefly two — bronchitis with atelectasis and diarrhoea. The association of rickets with scurvy is important, but not common. The occurrence of bronchitis is readily explained by the softened ribs and the distorted chest ; these entail atelectasis and emphysema, which in turn entail bronchitis ; the disease in the tubes, by still more preventing the ingress and egress of air, increases the amount of collapse, and the increasing collapse tends to increase the catarrh, and the collection of a muco-purulent secretion in the tubes. The causes of the diarrhoea can be less precisely stated ; but in an unhealthy child, with un- healthy secretions, congested viscera, diseased lymphatic glands, and severe disease of the bones — which are, at this time of life, most important elaborating organs for maintain- ing the blood at a normal standard — the existence of diar- rhoea is at any rate no cause for surprise. Scorbutic or acute rickets has been alluded to towards the end of the last chapter, p. 628. RICKETS AND BONE SOFTENING. e-47 Morbid Anatomy. — If wc take the epiphysial end of a moderately rickety bone — of the rib, for example — and make a section through the length of it and its adjacent cartilage, comparatively healthy bone is seen* on the one side, healthy cartilage on the other, and between the two a layer, more or less thick according to the severity of the disease, of blueish or pearl-grey translucent cartilage. The line of this towards the cartilage is regular, but streaked with large vascular lines; towards the bone it is irregular, and sometimes so much so as to intersect the bone immedi- ately adjacent, and to appear as islands of cartilage, with vascular and calcareous points scattered about. On further examination, the adjacent layer of bone is seen to be paler or yellower than normal, and more rarified. The superficial layer of the periosteum is unaffected — it can be peeled off the bone beneath, leaving a continuous surface ; but beneath it, on the bone adjacent to the cartilage, there is more or less of a vascular soft material, prolonged upon it for a short distance, and imperceptibly lost as the cartilage re- cedes. The pearly layer of swollen cartilage causes the beading of the ribs and the enlargement of the ends of the long bones so well known in rickets ; and as regards the former, it is always mpre marked on the pleural aspect, because the thoracic walls bend inwards at this point, and make a knuckle towards the lung. The bone elsewhere is softer and more rarified than usual, and the fatty appearance of the medulla is replaced by one of a more vascular sort. Under the microscope, an excessive activity of the carti- lage is observed. The cartilage cells become swollen and largely increased in number; but instead of making good bone, a process of calcification goes on in them, and the in- terstices between them become filled with a vascular mar- row instead of with natural bone. These medullary spaces 648 THE DISEASES OF CHILDREN. are continuous with the channels in the shaft, and thus is formed a spongy tissue, very vascular but with little bone in it. A similar process goes on in the vascular tissue under the periosteum : osteoblasts may be seen in all parts, but there is but little bone. The essential features of the bone changes in rickets, therefore, are excessive activity of growth of that cartilage which makes for bone, and the production of a large quan- tity of vascular embryonic tissue, or medulla. It can then be readily understood that, so soon as the rachitic condition — whatever it may be — is neutralized, all things are in favor of rapid ossification. This is what actually happens in many cases : the epiphysical lines ossify so quickly that the growth of the bone is curtailed by the perfection of the repair, and thus bygone rickets is likely to be represented by a stunted but unusually hard and ivory-like bone. As I have else- where implied, the rachitic process is either not always of the same intensity, or it varies somewhat in different regions ; and in the skull and spine there would seem at all times to be a probability of the production of more growth than in other parts, although still a soft spongy bone of indifferent quality. As regards the process of repair in these regions, it is difficult to speak ; but from the not uncommon occur- rence in adults of dense ivory-like skulls, and spines with eburnated surfaces, which want an explanation, it is proba- ble that a similar course is pursued, in at least some, to that which goes on in the bones of the extremities. From what has been said, it follows that there must be a considerable alteration in the chemical constituents of rickety bones, and analyses show a considerable deficiency of the earthy salts. Of other morbid appearances found in rickets not much need be said, as they are described in other places in this book — not much can be said, so little is known about them. RICKETS AND BONE SOFTENING. 649 Changes in the brain have been described, such as albu- minoid disease and chronic cerebritis. Both conditions must be very rare. Of hydrocephalus, again, as a post-mortem occurrence — except as following upon convulsions and some organic disease, and possibly in this way dependent upon rickets — I think the frequency must have been deduced from such clinical features as distension of the fontanelle and ful- ness of the vessels of the scalp. But the meaning of these symptoms alone in any case is decidedly equivocal, as I have attempted to show in dealing with hydrocephalus. The lymphatic glands undergo some change, probably of a fibroid nature, and reveal this by an indurated, scarcely enlarged condition. It is supposed, though without ade- quate proof, that this change is of a similar nature to that which the spleen and liver undergo. The albuminoid dis- ease of all these viscera had been described as a glue-like change peculiar to this disease; but the observations of Dr. Dickinson and others, already quoted in Chapter XXIX., make it clear that the actual change in the viscera — and it is more common by far in spleen than liver, and, I think, than in lymphatic glands — is an increase in the fibroid material which constitutes the connective tissue of the organs, and it differs in no respect from that of the chronic enlargement of the viscera met with sometimes in ague, etc. The disease of the spleen, commoner though it is than that of the liver, cannot be called common. At most I have only notes of forty-four cases, and in twenty-four of these the rachitic na- ture of the general ailment was doubtful. It would seem, therefore, that the changes in the viscera can hardly be an essential of rickets, and probably Gee is correct in consider- ing them due to some pre-existing conditions, which, pet- haps, they share in common with rickets. The condition of the blood in rickets has received but little attention. Chemically, it has practically received none. 65O THE DISEASES OF CHILDREN. I have made numerous microscopic observations upon the blood of rachitic children, and the changes in it are certainly remarkable. In some there is a simple deficiency of cor- puscles ; in some a deficiency of coloring matter ; in some the blood is crowded with a granular detritus ; and in some the corpuscles are represented by four or five different sizes. We are surely justified in assuming that these appearances indicate immaturity, poverty, and increased waste of the blood, when such are the exact conditions we should expect from what we know of the surroundings amongst which rickets finds its home. These must produce an inferior qual- ity of the circulating fluids, and an inferior quality of blood will produce a deteriorated bone ; the converse also holds true — bad bone will make bad blood, and the lymphatic glands and spleen are therefore doubly likely to suffer some chronic changes of the kind that are known to keep com- pany with blood diseases. Such being the morbid anatomy of rickets, what opinion can be arrived at as regards its pathology? In this regard one point in the histology of the disease seems to me to be pre-eminent — that the departure from the normal is one of perverted development. It is a disease only in so far as the material formed is not the best suited to the requirements of the body. This is important, for some pathologists are inclined to put all soft bones into one category. For such, rickets, mollities ossium, and the senile fragility of bone, which is not uncommon, are all related to each other; dif- fering chiefly in the age of the affected person — for whom, perhaps, the missing link to bridge the two periods of life may be found in what has been called " late rickets." Surely this is disproved by a study of their morbid anatomy. Rickets is clearly an arrest of development ; mollities is a degenera- tion of formed material. There can be no question that there is some truth in the remark that rickets can be produced by RICKETS AND BONE SOFTENING. 65 I feeding an infant on starchy food before it can digest it. No known condition of bad feeding will produce mollities os- sium ; diet a case of osteitis deformans how we will, no impression is made upon the disease, and both this disease and mollities are quite beyond our knowledge and our power. Many suggestions have been offered as to the cause of defective bone formation in rickets. Perhaps the most favorite one has been that an excess of lactic acid exists in the blood. Experiments were conducted upon animals by feeding them on phosphorus, while phosphate of lime was withheld from their food. This treatment produced rickets, it was supposed by the phosphorus acting as a stimulant to the would-be-bone, which was thus compelled to make bricks without straw. It is suggested that lactic acid, formed in the alimentary canal from milk and other food, may act in the same way, the materials for proper bone being want- ing. But no excess of lactic acid in the blood has ever been found. On the contrary, the latest observations make its presence extremely doubtful ; and the cause of the disease has by some been maintained to be a deficiency of hydro- chloric acid. The intimate pathology of rickets is still un- known. But if we dismiss the question, how T the softening of bone is effected, there are facts in the disease which are remarkably suggestive in attempting to frame a pathological conception of the conditions which determine it; and chief of these is this most remarkable fact, that rickets, qua rickets, invariably recovers if treated properly — that is, essentially, if the child be put upon a proper diet. There is, perhaps, no other argument of equal force in favor of the disease being due to something which is withheld — in favor, that is, of the disease being dietetic. Diagnosis. — When the bone changes are moderate the disease is frequently overlooked, and passes for mere back- 652 THE DISEASES OF CHILDREN. wardness, weakness, etc. Rickety children are often plump in the earlier stages ; afterwards, they become flabby and wasted. Apart from such general considerations as these, two or three errors in particular have to be avoided. One, of mistaking inflammatory and sanguineous effusions beneath the periosteum for simple rickets, as has no doubt frequently been done under the name of acute rickets (see p. 628). Another, of confounding the bone changes of con- genital syphilis for those of rickets. And lastly, many children are brought for paralysis, and inability to walk and dangling legs, in whom the whole disease is rickets. There may, indeed, be a greenstick fracture due to this cause; but apart from this, the pain and wasting of the muscles will produce a very complete inability to move the limbs, which may sometimes deceive an incautious observer. Bearing the fact in mind, a mistake can hardly arise. As regards the bone lesions of congenital syphilis, rickets — if we allow the nature of the changes in the skull to be an open question — is a cartilage producer, syphilis is a bone producer. Thus, syphilis produces more extensive and diffused thickening of the lower end of the diaphysis than does rickets. And further, the bone lesions of syphi- lis are destructive, leading to separation of the epiphysis from the shaft, and to the formation of abscesses. The Prognosis will always depend upon the extent of disease in the lungs and in the viscera. Given a case of uncomplicated bone disease, and it may be said almost in- variably to get well. On the other hand, splenic enlarge- ment, accompanied as it often is by a profound anaemia, will surely prove troublesome, and such a case may waste and die. Many such, however, do well eventually. The bron- chitis, with atelectasis and a distorted chest, is also a most serious matter. It is a great risk in itself, and it also pos- sesses a secondary risk in the liability that exists for the RICKETS AND BONE SOFTENING. 653 production of cheesy changes in the bronchial glands and a subsequent tuberculosis. Convulsions cause death in a large number of cases, although the risk may be much mitigated by keeping such cases under treatment. Laryngismus stridulus appears sometimes to cause death, although it is not always possible to be certain how far the fatal event has been caused by un- complicated laryngeal spasm, and how far by a general con- vulsion. Treatment. — In the first place, as will have been gathered from all that has gone before, rickets is a disease which may be prevented by the simple observance of such precautions as common sense would seem to dictate, without instruction. The child of a sickly or exhausted mother, with poor milk, will need additional food, according to the directions given in Chapter II. ; the child that is still suckled at two years of age must needs be weaned, and food of good quality supplied to it. In addition to this attention to the food, it is probably of hardly less importance to insist upon the most perfect hygiene; cleanliness, to the most minute detail, should be enforced ; a tepid bath should be given night and morning ; there must be no stint in the changes of the child's under linen and napkins; cleanliness must be observed in its bed- ding; cleanliness in its food and feeding apparatus; and its clothing must be thoroughly warm, yet not oppressive.* The air the child lives in must be attended to. The garret near the sky, hot, dark, and stuffy, is not the place for the * I have at page 54, alluded to the value of a knitted jersey, made at the suggestion of Dr. Lewis Marshall, of Nottingham, and which is most valuable in giving adequate covering and warmth to infants in lieu of so many folds of flannel bandage. This, and a pair of loose knitted drawers, cover the body completely, and form a light, warm underclothing admirably adapted for children. The " Elizabeth binder," as the jersey is called, is manufactured by Walker, Kempson & Co., of Leicester, and can be procured through any hosier or draper. The drawers are easily made at home. 654 THE DISEASES OF CHILDREN. nursery. To prevent rickets, the rooms inhabited by the child must be well ventilated, not draughty, and though warm, never hot. Plenty of out-door exercise must be given, and if the neighborhood be unhealthy, the child should certainly, if possible, be removed to some dry and bracing place at the seaside or elsewhere. The treatment of rickets must follow the same lines; but more than this, for the stomach of the child that has been fed on bread and butter, arrowroot, corn-flour, potatoes, and water bewitched with the milk of one cow, must be educated back to the digestion of milk and such things as beef-juice and gravy. The diet for a rachitic child must vary with its age; but seeing that most cases come under notice at eleven or twelve months old and upwards, they are for the most part able to digest good milk well, and they have also arrived at a time of life at which, once in a day, they may take good gravy and custard pudding, broccoli, or cauliflower. Older children, of eighteen months or more, may have underdone pounded meat with well-cooked cauliflower and gravy. Eustace Smith gives a diet which cannot be improved. It is as follows : Breakfast; a breakfast-cupful of milk, with one or two teaspoonfuls of Mellin's food dissolved in it. At eleven a.m.; a breakfast-cupful of milk, alkalinized by fifteen drops of the saccharated solution of lime. Dinner at two ; a good tablespoonful of well-pounded mutton-chop, with gravy and a little crumbled stale bread ; or a good tablespoonful of the flower of broccoli, well stewed with gravy until quite tender, thin bread and butter, and toast- water to drink. Tea at six ; as at breakfast, or a lightly boiled yolk of an egg, if no meat has been given. But there are many rickety children who at two years of age have the development of a child of twelve months ; per- haps there is bad diarrhoea, vomiting, etc., etc. In such cases RICKETS AND BONE SOFTENING. 655 the diet must be carefully adjusted to their condition. The amount of milk will perhaps have to be reduced, very likely jn great measure replaced by the cream and whey previously, recommended on page 50. In such cases as these, how- ever, much reliance may be placed upon beef juice as an additional article of diet. This is made as for beef-tea : A quarter of a pound of meat is to be finely minced and soaked in a quarter of a pint of cold water for an hour; it is then strained and well pressed through muslin, and the re- sulting fluid is given, either cold or warm, by the bottle or spoon. Should any repugnance to it be manifested, it may be generally disguised in an equal quantity of milk, or it may be sweetened with a teaspoonful of malt extract. It should be freshly made each day, the quarter of a pint being distributed over the day. As regards medicinal treatment, saving the presence of special symptoms, no drugs are so successful as cod-liver oil — which should be given in doses, from twenty drops upwards to half a drachm or a drachm three times a day, according to the age of the child — and iron. As regards the preparation of iron, some prefer the syrup of the iodide, others Parrish's food. I like the, already frequently recom- mended, syrup of the lacto-phosphate of lime and iron, as I am under the impression that children improve more rapidly with it than with other preparations. It may be given in half-drachm or drachm doses, well diluted. A teaspoonful of malt extract twice a day is another useful remedy, and orange juice or lemon juice, w r ell sweetened, is also of ad- vantage, and particularly, perhaps, in such cases as have a scorbutic tendency. The diarrhoea of rickets should be first treated by a pre- liminary laxative of fluid magnesia. Subsequently, if not relieved by the dieting and abstinence from starch, Formula 9 or 10 may be given, and to either, if necessary, half a drop 656 THE DISEASES OF CHILDREN. of opium to each dose can be added ;*or Formula 23 may- be given instead. The bronchitis, being of so much importance in these cases, must be treated carefully, even when it is of the slight- est. The child should then be kept in a warm room, the atmosphere of which is made moist by a bronchitis kettle. The bowels should be opened by an aperient, and warm fomentations (or poultices, if they be preferred) be applied to the chest. If there be much mucus in the tubes, an ipe- cacuanha emetic should be given, and subsequently carbo- nate of ammonium (F. 45), or other stimulating expectorant. Convulsions in any form must be kept at bay with bro- mide of potassium and chloral (as suggested at p. 540), while the general health is undergoing restoration. The ventila- tion of the nurseries requires special attention under These circumstances. More fresh air should probably be advised^ and the body should be sponged with cold or tepid water night and morning. There are cases no doubt in which it is necessary to steer between Scylla and Charybdis, for while it is important to reduce the undue nervous irritability by such measures as these, it is equally necessary to avoid the occurrence of those bronchial attacks which are so fatal. The deformities of the limbs in rickets are to be prevented by keeping the rachitic child entirely off its legs until its bones become stronger. To insure this, splints which render walking impossible must sometimes be applied ; but the less of splintjng the better. One of the essentials of rickets is muscular failure, and it is above all things necessary, while the bones are hardening, to keep the muscles in as healthy a state as possible. For this end it is hardly possible to take too much pains ; and shampooing or friction should be carried out regularly and thoroughly — the mother's or nurse's hand, well oiled, should gently rub and manipulate all the muscles of the trunk and extremities for half an hour regu- RICKETS AND BONE SOFTENING. 657 larly night and morning; and such stimulating treatment as salt baths and rubbing with a soft towel should be used in addition. As regards the remedy for the completed distortions of rickets, it is important to remember how common these are in childhood, how rare in adult life; the inference being, as is well known to be the fact, that, except in extreme cases, Nature herself repairs the deformities as the bones grow and strengthen. But surgical aid is often necessary, by the ap- plication in various forms of elastic extension, by splints, and, as a last resort, by the rectification of otherwise irremediable curvatures of the limbs, by osteotomy, etc. It is yet necessary to mention " late*rickets " and " foetal rickets." But when, at the outset, the question arises, Do such diseases exist ? it will be apparent that not much is known about them. Late Rickets is a rare but well-recognized condition, in which the bones of children eight or ten years old soften and undergo extreme distortion. This form of disease, therefore, does not occur until the rickety period has gone by. Yet it is called rickets. Sir W. Jenner says : " I have seen rickets begin in children seven and eight years old." There is much difficulty in coming to a definite conclusion on such a point, for, on the one hand, there is no improbability in the occur- rence of a true rachitic condition at this time of life, seeing that the skeleton is still in an active state of development and growth — on the other, it is equally admissible to hold that some such condition of resorption of mineral matters and degeneration takes place as appears to happen in mollities. Symptoms. — These children are born healthy, and in some cases at least, they have come of perfectly healthy stock. The recorded cases show that up to a certain period they have been strong, and then, perhaps after some serious illness such as measles or scarlatina, in an insidious way, 658 THE DISEASES OF CHILDREN. generally with more or less pain, the extremities have be- come bent. In more than one instance fracture has occurred in one or more of the bones. Then the thorax has flat- tened in, and thus the case has remained, sometimes for many years, with stunted growth, and sometimes also with childish intellect. In a few instances death has occurred, perhaps from bronchitis or some such thoracic affection. Morbid Anatomy. — Very few data exist on this head. Such as there are show (i) that in the majority of these cases the bones are exceedingly thin and brittle. This is seen («) from the frequency with which fractures have oc- curred, sometimes in several bones, from very insufficient causes ; and (/3) from observations such as that of Mr. Bar- well, who records that he operated upon one of these cases to remedy a deformity, and the chisel went through the bone with the greatest ease; while, on passing his finger into the wound, the bone was a mere thin shell, full of an excess of oil. (2) Another case is on record,* in a boy of eleven, who was subjected to examination by Dr. Hilton Fagge, Mr. Warrington Haward, and Dr. Drewett. These gentlemen considered the change to be identical with those of rickets. The wrist ends in this case were enlarged, the bones were much distorted, and the child was quite helpless. He sub- sequently died, and a post-mortem examination was made by Dr. Abercrombie and Dr. Barlow, and the epiphysial line of the bones was found thickened and irregular, as in com- mon rickets. (3) There is yet another case worth mention, in a girl of ten, under the care of my colleague, Mr. Davies Colley.f She had always been pale, thin, and delicate, and from an * A Case of Late Rickets, by Dr. Dawtrey Drewett : " Trans. Path. Soc, Lond." vol. xxxii., p. 386. f "Trans. Path. Soc., Lond.," vol. xxxv. RICKETS AND BONE SOFTENING. . 659 early age the ankles. grew outwards and the knees inwards. The humerus fractured, and subsequently the femur, and for this, at the age of ten, she first came to Guy's Hospital. It was then found that the long bones were very tender and flexible, and that their outer shell" could be pressed inwards like the skull in craniotabes. The urine was much deficient in phosphoric acid, only one-third the normal amount being present : the calcium was in excess. She died, at the age of thirteen, from a suppurative pyelitis, due to the formation of phosphatic calculi. After death several of the bones were much distorted — some were hypertrophied and dense, others light and thin, and in some were tumorous-looking expan- sions of a light porous bone, with fibrous-looking tissue .intersecting them. The microscopical examination by Mr. Symonds showed a complete absence of compact tissue and of Haversian systems, a porous bone being filled by fibrous tissue. Mr. Symonds remarks that this development of fibrous tissue with great wasting of the bone agrees with the description of late rickets, as described by Cornil and Ran- vier, rather than with osteo-malacia. But if it agrees with late rickets, it can hardly be said to do so with that of com- mon rickets; and I have stated the case of late rickets in a threefold manner in order to show that, whether or not all these cases are related to each other, there are at any rate several kinds of disease included under this term — some " identical with rickets ; " some (and I think the major- ity), evidenced by atrophy and fragility of bone, very like osteo-malacia; some not quite like either, possessing in addition peculiar features, which make them difficult to classify. Besides cases such as have now been mentioned, Rehn, of Frankfort, has described a condition, which he calls In- fantile Osteo-Malacia, which differs in some points from ordinary rickets. The bones of the skeleton become thin, 660 THE DISEASES OF CHILDREN. soft, and porous, and their medullary canals disappear before an advancing growth of soft porous bone. The bones so affected are quite readily cut with a knife ; but in the only two that were examined after death, there were distinct rachitic changes in the cartilage zone, though but moderate in degree. This state of things occurs in young children. A case that I suppose to have been of the same nature occurred to me in a girl of one and a quarter years. In the skull, the new growth and consequent thickening was enormous; a pile-like new bone gradually monopolized the diploic space; in the extremities, fusiform nodes were produced, in which more or less of the entire thickness of the shaft was con- verted into the same soft material. These changes were associated with pronounced rachitic changes in the ends of the bones, and some have considered the entire process a rachitic one ; but the marked degree of generalized bone- softening, and the enormous development of imperfect bone, are conditions which form no part of common rickets in the human subject. Bone changes, in many respects resembling these, have been found in unquestionably syphilitic infants. " But," borrowing the words of the committee that examined the specimens,* " that such are necessarily and solely syphi- litic appears to us in our present state of knowledge not proven. The apportionment of the effects produced sever- ally by rickets and syphilis in this and other cases cannot as yet be determined." Very much the same must be said of late rickets and its relation to osteo-malacia. Some cases more resemble rickets, others osteomalacia; but whether the real meaning of this be that the two diseases are the same, with now one part of the process now another in the ascendant; or whether we have several distinct diseases * Dr. Hilton Fagge, Dr. Barlow, Mr. Warrington Haward, and myself: " Trans. Path, Soc, Lond.," vol. xxxiv., p. 201. RICKETS AND BONE SOFTENING. 66 1 which in anatomical change resemble each other, is un- certain in our present state of knowledge. Let the ob- scurity that surrounds the subject stimulate the reader to investigate these very interesting diseases. I ought to add that Dr. Judson Bury, of Manchester, has recorded a case of a female infant of eight months,* which, in the absence of any rachitic changes in the appearances in the medulla, in the thinning and easy fracture of the bones, is not unlikely to have been an example of true osteo-malacia. Dr. Thomas Barlow was kind enough to show me specimens of bones from this case, and the appearances closely resemble those of the osteo-malacia of adults, whilst those of rickets are absent. Prognosis. — This must be somewhat guarded. Fractures in these cases repair readily, so that there is no want of activity of a sort, although it is hardly of the kind that is required. Some of these cases have lived sufficiently long to pass out of notice, a few have died from bronchitic and other complications. Treatment. — They must be treated on the same lines as the rachitic patient, and it will be unnecessary to say more. Inasmuch as the bones fracture spontaneously with the least force, the greatest care must be taken to avoid all undue movement and exertion. Foetal Rickets. — The occurence of true rickets at birth, or congenital rickets, is very rare. Most authorities doubt whether it ever occurs, although, as I have said, one need not be surprised at the occasional occurrence of such a condition. Steiner mentions the existence of a specimen of rickety foetus in the museum of the Hospital for Sick Chil- dren in Prague, and other cases are on record ; but none * A Case of Osteo-Malacia in a Child: British Medical Journal, 18S4, vol. i.,p. 213. 56 662 THE DISEASES OF CHILDREN. are free from doubt, owing to the fact that foetal rickets, which has not till lately been distinguished, is probably not rickets. In foetal rickets neither the bone nor cartilage lesions are those of rickets, but they are those of cretinism. Mr. Shattock, however, considers that some of the cases illus- trate a condition of rickets which has begun and ended in utero. The characteristics of foetal rickets are : the facial appearance — the small forehead ; thick lips ; flat nose and pallor; the flat, spade-like hand; the extremely stunted bones, the latter on section showing relatively large cartila- ginous epiphyses, and the absence of any irregularity of cartilage next the bone, or, indeed, of any rachitic change in the cartilage of any kind. INFANTILE SYPHILIS. 663 CHAPTER XL VI I. INFANTILE SYPHILIS. Hereditary Syphilis plays a large part in the diseases of infancy, and is of great frequency amongst hospital out- patients. I shall describe the disease much as I have seen it, and from notes of 158 cases now before me. The ages of these children when brought for treatment were as fol- lows ; 3 weeks 1 8 weeks 10 4 months 14 9 months 6 4 " 2 9 " 7 5 - 6 10 4 5 " 6 10 " 8 6 " 10 11 " 3 6 « 6 12 " 21 7 « 6 12 " 2 7 " 5 8 « 7 Ten others were between one and two years, and twenty- four cases occurred in older children. As is well known, syphilis is a common cause of miscar- riages and premature births, and it occasionally shows itself in the child at birth. But it is much more common in in- fants of a few weeks old, and from the fifth or sixth week up to the fourth month appears to be its favorite time. In most of such cases the tale is that " it was a beautiful baby born," and perhaps at a month, six weeks, two months, etc., a rash begins to appear. The symptoms are those of secondary syphilis in the adult, of the eruptive stage of an exanthem ; but they are somewhat less regular than in adults. As Mr. Hutchinson puts it, "the tertiary and secondary stages are sometimes strangely mixed " — to wit, the frequent occurrence of bone trouble in children at the same time as the cutaneous erup- 664 THE DISEASES OF CHILDREN. tion. It is probable that the symptoms are more regular and more severe the more recently either or both parents have suffered from the acquired disease. When syphilis occurs at birth the child is likely to be a shrivelled-up mite with a feeble cry, and a skin of a coppery color with scaling cuticle. The mouth and lips may be fis- sured and thick, the edge of the anus or buttocks ulcerated, and the soles of the feet red or coppery and scaling. In the worst cases the entire body may be covered with moist and brownish scales or crusts, and here and there blebs containing serum or sero-purulent material — a state of things which has been called syphilitic pemphigus, though " bullous syphilide " would be more appropriate. Most of these very early and severe cases die. They take food badly, and become exhausted. If we take a case in somewhat older infants, if the disease be severe, except that the child will in all probability be in plumper and better condition, its surface will be much in the same state. There will probably be a raised coppery erup- tion, with delicate scales or scurf covering its surface, and with serpiginous margin, spreading over the head, face, and trunk. The eyebrows may have come out, the nose and lips will be thick and fissured, perhaps small mucous tuber- cles will be visible at the angles of the mouth or the corners of the eyes, the nasal mucous membrane thick and the child " snuffling " — some think from mucous patches here also ; there will very likely be bullae or small ulcers about the penis and scrotum, condylomata about the anus, and scales of some thickness about the soles of the feet, and possibly the palms of the hands. In these severe cases I think the liver and spleen are less likely to be affected. In milder cases there is snuffling, more or less of a squamo- tubercular rash or a coppery roseola of irregular blotches, with fewer scales ; perhaps a fissured anus, with condylo- INFANTILE SYPHILIS. 665 mata. The syphilitic infant will sometimes present a dirty tint of face, called the cafe-an-lait tint; but this is more common in the severer than in the milder cases, in which the child, although the symptoms are so pronounced as to leave no doubt about the malady, may be plump and good- looking. Perhaps I should also add that the complex of symptoms is very varied. Let us take a few. In one case — a child of eight months — there was a well-marked cafe-an-lait tint, craniotabes, small circular ulcers in numbers round thq anus, and a history of snuffles. In an other, snuffles and craniotabes only. In another, a well-marked coppery scaly- syphilide round the mouth. In another, snuffles, thick lips, depressed alae nasi, and red indurated gummatous lumps in the skin of various parts of the body. In another, no evi- dence of the disease save condylomata and perhaps snuffles (this is a very common case). In another, a bullous erup- tion, followed by condylomata. In another, a diffused red- ness of the soles of the feet and the palms of the hands, with a faint maculation of the buttocks and legs. As regards the rash upon the skin in congenital syphilis, a gyrate scaly eruption, with slight thickening (the squamo- tubercular syphilide or syphilitic psoriasis) seems to me to be more common than a macular syphilide, or syphilitic roseola, as it has been called. A diffused redness and scal- ing of the soles of the feet is also very common ; so, too, are snuffling, Assuring of the lips, and mucous patches at the angle of the mouth, fissures of the anus, condylomata, superficial ulcerations over the buttocks and scrotum, inter- trigo, etc. As rarer conditions, furuncular eruptions may be mentioned — red indurated masses in the connective tissue — which suppurate, if at all, very slowly and by a small aperture in the skin. Sometimes the skin presents circular coppery patches, in the centre of which the cutide 666 THE DISEASES OF CHILDREN. is slightly raised and translucent, looking as if about to form a bleb. In others there may be an annular eruption, with the skin in the centre healthy, and not altogether un- like patches of tinea. Bullous eruptions are not very un- common, but the bullae are often only represented by cir- cular or oval superficial abrasions or crusts. Once I have seen a condition intermediate between these two cases last mentioned — a child of four months, in whom, distributed over the body, but chiefly on face and scalp, were slightly raised circular flat brownish spots, which vesicated superficial!}*, and then dried in the centre into a brown crust. The condition spread by circular ripples, and left superficial ulcers, which rapidly healed under mercurial treatment. In bad cases the skin generally will assume a brown, thickened, wash-leathen' consistence, from diffused chronic dermatitis. Syphilis sometimes causes extreme anaemia. Laryngitis is very common, as may be judged from the frequency with which hoarseness is met with. Henoch attributes this, and no doubt with some probability, to the formation of mucous tubercles about the larynx ; but so far as is actuallv known, a more general thickening of the mucous membrane of the epiglottis takes place, such as is so common in adult life. Sometimes extensive ulceration occurs ; an instance of this, in an infant of four months, I have already recorded in Chapter XX., when dealing with diseases of the larynx. Somewhat severe laryngeal symp- toms occured eleven times in the series of cases given, but in one case I am not sure that the symptoms ma}' not have been due to iodism. The child was three months old, and was only taking fifteen drops of the syrup of the iodide of iron three times a day. This it had done for ten days, a grain of hyd. c. cret being given twice daily in addition." Suddenly, when the macular syphilide was disappearing, a most pro- INFANTILE SYPHILIS. 667 fuse mucopurulent discharge began to come from the nose, with much hoarseness also, and subsequently angry boils appeared in various parts of the body. Hepatic and Splenic Enlargement occur not infre- quently, the latter far more commonly than the former. Dr. Gee says the spleen is palpable in about one-half the whole number of cases; I should not have put the propor- tion so high. It would appear that hepatic enlargement but seldom occurs by itself, for, of seventeen cases, eleven were simple enlargements of the spleen — in the remainder both liver and spleen were large. I have no note of any case of hepatic enlargement alone. Bone Disease. — For much that is interesting regarding the pathology of this form of syphilitic affection, I must refer the reader to what has been said under the head of rickets. I shall only repeat now that of late it has been contended, particularly by M. Parrot, that there is a syphilitic form of disease of the cranial bones, as well as one which attacks the epiphysial ends of the long bones. The disease of the cranium is characterized by a velvet-pile-like growth of bone upon the outer surface of the skull, which spreads over the bones around the anterior fontanelle, between the sutures and the centres of ossification. Thus the sutures come to form furrows, and the calvaria is bossed. In company with the new bone formation goes a process of softening and atrophy, and thus the occipital bone is usually, and the other parts are occasionally, thin, soft, and compressible (craniotabes). That this form of skull is found in syphilitic infants there is no doubt whatever; that it is found in syph- ilitic infants who are quite moderately rachitic there is also no doubt ; but whether it is ever present in infants who are free from all traces of rickets is doubtful ; and how much of the diseased process is due to the one disease, how much to the other, or how much to some combination of favoring 668 THE DISEASES OF CHILDREN. influences, is very uncertain. This much, however, may again be insisted upon, that syphilis is an energetic pro- ducer of new, though oftentimes of bad, bone. Rickets is pre-eminently a cartilage former. The exuberance of bony deposit is therefore in favor of syphilis rather than of rickets, which, even in its reparative stages is not generally known by a propensity of this kind. The disease, as it is seen in the ribs, is difficult to distinguish from the changes of rickets, unless, as is sometimes the case, it occurs in parts of the bones other than those bordering upon the costo- chondral articulation. As to the lesions in the other bones there is less doubt. They are certainly, in the main, quite distinct from rickets. The bene at the junction of the epi- physis with the shaft undergoes a slow caseous inflamma- tion ; more or less periosteal bone is developed from the epiphysis upwards along the shaft, giving rise to consider- able thickening ; subsequently an abscess forms, and the epi- physis becomes separated from the shaft. At the same time, the medullary parts of the diaphysis undergo atrophic changes by the overgrowth of a gelatinous medulla, and there are also minor changes of irregular ossification and calcification, such as might be expected from such an inter- ference with the natural processes of ossification. Here, again, as compared with the usual run of rachitic bones, syphilis is known by the amount of bone which is found in the periosteum ; and in such cases as I have seen there has been no evidence whatever of the growth of cartilage which characterizes rickets. It has not been my experience that many bones are liable to be affected at once ; three times only out of seventeen was it so. In the series of 158 cases, seventeen were examples of bone disease, not including cases of what might be called nodes, but once or twice ab- scesses formed ; in one case both elbows suppurated. The elbow was the seat of the disease eight times ; the shoulder INFANTILE SYPHILIS. 669 twice; the wrist thrice; the finger once; the knee twice; the middle of the shaft of the tibia once; the ribs twice ; the cranial bones twice. (The multiple lesions are counted separately). The spleen was enlarged in three cases of bone disease; the liver and spleen once. In most of the cases there were other well-marked evidences of congenital syphi- lis. The following case may be given as an illustrative one : A female child of six months was brought to the hospital for swollen joints of six weeks' duration. One child had been born dead, and when three months old this child had been covered with an eruption of some kind. The child was very small, with snuffles and a depressed nasal bridge ; the lower lip was deeply fissured, and the body was covered with small coppery blotches ; the buttocks were ulcerated ; the anus swollen and fissured. The two elbow joints, the left wrist and shoulder, both knees, and the left ankle, were con- siderably swollen, the joints being more distorted than is usual in rickets. The ulna and radius had a nodular thick- ening just below the articular surfaces of the elbow, the humerus a thickening above. A similar condition obtained in the other bones — viz., a nodular thickening just above the joint, and not quite continuous with the articular end of the bone ; the left knee and wrist were painful ; there was slight nodular swelling of the rib cartilages at the junction with the bones ; the spleen was hard, and extended down to the umbilicus ; the liver extended half-way to the umbilicus. The disease is one that occurs in very young children — from five weeks old. Three cases occurred in infants of two months and under ; five at three months and under ; three at four months and under; the remainder being six months or more. It causes a good deal of pain, and perhaps advice will be sought for the child, because, as in some cases of rickets, it cries whenever it is moved, or a limb ap- 57 67O THE DISEASES OF CHILDREN. pears to be paralyzed. When the disease has advanced sufficiently far to produce separation of the epiphysis, there may possibly be a faint crepitus obtainable. The immobility of the affected limbs has been called by M. Parrot syphilitic pseudo-paralysis, to distingush it from infantile paralysis of neural origin; but it must be added .that Henoch describes cases of paralysis — chiefly of the arms — in syphilitic infants, in which there were no evidences of bone disease. These cases must, however, be difficult to distinguish with certainty, because, in addition to the bone affection, the ten- dency to muscular inflammation — well known in adults — cannot be altogether excluded. There is, however, no reason to doubt that, as in adults, the nervous system suffers also in congenital syphilis, and Dr. Thomas Barlow has recorded two cases'* — one a female infant of a month old, with meningitis, arteritis of the cere- bral vessels, and choroiditis ; the other a male of fifteen months, with gummata on the cranial nerves and disease of the cerebral vessels. Ulceration of the Tongue, of all degrees, is very common in congenital syphilis, though I have more often seen a dorsal ulcer of some size and depth than a more superficial and generalized condition. Mr. Hutchinson, however, speaks of a diffuse stomatitis without ulcers, parallel to, and one may suppose part of, the general swelling which attacks the nasal mucous membrane. Of other rarer conditions, I may mention iritis and choroi- ditis as occasional occurrences, and a gummatous testis also. Henoch tells of several of the latter group of cases, and men- tions others recorded by different observers. The morbid anatomy of syphilis is seldom much. But, * Trans. Path. Soc, Lond., vol. xxviii., p. 287 et seq. INFANTILE SPYHILIS. 6/1 although definite lesions form the exception, syphilis is a fertile source of infantile atrophy, and sometimes of multiple visceral lesions. For example, there may be pleurisy ; the lung may be in that condition of consolidation which has been called white hepatization (p. 351); the bones may show the changes already described; the liver may contain gum- mata, or, as is more usually the case, may be hard or elastic and large, not much altered macroscopically, but much so mi- croscopically — the lobular arrangement being broken up by a diffused fibro-cellular growth, which some have thought to be derived from Glisson's capsule, others from the activity of growth of the hepatic cells themselves. The spleen, in like manner, may be large, dark-colored, hard, and traversed by tough fibrous bands ; whilst, as rarer conditions, Coup- land has found in a female child of three months, not only gummata in the liver and lung, but also interstitial myocar- ditis and nephritis.* Sequelae. — Congenital syphilis, once cured, is not liable to relapse — at any rate, so far as the eruption is concerned ; though an occasional condyloma may show itself about the anus or angles of the mouth, perhaps a sore throat or a laryn- gitis. But the chief peculiarity about the disease is that sometimes, not very often, it shows itself by symptoms quite distinct from those which occur in infancy. Of these the more characteristic are interstitial keratitis and teeth of a peculiar shape and arrangement. But these go with several other signs — to wit, a stunted development, distorted bones (either bent or nodose), a sallow lack-lustre skin, a sunken nose, and a fissured mouth. There may even be deafness, aural discharge, ozaena, chronic ulceration of the palate with perforation into the nose, unhealthy abscesses in various parts of the body, which may give rise to nasty discharges. * Path. Soc. Trans., vol. xxvii., p. 303. 6j2 THE DISEASES OF CHILDREN. Some of these cases are very puzzling; the thickened bones, with much irregularity of the surface, and perhaps curvature and caries, the unhealthy abscesses, and ozaena, compel us, in the absence of proof, to halt between syphilis and struma. Hutchinson calls these tertiary symptoms. Indeed, as in the adult, so also in the infant, the eruptive or secondary stage passes off, and health is regained, perhaps for good. Yet it may be after a variable interval further symptoms develop, such as those detailed. The lesions are usually symmetrical. The appearances of interstitial keratitis vary according as it is recent and acute or of old date. Hutchinson's description of the disease is practically as follows : In the acute stage both corneae are usually affected, and they become of a bluish opacity, due to the effusion of lymph into their substance. There is a zone of ciliary con- gestion, but no ulceration. There is considerable intolerance of light. The inflammation over the opacity clears consid- erably, but leaves opacities of a nebulous appearance, which are easy to overlook. The permanent teeth are peculiar, in being set with much irregularity, in being dwarfed, deformed, and tending to decay. The upper central incisors have a vertical central notch of a more or less crescentic shape; the canines are deformed, the crown of the tooth being peggy or pointed ; the molars may be dome-shaped ; all the teeth are small, and thus gaps are left between them. These various symptoms may be found at all ages, from seven or eight years up to eighteen or twenty, or even further. Hutchinson has repeatedly seen patients of various ages, from twenty to eight and twenty, become the subjects of syphilitic keratitis for the first time. Congenital syphilis is contagious, just as secondary syphilis in the adult is ; therefore no healthy woman should be allowed to suckle a syphilitic infant. Diagnosis. — The chief difficulty lies in the frequent failure INFANTILE SYPHILIS. 673 of many of the characteristic symptoms. A large number of children have no symptom but snuffling, which is suspi- cious, but not pathognomonic ; others perhaps have cranio- tabes ; others laryngitis and an enlarged spleen, or an en- larged spleen and a dirty anaemic tint of the face, and so on. Thus it often happens that a doubt remains ; and this is so, even if the most careful inquiries be made as to the parental illnesses — sore throat, rheumatism, eruptions, miscarriages, etc. At all stages of its history syphilis trails the scent of scrofula, and the evidence one way and the other must be balanced as well as may be. Prognosis. — Many children waste and die during the pro- gress of the eruptive stage ; but, if seen early and subjected to treatment, a great many recover, and may lose all traces of the disease, save for such scarring of the face or trunk as may be left behind by the former eruption. The severer generalized bullous forms of eruption are highly dangerous, and, if a child wastes persistently under treatment, the danger is great ; the same is true if there be much diarrhoea, snuffles, or bronchitis; but, failing all these things, the child will probably do well. Treatment. — "The only certain cure for infantile syphilis is mercury," writes Henoch ; and probably in that short summary lies the kernel of the experience of all. The mer- curial may be administered either by giving it to the mother (a plan which has been advocated strongly by some, but which I prefer least of all, as too uncertain), by internal administration as gray powder to the infant, or by inunction. I have nothing to add to the statement of Dr. Eustace Smith, that in the hydrargyrum c. creta, or the liquor hy- drargyri perchloridi, we have two effective and easily borne preparations. The former maybe given in grain doses night and morning, with two or three grains of bicarbonate of sodium or bismuth ; and this dose may, if necessary, be in- 674 THE DISEASES OF CHILDREN. creased to two grains of the mercurial. In case of diarrhoea, the solution of the perchloride may be given ; infants take it well in half- drachm doses, which may be gradually in- creased if necessary. The inunction is carried out by rubbing half a drachm of the mercurial ointment upon the abdomen,' back, or sides, and covering the part with a flannel roller afterwards. The child should be well bathed every morning with soap and warm water, before the daily inunction is made. Besides specific treatment of this kind, attention must be given to all those more general means which will ensure the preservation of the child's health. Its food must be attended to, and it should of course be suckled by the mother, if pos- sible. But here may come a difficulty. Supposing that she should show no signs of disease, is the child to be weaned for fear of contaminating her? This is a question that can- not be answered by a yes or no. It is held by some that the ovum can be infected through the father, and be born syphilitic, the mother all the while remaining intact. If that be the case, the answer must be yes. But, on the other hand, there is a strong a priori improbability of any such freedom being possible ; and there is also the fact, vouched for by many observers, that the infant thus syphilized in utero never contaminates the mother by suckling, although she may show no signs of having already been syphilized. If this be so, the answer will be no ; for the fact is inexplicable, except on the hypothesis that the mother is already proof in some way against infection, and this is certainly much the more probable belief. It is almost inconceivable that a foetus should lie in utero for many months, receiving from, and returning a constant blood supply to, the mother, without conveying the disease from which it is suffering, and which is known to be so easily inoculable. On the other hand, it is in consonance with all we know of infective disease that INFANTILE SYPHILIS. 6 75 the mode of introduction of the poison may lead to such modification of the disease as may render it more or less incapable of recognition. On the whole, therefore, it is prob- able that a mother that bears a syphilitic infant is proof against contagion, and may suckle her child if it be consid- ered advisable as, in most cases, it certainly will be. As a first thought, therefore, for the safety of the child, the mother's health must be attended to. Not at all improbably a little of the liquor hydrarg. perchlor. or some iodide of potassium may better her condition, and, while acting upon her, act upon the child through the medium of the milk; but all other means for improving her health, in the way of good food, fresh air, etc., must be adopted as well. If the mother is unable to suckle her child, then artificial human milk or goats' milk or asses' milk are the best sub- stitutes ; but Chapter II. and those which follow it will sup- ply all information on this head. Wasting, diarrhcea, and vomiting require the same kind of treatment that they receive under other circumstances, such as have been detailed in Chapters III., IV., and V. Of the local conditions, the enlargement of the liver will often readily subside under mercurial treatment. That of the spleen is much more troublesome, and its continuance is no warrant for the prolonged administration of mercury if all other signs of the disease are in abeyance. In the pneumonia and the bone disease of the syphilitic infant the specific must be continued, in the one case with stimulants such as carbonate of ammonium or alcohol, in the other with iron and cod-liver oil. The pneumonia is fortunately rare; but neither complication responds quickly to remedies, and a case of either kind, except where the bone disease is con- fined to the production of a natiform skull — which does not much influence the prognosis — must be treated as of doubt- ful issue. 6j6 THE DISEASES OF CHILDREN. A large number of the troubles of infantile syphilis are shown upon the skin. Condylomata are perhaps the most common. The parts are to be kept scrupulously clean by frequent bathing and change of linen, remembering that syphilis is always ready to pounce upon seats of. local in- flammation; cracks, fissures, excoriations of any kind, are likely to lead on to ulceration or condylomata. Condylo- mata are to be kept as dry as possible, and dusted with calomel night and morning. The calomel may be used pure, or mixed with an equal part of oxide of zinc or the sanitary rose powder.* The same treatment may be adopted for the small patches which occur at the angles of the mouth. In the dry eruptions nothing is generally needed but the internal treatment. For such patches as are intractable, the mercurial ointment may be applied, or a dilute solution of the oleate of mercury — the 5 per cent, strength diluted with three parts of carbolic oil, strength 1 to 40. For the ecthy- matous sores that form over the trunk and extremities, and about the nails, the ung. hydrarg. oxid. rub. is as good as anything, and for some of these cases a mercurial bath may be given twice a week. Dr. Eustace Smith recommends that half a drachm of the perchloride of mercury should be dis- solved in each bath. After the more definite symptoms have subsided, the child will usually require a prolonged course of iodide of iron and cod-liver oil, not only with the object of keeping up its strength, but to ensure if possible a freedom from chronic disease of bone, ozaena, and such things as go under the general term of struma, and which blight the happiness, not only of the child, but -of many a family also. * A preparation of boracic acid, suggested by Mr. Lund of Manchester, and prepared by James Woolley & Son of that city. DISEASES OF THE SKIN. 677 CHAPTER XL VI II. DISEASES OF THE SKIN. The skin diseases of children are so numerous, and the literature of dermatology is so extensive, that the subject does not readily lend itself to a manual which treats of gen- eral medicine. I must, however, refer shortly to those more common affections which are of every-day occurrence, and to some few of the rarer conditions such as I have met with personally. A fuller treatment of the subject will not be necessary, considering the many excellent manuals that have been written of recent years. As a preliminary, let me say that perhaps there is no organ of greater importance than the skin in childhood. It is in many cases a most sensitive index of inefficient working elsewhere; its suggestions as to constitutional peculiarities are often of the utmost value to the physician ; when not properly cared for it readily goes wrong ; and rough hand- ling is quickly resented. Its very activity is a source of danger if it be neglected, and many of the diseases of the skin in infant life are directly chargeable to neglect. There- fore, as a general principle, it is of the first importance to attend to scrupulous cleanliness. A good bath once a day is not too much for any child, and a bath night and morning should be given to young children. Most children perspire readily and excessively, particularly during sleep, and re- tained perspiration about the neck or in the groin, etc., pro- duces first miliaria, and then intertrigo. Plenty of bathing and the use of the sanitary rose powder, in such parts as are liable to retain the secretions, will no doubt avert many a 678 THE DISEASES OF CHILDREN. case of what would otherwise prove a troublesome eczema intertrigo. Warmth is another essential. Custom has prescribed that young children shall wear low dresses, short sleeves, petti- coats, and no covering at all for the lower part of the abdo- men and thighs, save a pair of linen drawers. This is a custom framed upon a weakest-goes-to-the-wall principle, which is opposed to the very raison d'etre of medicine. Children's clothing is to be light and loose and warm. The method of accomplishment of these aims hardly needs a more detailed statement. The more common affections of the skin are: Lichen — often called strophulus or lichen urticatus, from its almost inseperable connection with urticaria — eczema, impetigo, ecthyma, furuncular eruptions, herpes of all patterns, ery- thema likewise, psoriasis, tinea, alopecia, and molluscum contagiosum. Of rarer occurrence are pemphigus, ichthyosis, lupus, keloid, erysipelas, scleroderma, xanthelasma, and favus. Lichen urticatus, or strophulus, the red gum and white gum sometimes talked of, occurs chiefly from the age of five or six months onwards through the period of dentition. It is not unusual from two to four years, but its history may then be traced from a much earlier date; and even in older children, of eight, nine, or ten, a persistent lichen urticatus is occasionally met with. As seen in infancy, it occurs as rather sharply raised, whitish, rounded papules of a peculi- arly hard or shotty feel, and often with a translucent centre, looking like a vesicle, but from which no fluid comes when pricked. The forearms, legs, and trunk are its favorite sites. It is very irritable, and associated often with urticaria, and for this reason the appearances vary, the characteristic papules becoming lost in wheals or changed into a number of bleeding or crusted points, from the excoriation produced DISEASES OF THE SKIN. 679 by scratching. Closely allied to this disease and to urticaria is another, which has been called urticaria pigmentosa, or xanthelasmoidea, in which the trunk more particularly be- comes covered with yellowish-brown blotches, the skin at the affected spot being raised and thick, like soft leather. Urticaria wheals are frequently seen about the body, and the history is often that the pigmented thickenings have begun as such — a fact as to the truth of which I have on more than one occasion satisfied myself. This disease was first described by Dr. Tilbury Fox as xanthelasmoidea, and a good many cases have since then been recorded. Dr. Colcott Fox has given a careful summary of all these,* and in addition has added important information on two points — first, he shows that the disease tends to disappear as the child grows up ; and secondly, that the microscopical struc- ture of the affected tissue is that of a wheal. It is important to recognize in all these three affections that the difficulties of treatment lie less in the actual struc- tural changes in the skin than in the fact that all these chil- dren have what Hutchinson calls a pruriginous skin. The subjects of urticaria pigmentosa have, not only a pruriginous skin but, also, as some cases of pemphigus, a peculiar ten- dency to the deposition of pigment in the skin. It is the constitutional element, if it may be called so, which allows of lichen, while some slight disturbance is the immediate provocative. Most often this is gastric disturbance or indi- gestion during dentition ; sometimes it is the irritation of flea-bites ; sometimes, again, as Hutchinson suggests, a vari- cella or some other exanthem. Hutchinson distinguishes between a prurigo due to varicella and that due to other causes, by the former being vesicular the latter not; but I cannot think that this distinction is of much service. Some * u Trans. Med. Chir. Soc," vol. lxvi. 680 THE DISEASES OF CHILDREN. exceedingly practical and valuable remarks, however, are made concerning the production of a pruriginous skin by eruptions of any chronicity, for all must be familiar with the fact that to scratch an itching spot is not only to make the spot more irritable, but also to extend the actual area from which the abnormal sensation is transmitted. It is easy thus to make the body itch all over; and this condition begets a pruriginous habit of skin which is quite out of proportion to the external cause. Treatment. — Lichen urticatus is very obstinate. It and all three affections in this group are for the most part best treated by the strictest attention to the diet ; but it is in many cases very difficult to say exactly in what element the cause of indigestion lies. Some children are said to be worse when eating sugar, some when they have taken too much milk ; but I must confess to having been unable to reduce a not inconsiderable experience into concrete and dogmatic statements. Having already given full space to diet, I shall only say that it will require careful scrutiny and probably modifica- tion according to the rules already detailed. Next in impor- tance comes the necessity to deprive the surface as far as possible of all excuse for itching. This may be done both by external and internal means. Externally, the most scru- pulous attention is to be paid to cleanliness. The skin is to be bathed frequently ; the linen is to be changed frequently to ensure the absence of such pests as fleas ; and in hospital out-patients scabies and pediculi must be examined for and treated if present. The nature of the clothing next the skin must also be examined. Some people are unable to wear flannel, or particular kinds of flannel, merino, etc., and dyed flannels are sometimes in use which may account for external irritation. The itching of the papules may be mitigated by gently rubbing over them and the affected skin DISEASES OF THE SKIN. 68 1 a lotion of bicarbonate of sodium, glycerine, and elder- flower or rose-water (F. 46), or a lotion of corrosive sublimate; half a grain to each ounce is sometimes effective (F. 47). Borax and glycerine may be used for the same purpose, or the skin may be oiled with vaseline or carbolic oil (1 to 40). Hutchinson recommends a solution of the liquor carbonis detergens (one part to four or five of water). For the more chronic cases, a tar bath may be given, by adding the liquor carbonis detergens to water; or sulphur baths are useful — a tablespoonful of sulphur, or more, to a bath. For internal administration in the acute stages, bicarbo- nate of sodium or potassium may be given, or some fluid magnesia. Either of the F. 7-1 1 will answer the purpose. For older children, quinine in full doses, or cod-liver oil, seems to be of most service. I think, also, that the confec- tion of sulphur and euonymin are of value in regulating the bowels and stimulating the liver. Acute Urticaria is far less common than the chronic con- ditions just described. It is readily recognized when the wheals are out, unless, as is sometimes the case, these are exchanged for a more or less general oedema, when the face becomes swollen, like the visage of a child with pertussis, and the subcutaneous tissues of the extremities are rendered somewhat brawny. When the wheals are not out, there may be also a difficulty, very little remaining but small red papules, with perhaps — when the itching has been severe — a subdued ecchymosis or dusky condition of the skin. Acute urticaria is certainly due immediately to errors in diet, though it is not unlikely that idiosyncracy may be the remote cause. It is to be treated by attention to the diet, and usually some alkali, as in F. 8 or 1 1, is all that is neces- sary. To allay the severe itching, bicarbonate of sodium, 682 THE DISEASES OF CHILDREN. dissolved in equal parts of glycerine and water, or glycerine and rose-water, rubbed gently into the part, is one of the best remedies. Gentle friction with sweet oil is also useful ; and perhaps it is well to remark that whereas violent scratch- ing increases the irritation, gentle rubbing is one of the best calmatives possible to a pruriginous skin. Eczema is most commonly seen about the head, ears, and face, and in such other parts as are subject to chafing and to the irritation of excessive perspiration — in the creases of the neck, in the axillae, groins, scrotal and anal regions, and round the umbilicus. It may be hereditary, perhaps not as eczema from eczema, but from a rough or scurfy skin, or an abnormality of some sort. Like strophulus, it often owns an external cause which may be slight in comparison to the amount of the disease. In hospital out-patients it is often associated with scabies and pediculi — in both cases the erup- tion may be not only vesicular but pustular (eczema im- petigo). Eczema capitis is sometimes very chronic, and is one of the most obstinate affections of young children. Such cases sometimes remain for months in hospital and seem to derive no benefit from any remedy, notwithstanding that the child's general health improves or may even appear to be of the best. Eczema is a disease which has a distinct predilection for the first four or five months of life — twenty- five cases out of thirty-three, occurring in the first year of life, being under five months. Between one and two years the disease is common — ten cases in the thirty-six were over a year. From two to six years the disease is more evenly distributed, and after that it becomes uncommon. It is a disease which is often attributed to vaccination ; and I think it must be allowed that, although the charge is often a groundless one, nevertheless, in unhealthy children or those of pruriginous habit, it is a disease which is occasionally excited by the condition which vaccination engenders. It DISEASES OF THE SKIN. 68 3 may equally originate in a varicella, or after measles or any other exanthem. Treatment. — Acute Eczema. — This must be general and local. In the main, it requires careful dieting, abstinence from starch and saccharine matters, and the internal admin- istration of bicarbonate of sodium or potassium and nux vomica. A powder of bicarbonate of sodium (gr. v.) and sulphur (gr. v.) is a useful combination, and may be readily given in milk three or four times a day. Small doses of the tincture of rhubarb, the tincture of podophyllin, or of aloes, or of euonymin, may also be of service. A little hyd. c. cret. seems also to be useful in some cases ; and all these children are the better for a tonic of tartrate of iron after the rash has disappeared. For local applications, quite a number of things are useful at one time or another. In very acute cases, soothing ap- plications, such as lead lotion, will be required tempo- rarily ; but more generally the ung. metallorum (equal parts of the zinc, nitrate of mercury, and acetate of lead ointments) or some preparation of zinc. The zinc ointment is too thick; it may be made fluid by the addition of olive oil, or made with vaseline in place of the benzoated lard, or the oxide of zinc may be lightly dusted over the affected parts, after they have been freely smeared with olive oil. The glycerinum boracis is useful at times ; and for parts which require to be dried in some measure, the oleate of zinc, scented with thymol (Martindale), or the sanitary rose powder, is a useful preparation. In the more chronic and drier forms, arsenic and cod-liver oil are of most use internally; and as local applications, creasote ointment, or an application of the oil of cade one part, and vaseline four parts, or of any strength that may be deemed necessary. For chronic eczema of the scalp, the local application of 684 THE DISEASES OF CHILDREN. cod-liver oil is sometimes of use, in addition to the internal administration of the drug. But these are cases which require the utmost patience and perseverance. In the eczema impetiginodes of the scalp, all that is usually necessary is to see to the destruction of all pediculi, the removal of all dry crusts, by softening them with oil and poultices, and the application of the ung. metallo- rum. In the patches of eczema so common about the face, a little unguentum metallorum is the best remedy. For intertrigo, the parts should be bathed two or three times a day, dried carefully with a soft towel, and then dusted over with sanitary rose powder or oleate of zinc above mentioned. Should these fail, one or other of the applications already mentioned may be tried. The parts should be covered up as little as possible. Soap should be avoided in eczema, except in very chronic cases, the bath being one of warm water, with some fine oatmeal added. Children with a tendency to eczema require attention to their food and occasional tonics, more particularly for some few weeks after an attack — a few drops of cod-liver oil twice or three times a day, or the lacto-phosphate of lime and iron, combined with a little arsenic. Impetigo is most common on the scalp, where it is very generally associated with pediculi. If the disease is exten- sive, it is better to remove the hair as closely as possible, apply poultices and oil to remove the crust, and subse- quently some unguentum metallorum to the pustular sores, and a weak carbolic oil to the rest of the scalp. When the sores have healed up, then come free washings with soap and water, and perhaps some ammoniated mercury ointment (gr. v. to the ounce of vaseline), to get rid of the pediculi. Impetigo may occur on other parts of the body as scattered DISEASES OF THE SKIN. 685 pustules. These usually indicate that the child is out of health, that it is fed too well or too ill, or wants change of air or tonics. This complaint, like eczema, is liable to be set up by and mask scabies. Impetigo Contagiosa has been described as a special form which occurs in epidemics, runs through a house- hold, and is preceded by febrile disturbance ; it is dis- tinguished, in short, by the characteristics of an exanthem. I have myself seen several children suffering from impetigo in one house. Dr. Tilbury Fox states that he has " again and again reproduced the disease in others by inoculation.'' The nature of the disease is still obscure. It is said by Fox to begin as a vesicular disease, and thus to differ from other forms of impetigo, and also from pustular scabies, with which it may be confounded. It seems possible that it might also be mistaken for varicella. Treatment. — The contents of the pustules being inocu- lable, care must be taken to prevent the pustules being scratched, and to render the pus harmless. This is best done, according to the author quoted, by an ointment of ammoniated mercury. Some tonic medicine will in all probability be advisable as well. Ecthyma occurs in unhealthy children, who usually re- quire tonics and cod-liver oil. The crusts which form on the sites of the bullae of pemphigus may look like ecthyma in some instances, and the fact should be remembered. The unguentum metallorum is a good local application. Furunculi, or boils, are common at all ages, but they are chiefly met with in young children from one to three years, and in boys of eight to ten or twelve. In the younger subjects they are more prone to appear as red brawny in- durations, hardly to come to a head, and they run a rather slow course. Boils are often exceedingly troublesome — not so much in the cure of any one, although this is no light 5* 686 THE DISEASES OF CHILDREN. matter, for the pain and depression caused is quite out of proportion to the size of the local malady — but in the fact that certain individuals are subject to them, and when one breaks out it may be followed by others, and the illness ex- tend over some weeks ; not only so, but the skin under these circumstances is in an irritable condition, and, unless great care be exercised, the original boil becomes surrounded by a number. This is more particularly the case where poulticing has been carried on with vigor. In adults, boils are often the result of over-feeding, and some of the most intractable cases I have met with have been in large eaters of meat; but in children this is not so. A deteriorated state is generally indicated, which requires more generous living and sometimes stimulants. Occasion- ally the boils refuse to disappear, except under change of air. They may occur on any part of the body, but the back of the neck is the most common seat, or the buttocks. I have in particular instances thought them due to defective drainage. Treatment. — Every household either has, or can learn from its nearest neighbor, a recipe both for plaster and nostrum for the speedy cure of boils, but there is nothing that can be said to show a large percentage of successes. Locally, the inflammation must be shielded from all irrita- tion (the pain they give, however, insures this), and they- may be kept moist by lead lotion or supple by vaseline or carbolic oil. In the early stages, the removal of the small head, and the insertion of a minute drop of the pharmaco- pceial glycerinum acidi carbolici, sometimes eases the pain and arrests the extension of the slough. Poultices and cold- water dressing, though in many respects grateful, are dan- gerously liable to provoke the' appearance of more. As internal remedies, Dusart's or Easton's syrup may be given, and maltine or stout. For growing boys of ten to fourteen DISEASES OF THE SKIN. 687 or more, a mid-morning meal of half a tumbler of stout, with some bread and butter, is a very good pick-me-up. Sulphide of calcium has been recommended as especially valuable, but on two rather contradictory grounds : one will recommend it as effective in procuring resolution, another as a means of bringing about softening and evacuation. I have sometimes thought it of use in the latter way, but it has often failed, and I am not sure of its value. In general terms, we must look out for any faults in diet, or faults in hygiene, and then, having remedied these, betake ourselves to general tonics, such as I have named, and to maltine or stout as a food. Herpes is most commonly seen round the mouth. Its usual appearance is that of a collection of crusts, the vesicles characteristic of the disease having become abraded and dry. It is often associated with ulceration of the gums, and is liable to accompany acute febrile disturbance of any sort. It is, however, very commonly seen in the out-patient room in conditions of feeble health, without any certain evidence of the pre-existence of fever. Herpes zoster, or shingles, is also common. It occurs as a crop of vesicles containing neutral or feebly-alkaline fluid, mapping out the distribution of one or other of the cutaneous nerves. Of ten cases, two affected the superficial cervical plexus; four the ilio-inguinal, lumbar, or cutaneous nerves of the thigh ; one the internal cutaneous of the arm ; three the intercostal nerves ; the right side was affected seven times. Six were boys, four girls. The complaint is, in my experience, as has also been stated by others, more common in children than in adults. It is said to occur only once in each individual ; a statement I can neither confirm nor con- fute. It is a disease which is associated with more or less pain for a few hours before and during the formation of the vesicles ; but this usually quickly ceases, the vesicles dry up, 688 THE DISEASES OF CHILDREN. though remaining tender, and in four or five days the dis- ease is all but well. Herpes iris is rare : it is said to occur most frequently in the extremities, rarely on the face. In the two cases of which I happen to have notes it occurred in the latter situa- tion. It is recognized by a central vesicle, with secondary rings of vesicles, and more or less redness around them. Treatment. — Very little is required for any form of herpes. Some mild saline laxative may be given for a day or two, and, if the pain be severe, a small dose of opium : the saline is to be followed by a tonic* The eruption maybe treated by the application of some thick ointment, such as the un- guentum zinci, which in a measure protects the vesicles from friction, and thus eases the pain and gives time for them to shrivel ; or they may be kept well powdered with the sanitary rose powder, oxide or oleate of zinc; or they may be painted with flexible collodion. The part should be well covered with wool. Pemphigus is a not very uncommon disease in childhood. Two forms require mention, pemphigus neonatorum, and pemphigus occurring in children other than sucklings. To take the last first : it occurs usually in spare children, and, if extensive, may be associated with very obvious ill- health ; but this is not necessary. Its course is apyrexial in many cases. In three cases which have come under no- tice while writing this, one is a spare girl, but not in any strikingly wasted condition, nor by any means anaemic; another is a remarkably well-looking, stout country boy ; and the third — a boy, the disease having lasted for many months — as it is likely to do — is somewhat anaemic and thin. In all these cases there comes upon the healthy skin a patch of erythema. This may be bright-red from excessive * Quinia is very useful in herpes zoster. — Ed. DISEASES OF THE SKIN. 689 injection of the cutaneous capillaries, or a paler, more cop- pery tint. The patch becomes slightly raised, the cuticle becoming partially separated, and giving it a wrinkled, soft, leathery appearance. After this a full or flaccid bulla forms upon a slightly vascular non-indurated base, containing opalescent serum or thin puriform fluid. The vesicles rup- ture and dry after a certain time of tension, or gradually shrivel, with a dry crust forming in the centre. Ultimately the whole surface originally blistered becomes covered with a thin crust, which covers a superficial ulcer. This gradu- ally heals, and leaves behind it a brightly rose-colored or a coppery stain. Under arsenical treatment the blister formation is either entirely arrested or rendered abortive. In the latter case I have seen the trunk and extremities (legs particularly) cov- ered with coppery patches of slightly thickened skin, not at all unlike a condition of tinea versicolor on superficial ex- amination. It is a disease which is very prone to relapse and to recur through several years, but, according to Hutchinson, it is cured eventually under arsenical treatment. I have a case under my care at the present time which strikingly illustrates the tendency to relapse, the intractability as regards com- plete cure, but the ready temporary cure under the adminis- tration of arsenic — a boy of five and a half, who has been in the hospital twice, with an interval of some months, and who has been under medical treatment more or less for many months. Small doses of arsenic are of little use to him, but as soon as fifteen-minim doses are reached, the blebs shrivel and no fresh ones appear. But here comes his difficulty : a less dose fails to check the formation of vesicles ; the large dose, when continued for ten days or a fortnight, causes diarrhoea and vomiting, and necessitates its discontinuance. Pemphigus neonatorum is sometimes a disease of like 69O THE DISEASES OF CHILDREN. character to that just described. It then appears as scattered bullae in various parts of the body, avoiding the soles of the feet and the palms, and but rarely affecting the scalp. Bullae have occasionally been seen upon the gums and mucous membrane of the mouth. More commonly, how- ever, it is more acute and more diffused, sometimes being more of the nature of a general dermatitis, and is frequently of syphilitic origin. Syphilitic pemphigus is particularly prone to affect the soles and palms. The descriptions of pemphigus vary much. One can there- fore only suppose that the disease varies in its symptoms. Thus, a cachectic form is described by some, because it occurs in unhealthy children ; a pyaemic by others, because it occasionally indicates some bad condition of blood ; some have witnessed a contagious form ; and it is described as being sometimes associated with fever, sometimes not. Diagnosis. — This is for the most part not difficult, for the existence of scattered blisters determines it. But when, as may happen, the bladders have dried and crusted, or the disease is acute and diffused, and the body is covered with eczematous-looking crusts, one may well hesitate before coming to a conclusion. Prognosis. — This is only grave in young infants, or in the diffused forms in cachectic, pyaemic, or syphilitic in- fants. Treatment. — English authorities now very generally assent to the doctrine that arsenic is curative of non-syphi- litic pemphigus. Abroad, opinion is by no means unani- mous, and, by many, general tonics and blood restorers, such as cod-liver oil, iron, etc., are preferred before other remedies. The evidence collected by Hutchinson in favor of arsenic is very strong. It has been corroborated by a large number of other observers, and it so rarely fails to relieve and, event- DISEASES OF THE SKIN. 69I ually, to cure the disease, that it may fairly be called the treatment for pemphigus. Other means for improving the general health may well be resorted to at the same time, and, while such things as cod-liver oil, and iron are given internally, good food and fresh air should be provided also. For syphiJitic cases anti-syphilitic remedies, such as hyd. c. cret, or iodide of iron, are to be given internally, or a mercurial bath may be given externally, of a strength of two, three, or four grains to each gallon of water. The blebs may be powdered over with boracic acid or oleate of zinc, to encourage their shrivelling, drying, and healing. Psoriasis is often hereditary. It presents similar features in childhood to those of the disease in adults, and it is for the most part relieved by similar remedies — viz., the local application of tar soap and tar ointments, and the internal administration of arsenic ; but it is an intractable form of disease in children. The sapo carbonis detergens, or tere- bene soap, is good for these cases, and the oil of cade, one part to three of vaseline, with some oil of lavender, makes a serviceable ointment; as also does liq. carbonis detergens 5j to vaseline §j to §ij. The ung. acidi chrysophanici (ten grains to the ounce of benzoated lard) is also a useful rem- edy, but must be used with care, as it sometimes produces oedema, and some slight local inflammation of the part to which it is applied. It also stains the skin and linen, but the color can be removed by benzol or weak solutions of potash (Martindale). Erythema may assume various forms, but I shall only mention erythema nodosum. It is not uncommon. It is characterized by raised and tender lumps, which appear most often about the legs, on the front of the shin, and about the calf. They are not so very uncommon over the exterior surface of the forearm. The lumps quickly change color 692 the diseases of children. and pass through the phases of discoloration of a bruise, and gradually disappear. Erythema nodosum is often as- sociated with other forms of erythema, and has thus received the name of erythema multiforme. The disease occurs in rheumatic families, though not exclusively so (nineteen out of twenty-nine cases, see p. 585 •. It is usually attended by apparent ill-health, but the temperature is hardly raised. It is but seldom necessary to apply any local treatment, but, af-er paying attention to the bowels, a tonic of iron, or arsenic, or strychnia should be given. Sclerema Neonatorum hare.;}* comes within the range of practical medicine, it is so rarely seen. It appears to be a disease of the newborn amongst the poor of large towns, and to be more common in the winter than the summer months. The affection is stated to begin in the lower extremities as a hard or brawny cedema, which gradually spreads over the body. The suppleness of the skin becomes lost, and it is impossible to raise it with the fingers from the deeper parts ; skin, muscle, and bone appear as one solid log. The body heat sinks at the same time, the pulse becomes impercep- tible, the heart sounds almost inaudible, and may be the respirator}* movements are invisible. The infant thus be- comes ex y feeble, sucks little, takes little from the breast, and sin Parrot distinguishes between sclerema — in which the skin is hard and thickened by new material, whilst the fat is shrivelled and atrophied — and oedema of the new born ; but these two conditions have usually been confused. In this distinction he is followed by Henoch, and no doubt correctly. Of the cause of sclerema we are still quite in ignorance, but of cedema some cases originate in erysipelas, others in extreme atelectasis or weakness of the heart, and others, perhaps, in nephritis in early infancy, of which Henoch gives a case in an infant of four weeks old. DISEASES OF THE SKIN. 693 In cither case, however, the actual result seems much the same, and the post-mortem examination reveals visceral changes of like character in both — viz., atelectasis, lobular pneumonia, and various other lesions of dubious meaning, such as capillary infarctions, etc. Gerhardt attributes sclerema in great measure to lowering of the body temperature in feeble premature children, and in this light he advocates careful feeding, either by wet-nurse or otherwise ; and all such means as will raise the temperature — warm baths, hot packs, etc. Seborrhcea is an affection of the sebaceous glands, and, as affecting the scalp, it is not uncommon in infants, leading to a thick caking of the scalp, usually about the front, and to a secondary dermatitis ; whilst in older children it occa- sionally produces a condition of intolerable scurf. In the former class of cases, the crusted material must be softened by carbolic oil and poultices, and then removed — the further reaccumulation of material must be prevented by plenty of soap and warm water, and, if necessary, friction of the scalp with unguentum myristicse or some other mild stimulant. In older children, the hair should be kept short, frequently well washed with soap, and the scalp stimulated by being well brushed at least twice a day. Oily applications, such as weak carbolic oil or vaseline scented with oil of lavender, are useful, inasmuch as they prevent the accumulation of the natural secretion, and thus make a far more healthy condi- tion of the affected glands. Boracic acid in glycerine is also useful in the same way, and acts, moreover, as a mild stimulant. There are various other affections of the skin which might be mentioned, but they are rare — I might almost say unim- portant — and may well be left to special works on the subject. I will only mention Keloid as not uncommon in vaccination scars, and therefore affording opportunity for 59 694 THE DISEASES OF CHILDREN. the study of the natural history of a very remarkable form of tumor, in that it tends to disappear spontaneously. Molluscum Contagiosum also, as a form of glandular tumor, occurring about the face, neck, chest, genitals, etc., which many assert to be contagious, is a disease which, insignificant in itself, is of great pathological interest. It is easily eradicated by nipping off the little masses with the nail, and, if necessary, applying some mild astringent, or touching the bases with caustic. Congenital Xanthelasma may also find mention, in that it also may help, though of very exceptional occurrence, to a clearer knowledge of a still obscure disease in the adult. There yet remain the important group of parasitic dis- eases. These are tinea, with which I shall couple alopecia areata for the sake of convenience, favus, scabies and pedi- culi. Tinea occurs in two forms — the body tinea, when it ap- pears as a red, scurfy, gradually spreading ring on face, neck, arms, or other parts ; and the scalp tinea, which re- quires a more detailed description. Both forms are due to the same fungus, the tricophyton tonsurans. This is seen in minute spores, .which form strings or thickly clus- tered masses, which have been compared to fish-roe, and which are indestructible by liq. potassae or by ether (the latter distinguishes them from small globules of fatty matter, which sometimes make a difficulty in diagnosis for the student). It occurs in the scalp as isolated patches, which are more or less bald ; or diffused, without any definite baldness any- where. The scalp often presents the appearance of eczema or seborrhcea, and sometimes, though rarely, there is pustu- lation. The characteristic of the disease is the existence at any part of short bristly stumps, or hair-follicles with a DISEASES OF THE SKIN. 6 9 5 central black dot (which is the hair broken off quite short, or the empty orifice occluded by dust), or persistently bar- ren, though slightly swollen, hair-follicles. The isolated patches are often red or scurfy ; but the diffused disease is very difficult to detect, unless the scalp be very carefully examined, and the short stumps of broken-off hair be made the special object of search. As regards the diagnosis, the disease is so common and so often overlooked, that a diseased scalp of any kind should always be examined with the possibility of its existence in view. Scurfy heads particularly require this, as the stumps are liable to be hidden beneath the scales. The scalp must be examined methodically, the hairs being turned up with a pair of forceps, and the roots examined with a lens. Any suspicious stump must be (as much of it as possible) ex- tracted, and the minute fragment examined under the mi- croscope, after adding a drop of liquor potassae to clear the parts. Prognosis. — Recent cases are for the most part readily curable under energetic treatment; when the disease has existed some months, it may be very intractable. Even recent cases, however, require a guarded opinion upon the speediness of recovery, for some children appear to form an unusually favorable soil for its growth, and the disease spreads with great rapidity, notwithstanding treatment. It is impossible to say what the conditions in the child may be which favor the growth of tinea. The late Sir Erasmus Wilson believed that they were those of a depressed vitality which required extra food, and tinea is no doubt often found in thin anaemic children ; but there is equally no doubt that it is not uncommon in those who appear to be in very good health. Treatment. — I shall only give a bare outline here. For fuller information the reader cannot do better than refer to 696 THE DISEASES OF CHILDREN. Mr. Alder Smith's little book,* than which nothing could be more simple, precise, and admirable, and from which, fully convinced of its value by personal experience, I condense much of the advice which follows. Tinea upon the body is readily cured. Hyposulphite of sodium (5j ad §j), boracic acid dissolved in glycerine, iodine liniment, perchloride of iron, citrine ointment, and oleate of mercury, are all effective. Tinea upon the scalp is a much more troublesome affair, because the fungus dips down into the hair-follicles, and in- vades the hair itself. It is therefore difficult to get at the fungus, and of course this difficulty is proportionate to the duration of the disease. In all cases the hair upon, and for half an inch around, the patch is to be cut short. If the disease is at all exten- sive, the hair is to be cut to a two-inch length all over the head, a fringe being left back and front for the sake of the appearance. In recent cases the head is to be washed every morning, or every other morning, with carbolic soap, then well mop- ped with a lotion of hyposulphite of sodium (5j to the Sj). The actual patches may be blistered with glacial acetic acid, and afterwards some parasiticide applied — glycerine of car- bolic acid, one in five, is a good one ; but Alder Smith rec- ommends, above all things, an ointment of nitrate of mer- cury, sulphur, and carbolic acid (F. 48), which must be well pressed into the roots of the hair-follicles three times a day. Carbolic oil, one to ten, or F. 49, are good applications for the entire scalp. Epilation should be practiced over the diseased parts. When the disease is extensive, a weak ointment must be applied all over the head. If the head should become sore, the parasiticide is to be applied by painting only. * "Ringworm; its Diagnosis and Treatment," 2d edition. DISEASES OF THE SKIN. 697 In Chronic Ringworm the fungus will have reached the depth of the hair-follicles, and be more or less inaccessible to the effects of the parasiticide. Under these circumstances stronger remedies become necessary, and oleate of mercury appears to be one of the best applications. In children over ten, a ten per cent, solution may be used ; under five, a five per cent, solution. The oleate is to be well pressed into the diseased patches with a firm mop night and morning, the rest of the head being smeared with either carbolic oil or the weak compound ointment already mentioned (F. 48). If the disease is extensive, the oleate must be rubbed into the entire head. The head must not be washed oftener than once in ten days under the use of the oleate ; frequent washing impedes the penetration of the remedy. The hair must be kept short. This treatment will require to be continued for some time, often for several months. Mr. Alder Smith states that it is extremely rare for any ill effects to follow the use of the mercurial. In cases which resist even this treatment, the artificial production of kerion is recommended. This is, in short, the production of an cedematous inflammation of the scalp in such patches as are diseased. It must be done very cau- tiously, and only a small patch at a time, and the parents should be informed of the aim of the treatment. Croton oil is an efficient remedy for this purpose. This is painted on night and morning, and the part poulticed assiduously. In four or five days' time the scalp thus treated should be red, swollen, boggy, tender, and the stumps pro- truding from the swollen follicles. Epilation is then to be carried out, and carbolic oil, citrine and sulphur ointment, thymol, or some other parasiticide is to be applied to the surface. Water-dressing or weak carbolic oil may be applied to the parts until the inflammation subsides, when usually the 698 THE DISEASES OF CHILDREN. disease is cured, and a smooth, shining, bald patch results. Some stimulant hair-wash is then to be rubbed into the bald patches night and morning, and the hair is soon reproduced. This treatment is severe, should never be applied to young children under seven or eight, and only in cases in which energetic treatment of milder fashion over a long time has failed to eradicate the disease. Preventive Treatment. — The disease is contagious, and liable to spread in families or schools ; therefore all brushes, combs, sponges, flannels, towels, etc., used by the infected, must be scrupulously kept separate, and no other child allowed to touch them. Caps, coats, comforters, etc., must be kept quite separate, and well baked when no longer needed, or, still better, destroyed ; all linen that will wash should be well boiled. The heads of all other children in the house should be well pomaded with a white precipitate ointment, scented so as to render it agreeable (F. 49), or with carbolic oil (1 to 10). They should also be frequently washed and examined once a week, so that no early spots may go undetected. Recent cases of the disease, or any case where the disease is extensive, should be isolated. In the very chronic cases, when the disease is well in hand, and the head effectively covered with a parasiticide, etc., the child may, if it be imperative, mix with other children, without much fear of the disease being communicated. It is, of course, better when possible to isolate the child until it is well. No boy should be sent back to school unless he be absolutely well, or the disease be well under treatment and the medical officer consents to his return, it being, of course, fully understood that continued supervision and treatment will be necessary. Ringworm is very liable to relapse, and no child should be considered cured until the new downy hair is growing DISEASES OF THE SKIN. 699 well and no stumps are to be seen, and this after several examinations made at intervals. Alopecia Areata is placed here because so much discus- sion has taken place as to whether it is or is not due to the growth of a fungus, and because, if it be not, it is a condition which might be mistaken for ringworm. The fact that authorities have hitherto been divided upon the parasitic nature of this affection seems to me to point unmistakably to the conclusion that there is a disease (alopecia areata) which is non-parasitic, and that ringworm sometimes puts on very much the same appearances. The majority of living dermatologists are of opinion that alopecia areata is not due to a fungus. Alopecia is of various kinds, and any one of them may be found in childhood ; but the disease, which occurs in patches, is apparently distinct from these, although the condition of the hair is, equally with them, one of simple atrophy. The cause of this atrophy is unknown ; it is said to be sometimes hereditary. The hair falls out in patches, which increase at the circumference, and sometimes the entire scalp becomes bald. It is a common disease of child- hood, and is treated — and as a rule successfully — by stimu- lant applications to the scalp. The expressed oil of nutmeg, well rubbed into the patch night and morning, is a good remedy. Another favorite prescription is tincture of can- tharides, carbonate of ammonium, spirits of rosemary, and water (F. 50). Tincture of iodine may be applied, or, if the case prove obstinate, a patch may be gently vesicated, if not too large, by blistering fluid or iodine liniment. Steiner quotes Rindfleisch as recommending a lotion of tincture of capsicum and glycerine, and it is one that I should think would prove useful. The child will probably be benefited by tonics and good living. Of Favus no lengthy mention is required, it is so rare. I have seen it only twice. Kaposi notes its occurrence fifty- 700 THE DISEASES OF CHILDREN. six times in a total of nearly 26,000 cases of skin disease in a period of ten years. It appears as crusted cups of sul- phur-yellow color scattered over the scalp, and can scarcely be mistaken, though in very long-standing cases it may perhaps be so for the crusts of some other disease — pso- riasis, neglected eczema, seborrhcea, etc. The patches are more or less circular, of well-marked outline, situated round one or more hair-follicles, and when removed leave a moist, depressed surface of skin behind. Favus sometimes occurs upon the body, and sometimes affects the nails. The treatment is expressed, in short, by epilation, and the energetic application of some parasiticide afterwards. The ointment already given for tinea tonsurans may be rec- ommended. Kaposi states that it is unnecessary to epilate the hairs systematically all over the diseased area, all that is necessary being to take the hair in thin tufts — healthy and diseased indiscriminately — between such a thing as a spatula and the thumb, and then to make slight traction. By this means the diseased and loose hairs come away and leave the healthy behind, without causing pain. Any cakes of fungus must first of all be removed by the free inunction of oil, and by poulticing, and the parasiticide is to be rubbed in after every epilation. The disease is intractable, and requires long treatment. Scabies is a common ailment in the out-patient rooms of children's hospitals. It is often generalized over the body, it is often pustular, and it may be associated with an erup- tion of an eczematous appearance. It may in some cases be mistaken for eczema or impetigo, both common diseases in children; and it is also not easy to distinguish at first sight from lichen urticatus or strophulus, if the latter be very diffused and the skin scored by scratching. The diagnosis must be settled by detecting the acari. Should the burrows prove difficult to find, any eczematous DISEASES OF THE SKIN. 70I crusts may be scraped and detached and examined under the microscope for fragments of the acari, or ova. The treatment consists of applying some parasiticide to the affected parts, and afterwards thorough bathing — the infected clothes being well boiled or baked. Sulphur is the commonest remedy ; half a drachm to an ounce of vase- line makes a good application. The late Dr. Tilbury Fox recommended an ointment of sulphur, ammoniated mercury, and creosote (F. 51). Iodide of potassium ointment is said to be very efficacious, and has the advantage of having no smell. To pustules and inflamed parts a soothing lotion, such as lotio plumbi, must be applied. When the disease is generalized, time is saved by rubbing the sulphur oint- ment into the whole surface, the child remaining in a well- sulphured shirt and sheets for forty-eight hours. A thorough bath is then given, and clean clothing put on. But this plan can only be followed when the skin is sufficiently sound to allow of it ; it is not advisable in eczematous or pustular conditions. It will then be necessary to single out such parts as admit of and require the parasiticide, and others for the emollient treatment. Pediculi are mostly seen in the head. As a broad rule, enlargements of the glands in the segment of the neck behind the ears are caused by impetigo of the scalp, and impetigo is always associated with pediculi. Pediculi are often present without thepustulation; but given the existence of the latter, the former will generally be found. They are for the. most part recognized by the existence of the ova on the hair ; these are readily recognized by their elongated shape and their adhesion to the hair. Treatment. — The hair should be thinned as much as possibly ; in boys it may be cropped close to the head. If the head is not sore, the hair may be bathed with vinegar and water, with the object of loosening the cement which 702 THE DISEASES OF CHILDREN. unites the ova to the hair, and thus to allow of their re- moval by subsequent washing with soap and water. The ung. hyd. ammon., either undiluted or mixed with vaseline, and scented with oil of lavender, is perhaps, upon the whole, the best parasiticide. Some prefer a lotion of bichloride of mercury (two to four grains to the ounce), and benzol, is recommended by others ; but the ointment is, perhaps, safer than the one, and less repulsive than the other. Pediculi are not usually troublesome to eradicate, when once attention is directed to their existence. It perhaps more often happens that parents apply one thing after another to cure a sore head, and take no radical measures against the pediculi which are at the root of the mischief. When they are few in number, a fine comb and frequent washing with soap and water will easily remove them. One other point needs noting — viz., that pediculi are not always due to uncleanliness. It is no unfamiliar ex- perience, that the heads of patients in every way well tended may, as it were, suddenly swarm with vermin when disease has reached the stage of exhaustion preceding dis- solution ; and with children it is true, as I have said of tinea, that in ill health of any form, but particularly the thin mis- erable starveling, is the prey of these creatures of vulturous propensities. Fattening food and tonics are therefore very usually requisite in these cases. APPENDIX OF FORMULA. Aromatic spirit of ammonia, . Ipecacuanha wine, Tincture of yellow cinchona, Glycerine, .... Caraway-water to, One drachm three times a day. si- ^ss. gss. gjss. 2. Salicylate of sodium, gij. Liquid extract of liquorice, . . . . . . gss. Solution of acetate of ammonium, .... ^ss. Water to, . gij. Half a drachm to one drachm every three or four hours. Castor oil, Oil of sweet almonds, White sugar, Powder of acacia, . Cinnamon-water to, Two drachms for a dose. 39- aft- si- Tincture of opium, Castor oil, Oil of sweet almonds, White sugar, Powder of acacia, . Cinnamon-water to, One or two drachms for a dose. njeiij. sy- 3*j- 704 APPENDIX OF FORMULAE. 5. Sulphate of magnesium, Tincture of capsicum, . Syiup of ginger, . Dill-water* to, A drachm three times a day gss. 6. Manna, ....... Syrup, ........ Caraway-water to, ..... A drachm three times a day. 3»J- Eh 7. Spirit of nitrous ether, . Sulphate of magnesium, Oil of cajuput, .... Syrup of tolu, .... Solution of carbonate of magnesium,f A drachm twice or three times a 3J- Si- S»j. day. 8. Bicarbonate of sodium, . Tincture of nux vomica, Compound tincture of cardamoms, Syrup, 3)- a* * Aqua anethi, Br. P. — Ed. j- Liquor magnesiae carbonatis (Fluid Magnesia), Br. P., contains : Sulphate of magnesium, ..... 2 ounces. Carbonate of sodium, ...... 2]/ 2 ounces. Distilled water, . a sufficiency. For method of preparation consult British Pharmacopoeia, or Stille and Maisch's Dispensatory, p. 839. This solution contains about thirteen grains of carbonate of magnesium to the fluid-ounce. — Ed. APPENDIX OF FORMULA. 705 Chloroform-water,* gss. Water to, gij. A drachm every six hours (Eustace Smith). In this prescription, the alkali causes the separation of the strychnia from the tincture of mix vomica, but the amount of the alkaloid is so small that it is still held in solution by the water. 9. Bicarbonate of sodium, . . . . . £j. Solution of bismuth, ....... ^ij. Syrup of tolu, gij. Caraway- water to, ....... gij. A drachm four times a day. 10. Bicarbonate of sodium, ^j. Subnitrate of bismuth, ....... ^ss. Compound powder of tragacanth,f .... ^ss. Syrup of tolu, gss. Caraway-water to, gij. A drachm three times a day. 11. Bicarbonate of sodium, gjss. Tincture of rhubarb, . . . . . . . £ij. Syrup of orange, or ginger, gj. Infusion of calumba or peppermint-water to, . . . giij. One or two drachms three times a day. * Aqua chloroformi, Br. P., contains : Chloroform, . . 1 fluid-drachm. Distilled water, 25 fluid-ounces. Put into a two-pint stoppered bottle, and shake them together until the chloroform is entirely dissolved in the water. — Ed. f Pulvis tragacanthae compositus, Br. P., contains : Tragacanth, in powder, ...... 1 ounce. Gum acacia, in powder, ...... 1 ounce. Starch, in powder, ....... 1 ounce. Refined sugar, in powder, . . . .3 ounces. Rub them well together. — Ed. 706 APPENDIX OF FORMULAE. 12. Sulphate of magnesium, Ipecacuanha wine, Raspberry vinegar, Water to, Si- |jss. Two drachms twice or three times a day. 13. Euonymin, •. White sugar, Once, twice, or three times a day. gr. v. 14. Podophyllin, . . gr. j Rectified spirit, . . . . . . . • 3J- One or two drops on sugar once or twice a day. 15. Solution of arseniate of sodium, . . . . . £j. Glycerine, £ij. Compound decoction of aloes,* ..... 3 iij. Two drachms three times a day for a child of six to ten. * Decoctum aloes compositum, Br. P., contains : Extract of Socotrine aloes, . Myrrh, .... Saffron, .... Carbonate of potassium, Extract of liquorice, Compound tincture of cardamoms, Distilled water, .... For mode of preparation see British Pharmacopoeia, or Stille and Maisch's Dispensatory, p. 491. — Ed. 120 grains. 90 grains. 90 grains. 60 grains. I ounce. 8 fluid- ounces. a sufficiency. APPENDIX OF FORMULA. 707 16. Solution of strychnia,* ....... ff^xx. Solution of pernitrate of iron,f . . . . • Z)- Glycerine, !§ss. Caraway-water to, . . . . . . . giij. Two drachms three times a day. 17. Belladonna, . . . . . . . . gr. j. Glycerine, . . . . . . . . • ^j- Iron wine to, ........ §iij. Two drachms three times a day. 18. Creasote, ......... ^ ij— iv. Syrup of tolu, . . . . . . . . %). Camphor-water to, §j ss . A drachm when necessary. 19. Citrate of potassium, ....... 5jj. Solution of acetate of ammonium, .... giij. Ipecacuanha wine, . . . . . . . ^j. Syrup of mulberries, J . . . . . . . gss. Water to, . . . . . . . . . gij. A drachm every four hours. * Liquor Strychniae, Br. P., contains : Strychnia, in crystals, ...... 4 grains. Dilute hydrochloric acid, 6 minims. Rectified spirit, ....... 2 fluid-drachms. Distilled water, ....... 6 fluid-drachms. Mix the hydrochloric acid with four drachms of the water, and dissolve the strychnia in the mixture by the aid of heat. Then add the spirit and the remainder of the water. — Ed. f Equal to Liquor Ferri Nitratis, U. S. P.— Ed. J Syrupus mori, Br. P., contains : Mulberry juice, ...... I pint. Refined sugar, ...... 2 pounds. Rectified spirit, ...... 2}£ fluid-ounces. Heat the mulberry juice to the boiling-point, and when it has cooled filter. Dissolve the sugar in the filtered liquid with gentle heat, and add the spirit. —Ed. 708 APPENDIX OF FORMULAE. 20. Bicarbonate of potassium, Oil of sweet almonds, . Glycerine, .... Compound powder of tragacanth, Caraway-water to, A drachm every four hours 3'h gss. S l h £ss. 21. Sulphate of magnesium, . . • 3J- Sulphate of iron, ....... • g r - V11 J Dilute sulphuric acid, . gss. Syrup of ginger, . . gss. Caraway-water to, ... . giv. Two drachms three times a day. 22. Liquid extract of opium, ...... HJJxx. Sulphate of iron, ........ gr. xvi. Solution of carbonate of magnesia, . . . . .^ij- Syrup of ginger, 3J. Two drachms three times a day for children of five to ten years of age. 23. Extract of logwood in powder, . . . . . gr. xx. Ipecacuanha wine, ....... Trjjxx. Opium wine, . . . . . . . . nj?x. Chalk mixture, ... . . . . . . gij. A drachm every four hours. 24. Extract of logwood, . . . . . . . zij. Tincture of catechu, ....... ziij. s y ru P> 3 J J« Cinnamon-water, . . . . . . . . 5iij. Dose for a child two years old, two drachms (Hillier). APPENDIX OF FORMUUE. 709 25. Gallic acid, gr. x. Wine of opium, TTJJv. Rectified spirit, ........ ^jss. Chloroform-water to, ...... . 3Jss. A drachm three times a day. 26. Sulphate of copper, • g r -j- Dilute sulphuric acid, ...... . 3ss. Spirit of chloroform, . . . . . gss. Syrup, • E [ 'h Caraway-water to, ...... . gjss. A drachm three times a day. 27. Acetate of lead, . gr. viij Dilute acetic acid, ... . .. . • . . TT^XX. Opium wine, . njjx. Syrup, . ... . . giij. Water to, . . gjss. A drachm three times a day. 28. Chlorate of potassium, ..... • si- Tincture of yellow cinchona, • =53- Dilute hydrochloric acid, .... • si- Syrup of mulberries, . . . gjss Water to, . . ... • • gvj. Half an ounce every three or four hours for children of eight or ten years. 29. Compound tincture of camphor,* .... • 3J- Solution of acetate of ammonium, .... . siij. Citrate of potassium, ...... • 3J- Syrup of tolu, ' . gss. Water to, • §"j- One or two drachms every three hours. Equal : Tr. Opii Camphorata, U. S. P. — Ed. 6o 710 APPENDIX OF FORMULA. 30. Bicarbonate of potassium, . . . . . . gj . Tartrate of iron, £j. Liquid extract of liquorice, ...... Jss. Water or compound decoction of aloes to, . . . giij. Two drachms three times a day. 31. Oil of turpentine, ^ij. Honey, gjss. Compound powder of tragacanth, . . . . . gj. Peppermint- water to, ^vj. Two drachms three times a day. 32. Dilute hydrocyanic acid, ...... rcjjyj. Bicarbonate of sodium, • S»j- Glycerine, ^ss. Caraway- water, ........ ^iij. A drachm every three or four hours. 33. Calomel, gr. j. Resin of jalap, . . . . . . gr. ij. Scammony powder, gr. v. To be taken as a powder, with honey. Jalapine may also be conveniently administered by dissolving a gelatine lamel (Savory and Moore) in warm milk. 34. Sulphate of iron, , gr. xij. Liquid extract of liquorice, 5ss. Compound decoction of aloes to, 5iij. Two drachms to half an ounce three times a day. APPENDIX OF FORMULA. 711 35. Ipecacuanha wine, . . . gij. Spirit of nitrous ether, . . & Syrup of tolu, .... . . . . gj. Glycerine, ..... . gss. Water to, . ■ . . m A teaspoonful as often as may be necessary. 36. Alum, ........... gij. Boil in a pint of milk and sweeten. A tabiespoonful frequently. 37. Tincture of digitalis, Solution of acetate of ammonium, . Spirit of nitrous ether, Syrup of tolu, .... Caraway-water to, ... A drachm every two hours, gjss. 38. Ointment of nitrate of mercury, Glycerine, . Carbolic oil (1 x 4°)> . 3i- Eh 39. Carbolic acid, Glycerine, Caraway- water to, One or two drachms every four hours. gr. viij. a- 3*. 40. Iodoform, Eucalyptus oil, Glycerine or vaseline to, ^ss. gss. 3»J- 712 APPENDIX OF FORMULA. 41. Alum, ^ss. Ipecacuanha wine, ....... 3J SS - Syrup of tolu, ^ss. Dill water to, . . giij. Two drachms every three or four hours. 42. Solution of arseniate of sodium, 3J. Benzoate of sodium, Q). Syrup of tolu, §j. Water to, giij. Two drachms three times a day. 43. Chloride of calcium, 3J- Liquid extract of liquorice, . . . . . • S- Glycerine, 31J- Water to, giij. Two drachms three times a day. 44. Simple Elixir. An American vehicle for the administration of medicines. Spirit of orange (oil 1, rect. spt. 9), . . . . ^ss. Rectified spirit, ........ ^ivss. Distilled cinnamon- water, ...... ^vj. s y ru P> • • iyj. Mix and filter. Twenty drops to be added to any mixture. (Martindale and Westcott.) 45. Carbonate of ammonium, ...... gr. xxiv. Bicarbonate of potassium, ^ij. Liquid extract of liquorice, . . . . . . gss. Water to 3 giij. A drachm every three or four hours. APPENDIX OF FORMULA. 713 46. Bicarbonate of sodium, . Glycerine, Elderflower-water,* For a lotion. 47. Perchloride of mercury, Chloroform, . Glycerine, Rose-water to, 3y. gr. iij. TTJ^XX. For a lotion. 48. Carbolic acid (Calvert's No. 2). Nitrate of mercury ointment. Sulphur ointment. The proportions will vary with the age of the child ; equal parts will be borne by children over ten. For younger children, or for more extensive application to scattered patches, the carbolic and citrine ointments must be diluted with two, three, or four parts of sulphur ointment. The pure crystallized carbolic acid must be used, or the ointment will change color ; and the citrine ointment must be quite free from any excess of nitric acid. The carbolic acid is to be thoroughly mixed with the sulphur ointment first, and the citrine ointment rubbed in last — no heat is to be applied. The oint- ment should be freshly made every week or ten days. (Alder Smith.) 49. Ammoniated mercury, . Red oxide of mercury, . Essential oil of almonds, Benzoated lard, . g r - V J- ** Aqua sambuci, Br. P., contains : Fresh elder flowers, separated from the stalks (or an equivalent quantity of the flowers preserved, while fresh, with common salt), 10 pounds. Water, . . . . . . . . .2 gallons. Distil one gallon. — Ed. 7H APPENDIX OF FORMULAE. 50. Carbonate of ammonium, Tincture of cantharides, Spirit of rosemary,* Water to, E ss - gss. gss. 51. Sulphur, . . . . . . 3ss. Ammoniated mercury, .... . gr. iv. Creasote, ...... • nRiv. Oil of chamomile, .... . ^x. Lard, . . . . . ... ■ ■ . s-- 52. "Directions for making Artificial Human Milk" from Playf air's " Science and Practice of Midwifery" "Take half a pint of skimmed milk, heat it to about 96 , and put into the warmed milk a piece of rennet about an inch square. Set the milk to stand in a fender, or over a lamp, until it is quite warm. When it is set, remove the rennet, break up the curd quite small with a knife, and let it stand for ten or fifteen minutes, when the curd will sink. Then pour the whey into a saucepan, and let it boil quickly. Measure one-third of a pint of this whey, and dissolve in it, when hot, no grains of sugar of milk. When this third of a pint of whey is cold, add to it two-thirds of a pint of new milk and two teaspoonfuls of cream, and stir. The food should be made fresh every twelve hours, and warmed as required. The piece of rennet, when taken out, can be kept in an egg-cup, and used for ten days or a fortnight. " N.B. — It is often advisable during the first month to use rather more than a third of a pint of whey, as the milk is apt to be rather too rich for a newly born child." To this I would add that rennet can be procured of any butcher that kills, but in large towns these may be difficult to meet with. In this case some liquid essence of rennet may be used instead. * Spiritus rosmarini, Br. P., contains: Oil of rosemary, I fluid-ounce. Rectified spirit, 40 fluid-ounces. Dissolve. — Ed. APPENDIX OF FORMULAE. 7^5 53. Directions for the Artificial Digestion of Milk. (Roberts.) A pint of milk, diluted with a quarter of a pint of water, is divided into equal parts — one part being heated to boiling and the other remaining cold, and the two mixed. In this way the required heat is procured — an essential point, for the ferment is destroyed by a temperature of over 140 F. The dilution prevents the curdling of the milk on the addition of the digestive fluid. Into the milk thus prepared are put two teaspoonfuls of Benger's or Savory and Moore's liquor pancreaticus and twenty grains of bicarbonate of sodium, and the milk is then placed under a cosy near the fire. It is to be tasted occasionally, and as soon as a bitter taste is perceptible, the whole is boiled, to arrest any further action. It is then ready for use. It may be made more palatable by using skimmed milk, and restoring the cream after the digestion has been accomplished and the process stopped by boiling. If the digestion be allowed to proceed too far, the product is too bitter and unpalatable. [I prefer to peptonize, or artificially digest, milk by solid pancreatin. That prepared by Fairchild, Brothers and Foster, of New York, has proved most efficient in my hands. The mode of preparation is as follows : Into a clean quart bottle put 5 grains of Extractum Pancreatis, 15 grains of Bicarbonate of Sodium, and a gill of cool water. Shake ; then add a pint of fresh cool milk. Place the bottle in water so hot that the whole hand can be held in it with- out discomfort for a minute, and keep the bottle there for exactly thirty min- utes. At the end of that time put the bottle on ice, to check further digestion and keep the milk from spoiling. The degree of digestion is very easily regulated by the length of time in which the milk is kept warm. When the milk is digested so long that it acquires a slightly bitter taste, it is because the caseine has been entirely con- verted into peptone. It is very rarely necessary to carry the peptonizing to this point. Partially peptonized milk has no bitter taste — has, indeed, little ap- parent evidence of any change. After the contents of the bottle get warm, then every moment lessens the amount of caseine — the ingredient which is difficult to digest, and the degree of peptonizing necessary in each case is best determined by the readiness with which it is assimilated by the patient. Great heat destroys, or cold stops, the digestive action. It must be borne in mind that this is not a cooking or chemical process. The object is to sub- ject the milk to the action of the digestive principle at a temperature similar to that of the body. Always use fresh sweet milk. Peptonized milk may be sweetened to taste, or used for punch, with rum, 716 APPENDIX OF FORMULA. etc., or made into jelly; it may be employed also in the preparation of such foods as ordinarily require the use of milk. In the preparation of food for bottle-fed infants, it is perfectly feasible to prepare the milk for each meal in the nursing-bottle. Thus, for an infant of five or six months : &. Ext. pancreatis (Fairchild's), . . . . . gr. xviij. Sodii bicarbonatis, ....... gr. xlviij. M. et ft. in chart, (waxed papers), No. xij. S. — Put one powder into the nursing-bottle with four ounces of water and four ounces of fresh sweet milk, keep warm for about half an hour before feeding ; sweeten a little.] 54. Routine for Choreic cases treated by Massage, etc. At 5.30 A.M., half a pint of warm milk; 7 A.M., half a pint of milk and three slices of bread and butter (each slice an ounce in weight); 9.45 a.m., half an ounce of Kepler's malt extract in lemonade; 10 a.m., massage (fifteen minutes) followed by half a pint of warm milk; 12.30 P.M., rice pudding, half a pint of milk, green food and potatoes; 4.15 P.M., half a pint of warm milk, three slices of bread and butter, and an egg lightly boiled; 7 p.m., half an ounce of Kepler's malt extract in lemonade; 7.30 p.m., massage, followed by half a pint of milk. At the end of ten days or a fortnight the bread and butter is increased to four slices at 7 and 4.15 ; a lean chop is added to the midday meal, and an extra pint of milk is distributed over the twenty-four hours. I am indebted to Dr. John Phillips, Assistant Physician to the Chelsea Hospital for Women, for working out this diet. We have found it very useful. INDEX. Abdomen, 20 enlargement of, 20 examination of, 22 in typhoid fever, 280 retraction of, 471 Abdominal disease, cry of, 18 distention, 289 neuroses, 117 symptoms of, 1 17 tubercle, 410 Abscesses, glandular after scarlatina, 186 Abscess of lung during cancrum oris, ■ 98 peritoneal, 425 Acute endocarditis, 602 hydrocephalus, 464 nephritis, 448 pericarditis, 602 spinal paralysis, 508 tuberculosis, 393 pathology of, 393 discussion of, 394 symptoms of, 395 diagnosis of, 396 prognosis of, 396 treatment of, 397 Administration of food, points as to, 43 Affections of the oesophagus, 113 Ague. (See Malarial Fever.) Albuminuria, a sequel of measles, 161 in diphtheria, 21 1 ? 217 in scarlatina, 174, 179 Alopecia areata, 699 Alum in treatment of whooping-cough, 276 Anaemia, 631 diagnosis of, 631 prognosis of, 631 Anaemia, treatment of, 632 in malarial fever, 291 Anasarca, 183 in scarlatina, 182 Anatomical lesions of cholera infan- tum, 74 entero-colitis, 68 ulcerative stomatitis, 92 Anatomy, morbid, of acute diarrhoea, 64 atelectasis, 357 bronchiectasis, 335 bronchitis, 332 cancrum oris, 98 ch. diarrhoea, 8 1 cirrhosis of liver, 436 diphtheria, 219 enlargement of spleen, 430 intussusception, 145 mumps, 252 phthisis, 364 • pleurisy, 38 1 pneumonia, 340 scarlatina, 190 tabes mesenterica, 413 typhoid fever, 283 whooping-cough, 268 Aneurism, 621 Anterior polio-myelitis, 501 Anuria, 443 Anus, fissure of, 54, 59 malformation of a cause of con- stipation, 54 Aphthae, 91 Aphthous stomatitis, 91 Appendix of formulae, 703 Appetites, faulty, 42 Arachnoid, inflammation of the, 455. Arsenic, tolerance of, 26 Artificial human milk, 37 Ascaris lumbricoides, 135 61 ,-is INDEX. Ascite _ " ; _:- : r : : n:s ; :'. _ : - :". :. ". : ; - :: _: ~ treatmez: a : _:~ : >: Asses mi ; _: - : : 5 .hing, 294 Atelectasis, 3 5 4 seat : J54 ges : \ : :_ morbid anatomy of. 3 ' " diagnosis of, 3 5 proguos :.:ment of, 360 vhooping- cough. : 5 in measles : jj : : 5 A -.:/' : rase of constipa- tior. _:_ Atrop fa 4.6 cry : pulse of. treatment : progressive muscular : : I Lixtare, 200 I 1 1 : • _ rhoid fever, 2S9, 200 Belladonna in treatment of whooping- ::.:;:-.. :" Blood poisoning in ; : : E : ■. '. e .'. r. : .: r . : :. Boils see Furuwcuij Bowels, evacuations from. : : 1 Bre.ii: . : : m ; 294 in bronc. in pneumonia. 344 of children. : 4 Bromide of potassium, suscept b to, 25 Bronchial affections in measles, 160 phtr. ; _ 5 .107 :. : ;. ^ - : ? : ■= : :'. j. : > prognosis of, 409 treatment of, 409 Bronchiec : morbid anaton -5 pr : g ; 36 treatment of, 3 ::" : :~ .~toms of, :: ; duration c diagnos> P r chronic. - morbid anaton :ment of, 3 dun : g : in typhoid fever. : B : Broncho-pneumonia, during whoop- ing-, in cancrum or s in measles, 16c. Bn Dphy of, 490 Enlus, renal __- 454 symptoms : INDEX. 719 Cancrum oris, etiology of, 99 age most common at, 99 treatment of, 99 nourishment ir.. : of nursing-bottles and nipples, Carpo-pedal contractions, 536 Casts in urine in scarlatina, 1 " 5 Cataract, zonular, 645 Catarrhal spa-m, 303 stomatitis, 90 Causal factors of entero-colitis, 68 Cause of diphtheria, 210 Causes, exciting, of chorea. 572 Causes of acute bronchitis, 3 : 7 acute diarrhoea, 61 acute laryngitis ] z :.:::- ur:::i;:;.. z 5 1 :.~:::r = . _li v . j.z~ atrophy, 46 zr::".:r.ie::-..=:5. }}~ cancrum oris, 99 ch. bronchitis. *ch. diarrhcea, 77 ch. laryngitis, 320 ch. pneumonia. ] cirrhosis of liver, 436 coli: constipati:: - coryza, 299 cretinism. 5 5 2 diseases of spleen, 429 ±r." :i:ct ::.--: : :" sjleen. 429 enuresis. 4.5 : epilepsy, 541 facial paralysis. 5 : 5 flatulence, 50 furunculi, 686 :;;.:;:; :".:.= ir.itr. I r; heart disease. 598 r.fzv.z'.zz':^. ': - 1 hydrocephalus, 477 :r.:"-.n::".= : : n—-.s: : -s. 5 }' infantile palsy, 497 internal squint. 5 : " intussusception. [44 laryngismus stridulus, 306 — ■:;. = Its. ::.i Causes of mucous disease, 1 1 B nocturnal incontinence of urine, z ;:.•. r. :>. -il S pie pneumonia, J43 retro-pharyngeal abscess, 1 1 1 simple meningitis, 4 5 " simple wasting, 46 stomatitis, 88 stomatitis, catarrhal, 90 stomatitis, ulcerative, 92 v -:':.. z-z erit: r.::i-. 12 : ulcer of stomach vomiting, 126 Cerebral disease, cry of, htrv. irrhrut. _:. : zz.tz\zz.:z.:z. 5.14 sinuses, thrombosis of, 494 Ctrvi :i. :7:~:z.:::r.:r. 52S Cheesy glands after whooping-cough, 264, 265 Chest, 20 examination of. 2 2 in whooping-cough, 258 Czz'.tzi :t.:lzvizlz. z 5. 72. anatomical lesions of, "_ etiology o£ 74 symptoms of, 74 diagnosis of, 75 prognosis of, 75 treatment of, 75 :h.:rri. 557 symptoms of, 5 5 " definition of, 560 history of, 562 duration of, 562 pathology of, 565 tZ.lzy '-'-• ;~ > a;cr :: ~:=: frezuen: :::urren;e, exciting causes of, 572 prognosis of, 574 magna, 5 5 Chrcnic Bright's disease, 449 ringworm, 697 :::::::.::/. : :". f 17 Cirrhosis of liver, 435 :iu ; t5 : :". _l_: ; symptoms of, 436 morbid anatomy of. _ Cleft palate, 104 Cold (see Coryza). 720 INDEX. Colds during dentition, 29 Colic, 50 symptoms of, 50 causes o£ 50 treatment of, 51 flatulent treatment of, 52 Collapse of lung, 354 Coma in scarlatina, 177 Complexions, 20 Complications of diphtheria, 217 measles, 161 mumps, 251 rickets, 646 scarlatina, 177 whooping-cough, 263 Condensed milk, 36, 45 Congenital disease of heart, 610 xanthelasma, 694 Constipation, 54 causes of, 54 treatment of, 54 prescriptions for, 55 diet for, 55. symptoms of in childhood, 57 necessity of regular habits for re- lief of, 57 ' associated with sickness, 59 obstinate, 59 in typhoid fever, 289 Contagion of scarlatina, 189 Contagious nature of diphtheria, 210 whooping-cough, 267 Contagiousness of rotheln, 205 thrush, 95 Convulsions during chronic diarrhoea, 79 . dentition, 29 from worms, 138 entero-colitis, 70 infantile, 536 in scarlatina, 173, 177 treatment of, 199 in scarlatinal nephritis, 182 in whooping-cough, 263 Coryza, 298 symptoms of, 298 causes of, 299 chronic, 299 treatment of, 30, 300 Cotton jacket, 27 Cough in laryngismus stridulus, 310 pneumonia, 344 Course of intussusception, 150 Course of vaccine sore, 245 Cowling's rule for dosage, 25 Cows' milk, 34, 37 prepared to resemble human milk, 49 Craniotabes, 640 Cretinism, 551 causes of, 552 morbid anatomy of, 553 diagnosis of, 553 prognosis of, 554 treatment of, 554 Crisis in pneumonia, 345 Croup in measles, 161 • Crust of vaccine sore, 246 Crying, 34 Cry in chronic diarrhoea, 78 kinds of, 18 of atrophy, 47 Cyanosis, 620 Cynanche parotidea, 112 a sequel, 1 12 common termination of, 112 Cystitis, 445 treatment of, 445 D. Deglutition, 24 Dental symptoms of rickets, 646 Dentition, 28 time of appearance of milk-teeth, 28 occurrence of diarrhoea in, 29 of vomiting in, 29 convulsions during, 29 bronchitis during, 29 pneumonia during, 29 .colds during, 29 occurrence of indigestion during, 30 of strophulus during, 30 coryza during, 30 fever during, 30 second, 31 fever. (See Gastric Disorder.) Description of diarrhoea, 60 Desquamation in rotheln, 206 in scarlatina, 175 Desquamative stage of measles, 160 Diagnosis, differential, of causes of vomiting, 129, 132 of measles and scarlatina, 191 INDEX. 721 Diagnosis of acute diarrhoea, 65 from acute enteritis, 65 from intussusception, 65 acute tuberculosis, 396 anaemia, 631 ascites, 427 atelectasis, 359 atrophy, 47 bronchitis, 329 bronchial phthisis, 408 cholera infantum, 75 chronic diarrhoea, 82 cretinism, 553 diphtheria from croup, 224 from scarlatina, 226 from tonsillitis, 227 dysuria, 444 encephalic tumors, 487 enlargement of spleen, 431 entero-colitis, 70 epilepsy, 542 external hydrocephalus, 484 haemophilia, 627 headache, 547, 548 hemorrhage into substance of brain, 493 hydrocephalus, 479 idiocy, 553 infantile palsy, 506 from hemorrhage into cord, 508 from paraplegia from com- pression, 507 from pseudo-hypertrophic paralysis, 508 from rachitic paralysis, 507 intussusception, 149 laryngitis, acute, 315 chronic, 320 malarial fever, 292 measles, 166 mucous disease, 120 mumps, 253 pemphigus, - 690 peritoneal abscess, 427 peritonitis, 419 phthisis, 368 from empyema, 368 pleurisy, 382 pneumonia, 348 from acute consolidation, 349 from acute tuberculosis, 349 from atelectasis, 349 Diagnosis of pneumonia from menin- gitis, 349 from pleurisy, 349 progressive muscular atrophy, 523 pseudo croup, 304 pseudo-hypertrophic paralysis, 522 rheumatism, 588 rickets, 651 rotheln, 207 scabies, 700 scarlatina, 194 from measles, 194 scurvy, 630 simple meningitis, 460 simple wasting, 47 syphilis, 672 syphilitic hepatitis, 438 tabes mesenterica, 414 tinea, 695 tonsillitis from diphtheria, 106 from scarlatinal sore throat, 106 tubercular meningitis, 471 from simple meningitis, 471 from typhoid fever, 472 tuberculosis from mucous disease, 120 typhlo-peritonitis, 424 typhoid fever, 285 from meningitis, 286 from ulcerative endocarditis, 287 from tuberculosis, 286 varicella, 243 from pemphigus, 244 from variola, 243 vesical calculus, 454 whooping-cough, 270 from enlarged bronchial glands, 270 worms, 137 retrospective, of scarlatinal ne- phritis, 183 Diarrhoea, 60 description of, 60 a symptom of disordered function, 60 of long standing, 61 summer, 61 acute, 61 causes of, 61 symptoms of, 63 22 INDEX. Diarrhoea, acute evacuations in, 63 morbid anatomy of, 64 diagnosis of, 65 from acute enti from intussusception, 65 ::, 65 treatment of, 65 chronic. - dus beginning of, 76 ises :". "" 5ympf Mas ;f. "* intercurrent dis e a is e - symptoms of, in older chil- dren, 79 lienteric ( diarrhee ner ease 80 symptoms of, 80 morbid anatomy of, 8 1 diagr prog: a complication of measles, 162 during dentition, : in scarlatina, 1 " " Diet, 32 .:ency of fee interval between me: cows infant foe condensed milk, y: quantity of milk required, 36 goats' mi. whe; - peptonized milk artificial human mil strij wet-nurse, :- human milk, proper, ies :. S boiled flour, 39 meal- _: likes and lisfikes be food, 42 faulty : : : etite, _: points as to administration of food, 43 care of nursing-bottles and nip- ple?. 44 _5 - - - for cbioni for constipatior.. 55 fbrmncons lisease, 120 for thrush, 96 Diet, for typhoid fever, 288 Z :::ion of heart in scarlatina, 192 simple of heart, 603 Diphtheria, 210 age of occurrence, 210 r 2IO ccr. ss of, 210 relation to othc :io n to crouT : : : incubation of, 211 eruptive stage of, 211 2 : : membrane of, 211 albuminuria in, 211 ::.:r.T.^::'.. 212 -Dtoms of, 2:2 throat in. 212 urine in. 2 : j paralysis of soft palate afte modifications c f causes of death in, 2 : 5 blood poisoning in, 2 : 5 : 1 5 asthenia ii suffocation in, 216 laryngeal, 216 symptoms : : _ complications and sequelae of, 217 albuminuria in . 2 : ~ morbid an patholog diagnosis from croup from scarlatina, 226 endocarcti: 22 heart-clot in, 226 gnosis from tonsil 227 treatment of, 227 local treatment of, 2 : internal treatment of. tracheotomy in, treatment of paralysis of, 237 afte: in scarlatina, 1 ~ - Diphtheritic paralysis, 218 Directions for - ' 5 hi:: - :_ Z isease of mediastinal glands after measles, 163 the genito-urinary org 441 INDEX. • 723 ses of the liver. 4 lymphatic glands, nervous system, 455 677 remarks upon, 677 Disinfection after scarlatina, 202 Disorders of movement, 496 Dosag. Dropsy of scarlatina, 1 7 3 treatment of, 198 without albuminuria in scarlatinal nephritis, 183 Dura arachnoid, inflammation of, 455 n of chore*. 562 intussusception, 150 mumps, 250 typhoid fever, 2 ; j whooping-cough, 261. 268 Dysentery, 87 yms of, 87 toms of, 87 treatment of, 87 Dyspepsia, acute. See Gastric Dis- order.) -v.ria, \<\<\ , j j t diagnosis of, 4__ treatment of, 444 E. ifTections in measles, 161 m :. . 685 during chronic diarrhoea, 79 Eczema, 682 description of, 682 time of most frequent occurrence, 682 treatment. during chronic diarrhoea. 7; Ejecta, 24 Empyema. 575 after scarlatina, 186 prognosis of, 35^ treatment of, 3 Encephalic tumor-, i B 5 symptoms or", 485 optic neuritis in, morbid anatomy of, 486 diagnosis of, 487 prognosis of, 4SS treatment of, 488 Endocarditis after scarlatina, 186 acute, 602 in diphtheria, 226 in scarlatina, 177 Enema for cholera infantum. ~ for constipation for entero-colit i Enemata for thread worms, 140 in chronic diarrhoea, 86 method of giving. Enlargement of spleen, 429 ises of, 429 morbid anatomy of, 430 mptoms of, 430 diagnosis ::. .131 prognc sis ::, 431 treatment of, 432 Enteritis, acute diagnc = i~ from acute diarrhoea. 65 Entero-colit: s, 6 S age at which, most frequent. 68 class most common in, 68 anatomical lesions of, 68 etiology of, 68 symptoms of, 69 vomiting in, 69 stools in, 69 tongue of, 69 temperature in, 69 wrahting in. 70 fontanelle in. 73 skin in. ": convulsions in. 70 diagnosis of, 73 prognosis of, 70 treatment of, 70 prescriptions for, 73 Enuresis. 4.51 Epidemic nature of rotheln, 205 of scarlatina, 173 : : v. hooping-cough, 266 roseola. -'See Rotheln. Epilepsy . :_: oe of occurrence, 541 causes of. 541 symptoms of, 541 diagnosis of, 542 prognosis of, 5^2 treatment of, 542 Epiphysial lesions in rickets, 642 502 treatment of, 302 in whooping-cough, 263 724 INDEX. Equino varus, 506 Eruption of rotheln, 205 scarlatina, appearance of, 173 time of appearance of, 173 Eruptive stage of diphtheria, 211 of measles, 15S of scarlatina, 173 Erythema, 691 Erythematous rash in thrush, , 95 Essential paralysis. 496 Etiology- of cancrum oris, 99 cholera infantum, 74 chorea, 568 enterocolitis, 6S measles, 164 mumps, 252 rickets, 633 scarlatina, iSS whooping-cough, 266 Examination of abdomen, 22 of chest, 22 of child, 21 Exanthems occurring in scarlatina, 177 Exhaustion, cry of, iS External hydrocephalus, 4S3 symptoms of, 4S4 diagnosis of, 484 treatment of, 4S4 Eyes, appearance of, in whooping- cough, 25S F. Face, 19 id cholera infantum, 75 in chronic diarrhoea, 7S Facial paralysis, >,2^ causes of, 52^ Fauces, inflammation of, in scarlatina, 177 ulceration of, in scarlatina, 177 Fecal distension, 421 symptoms of, 422 Fever, gastric, 2S0 malarial, 291 scarlet. 1 See Scarlatina.) treatment of, 30 typhoid. 279 First dentition, 2$ Fissure of anus, cause of constipation, 54, 59 Flatulence, 50, ^2 of emptiness, 52 treatment of, 52 Flatulence from indigestible food, 52 Flatulent colic, treatment of, *> 2 Flavus, 699 treatment of, 700 Flour, boiled, 39 Foetal rickets. 661 Food in diphtheria, 231 infants, 35 points as to administration of, 43 likes and dislikes to, 42 Fontanelle, 19 in entero-colitis, 70 Foreign bodies in trachea, ^2^ treatment of, 324 Formulae, 703 Frequency of feeding, 32 Functional disease of liver, 43S treatment of. 439 nervous disorders. 545 Fundus oculi in tubercular meningitis, 470 Furunculi, 6S5 causes of. 6S6 treatment of, 6S6 Gangrene in chronic diarrhoea, 79 Gangrenous stomatitis. | See Cancrum Or: Gastralgia. (See Gastric Disorder.) Gastric disorder, 114 synonyms of, 1 14 symptoms of, 114 causes of, 115 treatment of, 1 16 Gastric fever. 2S3 is infective, 2S0 Gastro-malacia, 134 German measles. (See Rotheln.) Glands, lymphatic, in scarlatina, 174 Glandular abscesses after scarlatina, 1S6 affections in measles. 161 symptoms of rickets, 645 Glottis, direct spasm of, 305 Goats' milk, 37 H. Haemato-myelia, 50S Haematuria, 441 INDEX. 725 Hematuria, causes of, 441 treatment of, 443 Haemophilia, 626 symptoms of, 626 pathology of, 627 diagnosis of, 627 prognosis of, 627 treatment of, 627 Haemoptysis in whooping cough, 263 Harelip, 104 Headache, 547 causes of, 547 diagnosis of, 547, 548 symptoms of, 548 treatment of, 549 Head, hydrocephalic, 18, 475 rickety, 18 syphilitic, 18 Heart burn, 56 Heart clot in diphtheria, 226 Heart dilatation 'of in scarlatina, 192 Heart disease, 595 variation of normal heart signs, 595 causes of, 598 nature of valvular disease, 599 acute pericarditis, 602 endo-carditis, 602 simple dilatation, 603 symptoms of, 604 prognosis of, 605 treatment of, 606 paracentesis of pericardium, 609 symptoms in scarlatinal nephritis, i8r Hemiatrophia facialis, 526 Hemiplegia, 511 causes of, 511 morbid anatomy of, 513 symptoms of, 515 prognosis of, 515 treatment of, 516 after scarlatina, 193 Hemorrhage cerebral, 491 into substance of brain, 492 symptoms of, 492 diagnosis of, 493 prognosis of, 493 treatment of, 493 meningeal, 491 symptoms, 492 prognosis, 492 Hepatic enlargement in syphilis, 637 Hereditary syphilis. (See Syphilis) Herpes, 687 iris, 688 zoster, 687 treatment of, 688 Histology of tubucular meningitis, 466 History of chorea, 562 Human milk, artificial, 2>7 Hunger, cry of, 18 Hydrocephalic head, 18 Hydrocephalus, 474 acute, 464 spurious, 474 definition of, 475 shape of head in, 475 bones of skull in, 476 . morbid anatomy of, 476 causes of, 477 symptoms of, 478 diagnosis of, 479 prognosis of, 481 treatment of, 482 tapping in, 4*83 Hygiene in chronic diarrhoea, 85 Hyperaesthesia, 471 Hypertrophy of brain, 490 of pharyngeal mucous membrane, no condition of parts in, no symptoms of, no treatment of, no of tongue, 104 of tonsils, 108 symptoms of, 108 . treatment of, 109 Icterus neonatorum, 433 causes of, 433 treatment of, 434 Idiocy, 550 causes, 550 Impetigo, 684 contagiosa, 685 treatment of, 685 during chronic diarrhoea, 79 Incubation of diphtheria, 211 of measles, 157 of mumps, 249 of rotheln, 205 of scarlatina, 173 726 INDEX. Incubation of typhoid fever, 288 of varicella, 240 of whooping-cough, 255 Indigestion chronic, 120 during dentition, 30 Infant foods, 35 Infantile convulsions, 536 causes of, 537 symptoms of, 537 diagnosis of, 538 results of, 539 prognosis of, 539 treatment of, 540 palsy, 49 6 time of occurrence, 497 causes of, 497 symptoms of, 497 characteristic features of, 499 morbid anatomy of, 500 pathology of, 500 diagnosis of, 506 prognosis of, 509 treatment of, 509 paralysis, 496 remittent fever, 280 spasm, 307 history of, 307 syphilis. (See Syphilis) Infectious nature of scarlatina, 188 Infective gastritis, 280 Inflammation of all the coats of caecum and appendix, 422 symptoms of, 422 of caecal mucous membrane, 422 symptoms of, 422 of the dura arachnoid, 455 Inflammations after scarlatina, 186 Inspiratory crow, 260 Intra-cranial tumors, 485 Inter-current disease during chronic diarrhoea, 79 Internal strabismus, 526 causes of, 527 Intertrigo during entero-colitis, 73 Interval between meals, 7,^ Introduction, 13 Intussusception, 143 description of, 143 location of most frequent occur- rence, 143 pathology of, 143 age of most frequent occurrence, H3 Intussusception, frequency of, 143 cause of, 144 morbid anatomy of, 145 symptoms of, 147 with strangulation, 148 without strangulation, 148 diagnosis of, 149 course of, 150 duration of, 150 prognosis of, 150 treatment of, 151 table of cases operated on, 154 diagnosis of, from acute diarrhoea, 65 Irregularity of pupils in worms, 138 J. Jadelot's lines, 19, 70 Jaundice, catarrhal, 434 simple, 433 Journey, preservation of milk for, 45 K. Keloid, 693 Kidney, sarcoma of, 449 scrofulous, 446 Kidneys in scarlatina, 191 Labial discharges, 454 treatment of, 454 line, 20 Laparotomy for intussusception, 154 Laryngeal diphtheria, 217 Laryngismus stridulus, 305 causes of, 306 nature of, 306 time of year most frequent, 306 symptoms, 309, 314 wheezing, 310 cough in, 310 prognosis of, 310 treatment of, 311 Laryngitis, 312 synonyms, 312 acute simple, 312 causes of, 312 INDEX. 727 Laryngitis, acute simple, age at of most frequent occurrence, 313 symptoms of, 314 diagnosis of, 315 prognosis of, 315 treatment of, 316 acute membranous, 317 chronic, 318 origin of, 318 diagnosis of, 320 causes of, 320 prognosis of, 321 treatment of, 321 cry of, 18 in syphilis, 666 Late rickets. (See Rickets.) Lepto-meningitis, 457 Lesions, anatomical, of cholera in- fantum, 74 of entero-colitis, 68 of ulcerative stomatitis, 92 Leucocythaemia, 405 Lichen urticatus, 678 description of, 678 treatment of, 680 during dentition, 30 Lienteric diarrhoea, 80 treatment of, 84 Likes and dislikes to foods, 42 Line, labial, 20 nasal, 19 oculo-zygomatic, 19 Lines of Jadelot, 19, 70 Lithsemia, 439 treatment of, 440 Long-standing diarrhoea, 61 Lung, abscess of, during cancrum oris, 9 8 Lymphatic glands in scarlatina, 174 M. Malarial fever, 291 characters of, 291 anaemia of, 291 spleen in, 292 symptoms of, 292 stages of, 292 diagnosis of, 292 prognosis of, 292 treatment of, 292 Malformation of anus cause of consti- pation, 54 of heart, 610 symptoms of, 616 prognosis of, 619 treatment of, 620 Massage in hypertrophied tonsils, no Masturbation, 139 Meals, 40 Measles, 157 synonyms of, 157 incubation of, 157 prodromal stage of, 158 cough in, 158 eruption on soft palate in, 158 eruptive stage of, 158 character of eruption of, 158 desquamation in, 160 bronchial trouble in, 160 modification in, 160 complications of, 161 sequelae of, 161 etiology of, 164 isolation in, 164 morbid anatomy of, 165 diagnosis of, 166 from scarlatina, 166 German, 167 treatment of, 167 ear affections in, 170 bastard. (See Rotheln.) Mediastinal glands, disease of follow- ing measles, 163 Melaena, 123 neonatorum, 125 Membrane of diphtheria, 21 1 Membranous laryngitis, 317 in measles, 161, 162 Meningeal hemorrhage, 491 symptoms of, 492 prognosis of, 492 treatment of, 493 Meningitis following scarlatina, 186 simple, 457 causes of, 457 symptoms of, 458 diagnosis of, 460 prognosis of, 461 treatment of, 462 tubercular, 464 synonyms of, 464 description of, 465 histology of, 466 728 INDEX. Meningitis, tubercular, symptoms of, 467- fundus oculi in, 470 temperature in, 470 diagnosis of, 471 prognosis of, 472 treatment of, 473 Micrococci in blood of measles, 165, 166 of scarlatina, 190 Milk. (See Diet of Children in Health.) condensed, 36, 45 of asses, 37 of cow, 34, 37 prepared to resemble human- milk, 49' methods of preparing, 34 of goats, 37 human, artificial, 37 properties of, 38 peptonized, 37 . preservation of, for journey, 45 quantity taken, 36 Milk teeth, time of appearance, 28 Modifications of measles, 160 of scarlatina, 175 Molluscum contagiosum, 694 Morbid anatomy of acute diarrhoea, 64 of cancrum oris, 98 of chronic diarrhoea, 81 of cretinism, 553 of encephalic tumor, 486 of hemiplegia, 513 of hydrocephalus, 476 of infantile palsy, 500 of late rickets, 658 of measles, 165 of pseudo-hypertrophic pa- ralysis, 517 of rickets, 647 of syphilis, 670 Morbilli, 157 Mortality during dentition, 29 iri whooping-cough, 261 Mouth, syphilitic ulceration of, 102 ulceration of, 102 Mucous disease, 118 symptoms of, 119 causes of, 118 course of, 119 diagnosis of, 120 treatment of, 120 Mucous disease, diet for, 120" after whooping-cough, 266 Mumps, 112, 249 incubation of, 249 symptoms of, 250 swelling in, 250 duration of, 250 complications in, 25 1 metastasis in, 251 orchitis in, 251 meningitis in, 252 sequelae of, 252 etiology of, 252 morbid anatomy of, 252 diagnosis of, 253 treatment of, 253 Muscular atrophy, progressive, 523 symptoms of rickets, 645 N. Nasal line, 19 Natiform skull, 19 Nature of valvular diseases, 599 Nephritis, acute, 448 Nephritis, scarlatinal, 179 anasarca in, 182 ascites in, 182 convulsions in, 182 heart symptoms of, 181 oedema of lungs in, 182 retrospective diagnosis of, 183 symptoms of, 181 treatment of, 198 unfavorable symptoms in, 182 urine in, 181 Nervousness, 586 Nervous symptoms of rickets, 645 system, diseases of, 455 in typhoid fever, 282 Neuroses, abdominal, 117 New growths of kidney, 449 treatment of, 450 Nightmare, 543 Night terror, 543 treatment of, 544 Nocturnal incontinence of urine, 451 causes of, 451 treatment of, 452 Nodding spasm, 523 INDEX. 729 Noma. (See Cancrum Oris.) pudendorum, 454 Nose, 298 Nursing bottles and nipples, care of, 44 gmus, 527 O. Obstinate constipation, 59 Oculo-zygomatic line, 19 CEdema of lungs in scarlatinal nephri- tis, 182 CEsophagus, 113 affections of, 113 Oidium albicans, 93 Oily matter in stools, 125 Opisthotonos, cervical. 52S Opium, susceptibility of children to, Ophthalmia following measles. 170 Optic neuritis in cerebral tumor, 4S6 Orchitis during mumps. 251 symptoms of, 252 Otitis in scarlatina, 1S7 in typhoid fever. 2S4 Otorrhoea after scarlatina, treatment of, 201 Oxyuris vermicularis 135 Ozaena, 299 treatment of. ;oo Pain in pleurisy, 375 in pneumonia, 344 Palsy infantile. 496 Paracentesis of pericardium, 609 Paralysis, diphtheritic, 213, 21S essential, 496 facial. ^2^ infantile, 496 pseudo-hypertrophic, 517 spastic, 529 Parotitis. (See Mumps.) in typhoid fever, 2>4 Paroxysm of whooping-cough. 25 S Pathology of acute tuberculosis, 393 of chorea, 565 of diphtheria, 219, 221 of haemophilia, 627 of infantile palsy, 500 Pathology of intussusception, 143 of purpura, 625 of rickets, 650 of whooping-cough, 266 Pediculi, 701 Pemphigus, 6SS diagnosis of, 690 prognosis of, 690 treatment of, 690 Peptonized milk, 37 Perforative ulceration of caecum and appendix, 423 Pericarditis, acute, 602 Peritoneal abscess, 425 diagnosis of, 425 treatment of, 426 Peritonitis, 41 S causes of, 41 S symptoms of, 419 diagnosis of, 419 prognosis of, 420 treatment of, 420 tubercular, 410 Perityphlitis. (See Typhlo-perito- xitis.) Pertussis. See Whooping Cough.) a sequel of measles, 162 Pharyngeal diphtheria, 212 Phthisis, 361 description of, 361 chest of subjects of, 362 symptoms of, 363 morbid anatomy of, 364 complications of. 3 : 8 diagnosis of, 36S prognosis of, 369 treatment of, 370 Physical examination of chest, 295 signs of pleurisy. 377 of pneumonia, 345 Pitting in varicella, 243 Pleurisy, 373 causes of, 374 symptoms of. 375 physical signs of. 377 morbid anatomy of, 381 complications of, 3S1 diagnosis of. ; s 2 prognosis of, 3S4 treatment of, 3S4 during chronic diarrhoea, 79 in whooping-cough, 264 Pneumonia, 337 I 730 INDEX. Pneumonia, kinds of, 357 part of lung most frequently af- fected. 338 sex oftenest affected, 339 age most affected, 339 morbid anatomy of, 340 causes of, 343 symptoms of, 344 duration o\\ 344 pain in, 344 cough in, 344 cerebral, 314 respiration in, 345 crisis in, 345 urine in, 345 physical signs in, 345 complications of, 34S diagnosis of, 34S prognosis of, 349 results of. treatment of, 350 chronic, 351 causes of, 351 during dentition, 29 Points in administration of food, 43 Polypus of rectum, S2 rectal, 124 Polyuria, 444 Post-hemiplegic chorea, 515 Potassii bromidum, susceptibility to, 25 Poultices, 27 Prescriptions for constipation, 55 for entero-colitis, 73 Preventive treatment of scarlatina, 201 Prodromal stage of measles, 15S of scarlatina, 173 Prognosis of acute bronchitis, 330 of acute diarrhoea, 65 of acute laryngitis, 315 of acute tuberculosis, 396 of anaemia, 631 of atelectasis, 359 of bronchial phthisis, 409 of bronchiectasis, 336 of cholera infantum, 75 of chorea, 574 of ch. bronchitis. 333 of ch. diarrhoea, 82 of ch. laryngitis, 321 of cretinism, 5^4 of empyema, 3S4 of encephalic tumor, 488 Prognosis of enlargement of spleen, 431 of entero-colitis, 70 of epilepsy. 542 of haemophilia, 627 of heart disease, of hemiplegia, 515 of hemorrhage into substance of brain, 493 of hydrocephalus, 4S1 of infantile convulsions, 539 of infantile palsy, 509 of intussusception, 150 of laryngismus stridulus, 310 of late rickets, 661 of malarial fever, of malformation of heart, 619 of meningeal hemorrhage, 492 of pemphigus, 690 of peritonitis, 420 of phthisis, of pleurisy. 384 of pneumonia, 349 of pseudo-hypertrophic paralysis, 522 of retro-pharyngeal abscess, 1 12 of rickets, 652 of scarlatina, 195 of scurvy, 630 of simple meningitis, 461 of spa-tic paralysis, 535 of syphilis, 073 of syphilitic hepatitis, 43S of tabes mesenterica, 415 of tinea, 695 of typhlo-peritonitis, 424 of tubercular meningitis, 4 of whooping-cough, 27 1 Progressive muscular atrophy, ?2$ diagnosis of, 525 treatment of, 525 Prolapse of rectum. Si Prolapsus ani, treatment of, S3 Pruritus ani. 138 Pseudo-croup, 303 diagnosis of, 304 treatment of, 304 Pseudo-hypertrophic paralysis, 517 morbid anatomy of, 517 features o(, 51S diagnosis o(, ^22 prognosis of, 522 Psoriasis, 691 INDEX. 731 Psoriasis, treatment of, 691 Pulmonary tuberculosis. (See Phth- isis). Pulse, 23 in atrophy, 47 of scarlatina, 174 Purpura, 623 pathology of, 625 treatment of, 625 Pyrexia, treatment of, 30 Quantity of milk taken by a child, 36 Quarantine in scarlatina, 189 R. Rachitic skull, 480 Rash of scarlatina, appearance of, 173 rose, 167 Rectal polypus, 124 prolapse in entero-colitis, 69 Rectum, polypus of, 82 prolapse of, 81 Recurrence of scarlatina, 179 Red-gum. (See Lichen Urticatus.) Reflex spasm, 308 vomiting, 132 Regular habits for relief of constipa- . tion, 57 Relapse in scarlatina, 179 Relaxed throat, no Remittent, infantile, 280 Renal calculus, 447 treatment of, 448 tumors, 449 Respiration, 23, 294 in pneumonia, 345 Respiratory system, diseases of, 294 asymetrical breathing, 294 Cheyne-Stokes breathing, 294 physical examination of chest, 295 percussion, 295 respiratory murmur, 297 Retraction of abdomen, 471 Retropharyngeal abscess, in cause of, 1 1 1 age at which most frequent, ill symptoms of, in Retro-pharyngeal abscess, prognosis of, 112 treatment of, 112 Retrospective diagnosis of scarlatinal nephritis, 183 Rheumatism, 578 description of, 578 symptoms of, 583 diagnosis of, 588 causes of death in, 590 treatment of, 590 scarlatinal, 177, 187 treatment of, 200 Rickets, 633 etiology of, 633 symptoms of, 637 head in, 637 craniotabes in, 640 epiphysial lesions in, 642 muscular symptoms of, 645 nervous symptoms of, 645 zonular cataract in, 645 glandular symptoms of, 645 dental symptoms of, 646 complications of, 646 morbid anatomy of, 647 pathology of, 650 diagnosis of, 651 prognosis of, 652 treatment of, 653 late, 657 symptoms of, 657 morbid anatomy of, 658 prognosis of, 661 treatment of, 661 foetal, 661 characteristics of, 662 Rickety head, 18, 637 Ringworm, chronic, 697 Roseola. (See R6thkln.) diagnosis of, from scarlatina, 195 Rose rash, 167 spots in typhoid fever, 282 Rotheln, 203 synonyms of, 203 description of, 263 epidemic nature of, 204 age at which most common, 205 contagiousness of, 205 quarantine in, 205 definition of, 205 incubation of, 205 eruptive stage of, 205 732 INDEX. Rotheln, symptoms of, 206 desquamation in, 206 diagnosis of, 207 treatment of, 207 diagnosis of, from scarlatina, 194 Rougeole anomale, 161 Roundworm, 135 Routine for choreic cases, 716 Rubella. (See Rotheln.) Scabies, 700 diagnosis of, 700 treatment of, 701 Scaphoid skull, 19 Scarlatina, 172 description of, 172 age at which most frequent, 172 epidemic nature of, 173 incubation of, 173 prodromal stage of, 173 vomiting in, 173 convulsions in, 173 sore-throat in, 173 eruptive stage, 173 rash of, 173 punctated character of, 173 pulse of, 174 sore-throat in, 174 tonsils in, 174 lymphatic glands in, 174 albuminuria in, 174 ■ casts in urine in, 174 temperature in, 175 desquamation of, 175 modifications of, 175 complications of, 177 ulceration of fauces in, 177 inflammation of fauces in, 177 convulsions in, 177 coma in, 177 diarrhoea in, 177 rheumatism in, 177 heart affections in, 177 with exanthems, 177 surgical, 178 relapses in, 178 recurrence of, 178 sequelae of, 179, 188 nephritis, 179 albuminuria, 179 Scarlatina, sequelae of, dropsy, 179 time of appearance of, 179 frequency of, 180 duration of, 180 nephritis of, symptoms of, 1 81 heart symptoms of, 181 urine in, 181 unfavorable symptoms in, 182 convulsions in, 182 oedema of lungs in, 182 anasarca in, 182 ascites in, 182 retrospective diagnosis, 183 dropsy without albuminuria, .183 microscopic examination of urine in, 184 serous inflammations after, 186 empyema after, 186 endocarditis after, 186 meningitis after, 186 glandular abscess after, 186 sloughing of skin after, 186 diphtheria after, 187 otitis after, 187 rheumatism following, 187 synovitis after, 187 etiology of, 188 infectious nature of, 188 contagion of, 189 • quarantine in, 189 morbid anatomy of, 190 micrococci in blood of, 190 kidneys in, 191 dilatation of heart in, 192 hemiplegia after, 193 diagnosis of, 194 from measles, 194 from rotheln, 194 from tonsillitis, 195 from roseola, £95 prognosis of, 195 treatment of, 195 of dropsy in, 198 of convulsions in, 199 Basham's Mixture in, 200 of rheumatism in, 200 of otorrhoea in, 201 preventive of, 201 disinfection after, 202 Scarlatinal albuminuria, 179 INDEX. 733 Scarlatinal dropsy, 179 nephritis, 179 rheumatism, 187 synovitis, 187 Scar of vaccina, 246 Sclerema neonatorum, 692 Sclerosis of brain, 490 Scrofula, 403 Scrofulous habit, description of, 398 kidney, 446 treatment of, 446 Scurvy, 628 diagnosis of, 630 prognosis of, 630 treatment of, 631 Seat worms, 135 Seborrhcea, 693 treatment of, 693 Second dentition, 31 Selection of wet-nurse, ^ Sequelae of diphtheria, 217 of measles, 161 of mumps, 252 of scarlatina, 179 of syphilis, 671 of varicella, 244 of whooping-cough, 264 Serous inflammation after scarlatina, 186 Sickness accompanied by constipa- tion, 59 Simple anasarca, 183 dilatation of heart, 603 wasting. (See Atrophy.) Sniffles, 298 Skin in cholera infantum, 75 in ch. diarrhoea, 78 in entero-colitis, 70 Skoda's tympanitic resonance, 347, 379 Skull, natiform, 19 scaphoid, 19 Sleep, 24 Sloughing of skin after scarlatina, 186 Softening of stomach, 134 Sore-throat a prodrome of scarlatina, 173 of scarlatina, 174 Sore of vaccine disease, 245 Spasm of glottis, 305 Spastic paralysis, 529 symptoms of, 530 cases of, 530 Spastic paralysis, prognosis of, 535 treatment of, 535 Spleen in malarial fever, 291 Splenic enlargement, 429 in syphilis, 667 in typhoid fever, 283 Sponging, 27 in typhoid fever, 289 Spurious hydrocephalus, 474 symptoms of, 475 treatment of, 475 Stomach, softening of, 134 tubercular ulceration of, 133 Stomatitis, 88 catarrhal, 90 aphthous, 91 ulcerative, 92 gangrenous. (See Cancrum Oris.) Stools, blood in, 123, 148 in acute diarrhoea, 63, 79 in cholera infantum, 74 in ch. diarrhoea, 78 in dysentery, Sy in entero-colitis, 69 in intussusception, 148 in lienteric diarrhoea, 80 in tubercular ulceration of intes- tines, 80 oily matter in 125 Strawberry tongue, 174 Stoppings, 37 Strophulus. (See Lichen Urticatus.) during dentition, 30 Sudamina in typhoid fever, 282 Suffocation in diphtheria, 216 Summer diarrhoea, 61 Surgical scarlatina, 178 Susceptibility to bromide of potassium, 25 to opium, 25 Symptoms, general, of vaccina, 246 local, of vaccina, 245 of abdominal neuroses, 117 of acute bronchitis, 328 of acute diarrhoea, 63 of acute laryngitis, 314 of acute tonsillitis, 105 of acute tuberculosis, 395 of ascites, 419, 427 of atelectasis, 356 of atrophy, 46 of bronchial phthisis, 407 62 ;34 INDEX. Symptoms of bronchiectasis, 334 of cancrum oris, 97 of cholera infantum, 74 of chorea, 557 of ch, bronchitis, 332 of ch. diarrhoea, 77 of ch. diarrhoea in older children, 79 of ch. tonsillitis, 108 of cirrhosis of liver, 436 of colic, 50 of constipation, 57 of coryza, 298 of diphtheria, 211 of dysentery, 8j of encephalic tumors, 485 of enlargement of spleen, 430 of entero-colitis, 69 of epilepsy, 541 of external hydrocephalus, 484 of fecal distension, 422 of flatulence, 50 of gastric disorder, 1 14 of haemophilia, 626 of headache, 548 of heart disease, 604 of hemiplegia, 515 of hemorrhage into substance of brain, 492 of hereditary syphilis, 663 of hydrocephalus, 478 of hypertrophy of pharyngeal mu- cous membrane, no of infantile convulsions, 537 of infantile palsy, 497 of inflammation of all the coats of caecum and appendix, 422 of inflammation of caecal mucous membrane, 422 of intussusception, 147 of laryngeal diphtheria, 217 of laryngismus stridulus, 309 of late rickets, 657 of malarial fever, 292 of melaena neonatorum, 125 of malformation of heart, 616 of meningeal hemorrhage, 492 of mucous disease, 117 of mumps, 250 of orchitis, 252 of phthisis, 363 of pleurisy, 375 of pneumonia, 344 Symptoms of pseudo-hypertrophic par- alysis, 518 of relaxed throat, no of renal calculus, 447 of retro-pharyngeal abscess, III of rheumatism, 583 of rickets, 637 of rotheln, 206 of simple meningitis, 458 of simple wasting, 46 of sniffles, 298 of splenic enlargement, 430 of spastic paralysis, 530 of spurious hydrocephalus, 475 of stomatitis, 88 of stomatitis, aphthous, 91 catarrhal, 90 ulcerative, 92 of syphilitic hepatitis, 437 of tabes mesenterica, 41 1 of thrombosis of cerebral sinuses, 495 of thrush, graver cases of, 95 without inflammation, 94 of tubercular meningitis, 467 of typhlitis, 422 of typhoid fever, 279 of typhlo-peritonitis, 421 of ulcer of stomach, 133 of varicella, 241 of vomiting in nurslings, 127 of whooping-cough, 257 of worms, 137 unfavorable in scarlatinal nephri- tis, 182 Syncope in diphtheria, 215 Synovitis, scarlatinal, 187 Syphilis, hereditary, 663 time of most frequent occurrence, 663 symptoms of, 663 laryngitis of, 666 hepatic enlargement in, 667 splenic enlargement in, 667 bone disease in, 667 ulceration of tongue in, 670 morbid anatomy of, 670 sequelae of, 671 diagnosis of, 672 prognosis of, 673 treatment of, 673 Syphilis, infantile, 663 Syphilitic head, 18 INDEX. 735 Syphilitic hepatitis, 436 symptoms of, 437 diagnosis of, 438 prognosis of, 438 treatment of, 438 ulceration of mouth, 102 Tache cerebrale, 460, 471 Tabes mesenterica, 410 symptoms of, 411 morbid anatomy of, 413 diagnosis of, 414 prognosis of, 415 treatment of, 415 Taenia mediocanellata, 136 solium, 136 Talipes equinus, 506 Tape worms, 136 Tapping in hydrocephalus, 483 Temperature in bronchitis, 328 in cholera infantum, 75 in chronic diarrhoea, 79 in entero-colitis, 69 in measles, 161 in pleurisy, 375 in pneumonia, 344, 345 in scarlatina, 175 in stomatitis, 89 in tubercular meningitis, 470 in tubercular ulceration of intes- tines, 80 in typhoid fever, 280, 281 Tetany, 536 Throat in diphtheria, 212 Thrombosis of cerebral sinuses, 494 symptoms of, 495 treatment of, 495 Thrush, 93 without inflammation, 94 contagiousness of, 95 graver cases of, 95 treatment of, 96 Time of feeding in whooping-cough, .277 Tinea, 694 diagnosis of, 695 prognosis of, 695 treatment of, 695 preventive treatment of, 698 Tolerance to arsenic, 26 to belladonna, 26 Tongue, hypertrophy of, 104 in cholera infantum, 75 in chronic diarrhoea, 78 in scarlatina, 174 in typhoid fever, 283 in acute diarrhoea, 63 in entero-colitis, 69 strawberry, 174 Tonics in chronic diarrhoea, 8"J Tonsillitis, acute, 105 diagnosis from diphtheria, 106 from scarlatinal sore throat, 106 chronic, 108 treatment of, 109 diagnosis from scarlatina, 195 Tonsils in scarlatina, 174 Torticollis, 529 Trachea, foreign bodies in, 323 Tracheotomy for diphtheria, 231 for foreign bodies in trachea, 324 Treatment, 24 of acute bronchitis, 331 of acute diarrhoea, 65 of acute laryngitis, 316 of acute tuberculosis, 397 of acute urticaria, 681 of alopecia areata, 699 of anaemia, 632 of anuria, 443 of aphthae, 91 of ascites, 427 of atelectasis, 360 of atrophy, 48 of bronchial phthisis, 409 of bronchiectasis, 336 of cancrum oris, 99 of cerebral hemorrhage, 493 of chorea, 575 of ch. bronchitis, 333 of ch. diarrhoea, 8^ of ch. laryngitis, 321 of ch. tonsillitis, 109 of ch. vomiting, 130 of colic, 51 of constipation, 54 of coryza, 300 of cretinism, 554 of cystitis, 445 of diphtheria, 227 of diphtheritic paralysis, 237 736 INDEX. Treatment of dysentery, $7 of dysuria, 444 of eczema. 683 of empyema, 385 of encephalic tumors, 4SS of enlarged spleen, 432 of entero-colitis, 70 of enuresis, 451 of epilepsy, 542 of epistaxis, 302 of external hydrocephalus, 4S4 of flatulence, 51 of flatulent colic, 52 of favus, 700 of foreign bodies in trachea, 324 of functional disease of liver, 439 of furunculi, 6S6 of gastric disorder, 116 of hematuria, 443 of haemophilia, 027 of headaches, 549 of heart disease, 606 of hemiplegia, 516 of herpes, oSS of hydrocephalus, 4S2 of hypertrophy of pharyngeal mucous membrane, no of impetigo contagiosa, 685 of infantile convulsions, 540 of infantile palsy, 509 of intussusception, 1 5 1 of labial discharges, 454 of laryngismus stridulus, 311 of lichen urticatus, 0S0 of lithsemia, 440 of malarial fever, 202 of malformation oi~ heart, 620 of measles, 167 of melsena neonatorum, 125 of mucous disease, 120 of mumps, 253 of new growths in kidney, 450 of nightmare or night terror, 544 of nocturnal incontinence of urine, 451 of otorrhcea in scarlatina, 201 of pediculi, 701 of pemphigus, 690 of peritoneal abscess, 426 of peritonitis, 420 of phthisis, 370 of pleurisy, 384 Treatment of pneumonia, 350 of progressive muscular atrophy, 525 of prolapsus ani, S3 of pseudo-croup, 304 of psoriasis, 691 of purpura, 025 of pyuria. 445 of rectal polypus, 124 of relaxed throat, no of renal calculus, 44S of retro-pharyngeal abscess, 1 12 of rheumatism, 590 of rickets, 053 of roseola, 209 of rotheln, 207 of scabies, 701 of scarlatina, 195 of scarlatinal rheumatism, 200 of scrofula, 403 of scrofulous kidney, 446 of scurvy, 631 of seborrhea. 003 of simple meningitis, 402 of spastic paralysis, 535 of spurious hydrocephalus, 475 of stomatitis, 93 aphthous, 91 catarrhal, 90 ulcerative. 02 of syphilis, 673 oi syphilitic hepatitis, 438 o\ tabes mesenterica, 415 of thrombosis oi cerebral sinuses, 495 of thrash, 94 of tinea, 695 of torticollis, 529 of tubercular meningitis, 473 of typhoid fever, 2SS of typhlo-peritonitis, 424 of ulcer of stomach, 133 of vaginal discharges, 454 of varicella, 245 of vomiting of nurselings, 129 of warty growths of larynx, -^22 of worms, 139 of whooping-cough, 272 preventive of scarlatina, 201 Trycophyton tonsurans, 694 Tubercular appearance, 362 chest, 362 INDEX. 737 Tubercular disease of liver, 432 peritonitis, 410 ulceration of intestines, 80 of stomach, 133 Tuberculosis. (See Phthisis.) acute, 393 after whooping-cough, 265 a sequel of measles, 161 Tumor, intracranial, 485 in intussusception, 148 renal, 449 Typhlitis, 422 Typhoid fever, 279 symptoms of, 279 remittent type, 279 temperature in, 280, 281 nervous symptoms in, 282 rose spots in, 282 bronchitis in, 282 splenic enlargement in, 283 tongue in, 2S3 duration of, 283 morbid anatomy of, 283 diagnosis of, 285 incubation of, 288 treatment of, 288 diet of, 288 Typhlo-peritonitis, 420, 423 causes of, 420 symptoms of, 421, 423 diagnosis of, 424 prognosis of, 424 treatment of, 424 U, Ulceration intestinal, 80 of fraenum linguae, 103, 260, 263 of mouth, 102 syphilitic, 102 treatment of, 103 of tongue in syphilis, 670 of tonsils, 106 tubercular, of intestines, 80 Ulcer of stomach, 132 Urine, absence of chlorides in pneumo- nia, 345 in diphtheria, 213 in scarlatinal nephritis, 181 Urticaria, acute, 681 pigmentosa, 679 V. Vaccina, 245 local symptoms of, 245 course of sore, 245 vesicle of, 246 crust of, 246 scar of, 246 general symptoms of, 246 Vaccination, 246 means of introducing virus, 246 kinds of virus used, 246 scarification, 246 puncture, 247 abrasion, 247 from arm to arm, 247 with crust, 247 with bovine lymph, 247 age most suited to, 248 point best suited for inoculation, 248 Vaginal discharges, 454 treatment of, 454 Varicella, 240 incubation, 240 eruptive stage of, 241 symptoms of, 241 diagnosis of, 243 sequelae of, 244 treatment of, 245 following measles, 163 Vesical calculus, 454 Vomiting, 126 of nurslings, 127 as an acute symptom, 128 differential diagnosis of, 129, 132 of nurselings, treatment of, 129 chronic, 130 of older children, 132 reflex, 132 of brain disease, 132 in acute diarrhoea, 65 in cholera infantum, 74 in dentition, 29 in entero-colitis, 69 in intussusception, 65, 148 in meningitis, 471 in scarlatina, 173 in whooping-cough, 258 738 INDEX. W. Warty growths in larynx, 321, 322 treatment of, 322 Wasting. ( See Atrophy.) in cholera infantum, 75 in chronic diarrhoea, 78 in entero-colitis, 70 Wet-nurse, selection of, 37 Wheezing, 310 Whey, 37 White gum. (See Lichen Lrtica- TUS. I Whooping-cough, 255 incubation of, 255 symptoms of, first stage, 257 duration of first stage, 257 symptoms of second stage, 257 paroxysm, 258 vomiting of, 258 appearance of eyes in, 25S chest in, 258 the whoop of, 259 ulceration of fraenum linguae in, 260 duration of, 261 age at which, most frequent, 261 mortality in, 261 causes of death in, 262 modifications of, 262 complications of, 263 results and sequelae of, 264 etiology of, 266 Whooping-cough, pathology of, 266 epidemic nature of, 266 morbid anatomy of, 26S diagnosis of, 270 prognosis of, 271 treatment of, 272 a complication of measles, 161, 162 Worms, 135 varieties, 135 seat, 135 habitat of, 135 description of, 135 round, 135 description of, 135 habitat of, 136 tape, 136 description of, 136 symptoms of, 137 diagnosis of, 137 a cause of convulsions, 138 treatment of, 139 Wry neck, 529 X. 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