Glass ^P j^S Book_ - O y~(S Copyright N° COPYRIGHT DEPOSIT. DISEASES OF INFANTS AND CHILDREN BY HENEY D WIGHT CHAPIN, A. M.. M. D. M professor of diseases of children, new york post-graduate medical school and hospital; supervising physician of the children's department, new york post-graduate hospital; attending physician at the willard parker and riverside hospitals; consulting physician to the Randall's island hospital and to st. agnes hospital, white plains AND GODFREY ROGER PISEK, M. D. PROFESSOR OF DISEASES OF CHILDREN, UNIVERSITY OF VERMONT - , ADJUNCT PROFESSOR OF DISEASES OF CHILDREN AND ATTENDING PHYSICIAN TO THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL; ATTENDING PHYSICIAN TO THE DARRACH HOME FOR CHILDREN WITH 179 ILLUSTRATIONS AND ELEVEN COLORED PLATES NEW YOEK WILLIAM WOOD AND COMPANY MDCCCCIX ^, Copyright, 1909, By WILLIAM WOOD AND COMPANY © S£ f Id. A I SEP » ^ 1909 246413 8 1909 Printed by The Maple Prea York, Pa. TO THE STUDENTS BOTH GRADUATE AND UNDERGRADUATE IN THE UNITED STATES AND CANADA WHOM IT HAS BEEN OUR PLEASURE TO TEACH THIS BOOK IS DEDICATED. PREFACE. This volume has been written by teachers who feel that a large contact with students has made them fairly familiar with their needs. Probably the first requirement at present is to bring each branch of medicine into as compact a form as is consistent with a thorough presentation of the subject. Our aim has been to accomplish this with pediatrics. To many, the diagnosis and treatment of diseases of infants and children are most perplexing. These difficulties can only be overcome by first sharply differentiating the anatomical and physiological peculiarities of the infant and child, and then consider- ing their practical bearings. The student must be familiarized with all the more recent tests, as well as the older practical bedside experience, in the study of disease. He will then, by a sj^stematic examination of the patient, be able to make a scientific diagnosis. He must also be taught to treat rationally and with a distinct purpose in mind. We have aimed to present the subject in this way, and thus to make the work as practical as possible. The physician needs such a description of disease as he will actually encounter at the bedside. Where pictures can serve as a type, we have used illustrations, most of which are original. Theory and pathology have only been considered in so far as may be necessary to an understanding of the diagnosis, course and treatment of disease. We have tried to take a middle course between the compendium, which is usually unsatisfactory, and a too exhaust- ive work, which, by dwelling overmuch on theory and exceptions, tends to confuse the reader. Our thanks are due to our hospital assistants, Drs. Dennett and Albee, for their help during the progress of the work. While a book of this sort must be indebted to all the workers in pediatrics, whom we have freely consulted, our personal experience at the Infants' and Children's Wards of the New York Post-Graduate Hospital, and in private practice, has formed the essential basis of our description of the diseases and their treatment. Our thanks are due to the publishers for their care and courtesy in the preparation of the book. The Authors. New York, September, 1909. CONTENTS. SECTION I. The Newly-born. CHAPTER I. Page The Management and Care of Premature Infants 1 CHAPTER II. Injuries During Birth. Deformities of Head; Caput Succedaneum; Cephalhematoma; Injuries to Bone and Muscle; Birth Palsies; Facial Paralysis; Upper-arm Paralysis (Duchennes); Central Paralysis; Asphyxia; Congenital Atelectasis; Fetal Death 6 CHAPTER III. Diseases of the Newly-born. Acute Infectious Diseases; Sepsis of the Newly-born; Umbilical Hemor- rhage; Umbilical Vegetations; Umbilical Hernia; Epidemic Hemoglo- binuria (WinckePs Disease) ; Fatty Degeneration of the Newly-born (Buhl's Disease); Icterus Neonatorum; Tetanus Neonatorum; Conjunc- tivitis; Ophthalmia Neonatorum; Mastitis; Spontaneous Hemorrhages in the Newly-born 14 SECTION II. Hygiene of Infancy. CHAPTER IV. Hygiene of Infancy. Clothing; The Nursery; Bathing; Exercise and Fresh Air; General Habits 91 CHAPTER V. Weight and Development. Weight; Length; General -Shape; Head; Brain; Spine; Glands; Stomach Intestines and Liver; Bladder; Muscles; Dentition; Delayed Dentition; Disturbances of Dentition; Care of Temporary Teeth; Permanent Teeth: Hutchinson's Teeth; Growth during Childhood; Mental and Moral Growth; Adolescence 28 vii VI 11 CONTENTS. SECTION III. The Examination of the Sick Child. CHAPTER VI. The Examination of the Sick Child. Page History; Inspection; Palpation; Auscultation; Percussion; Mensuration; Rectal Examination 41 CHAPTER VII. Special Examinations. Lumbar Puncture; Estimation of Hemoglobin; Test for Indican; Trans- udates and Exudates; Aspiration of Pleural Cavity ;Tuberculin Tests: Thread Reaction in Pyelitis ; Wasserman Test for Syphilis 51 CHAPTER VIII. Signs of Illness in Infancy. Irritability of Temper; Restless Sleep; Changes in Features; State of the Discharges 57 CHAPTER IX. General Therapeutics. Drug Administration; Table of Average Doses; Introductory Remarks; Psychotherapy; Aerotherapy; Hydrotherapy; Nasopharyngeal Toilet; Lavage; Enteroclysis; Gavage; Rectal Feeding; Vaccine Therapy; Exercises 60 CHAPTER X. Suggestive Scheme for Diagnosis. Head; Neck; Face; Mouth; Swallowing; Abnormalities in Breathing; Chest; Abdomen; Inguinal Region; Delayed Growth; Hemorrhages; Extrem- ities SI SECTION IV. Infant-Feeding. CHAPTER XL The Infant from the Nutritional Standpoint. The Infant; Life Divided into two Nutritive Periods; Essential Unity of Foods; Foods of the First Nutritive Period; The Infant a Mammary Fetus; Breast Secretions; Specialized Foods; Composition and Properties of Breast Secretions; Comparative Anatomy and Physiology of Digestive Organs; Comparative Mammary Secretions; Chemical and Biological Standards 89 CONTENTS. IX CHAPTER XII. Breast-feeding. Page Importance of; Preparation for Maternal Feeding; Management; Regularity; Milk Agrees; Flow Scanty; Elimination of Drugs and Excretory Products in Milk; Milk Plentiful but Disagrees with Infant; Examination of Breast Milk; Nursing not Possible; Contraindications for Nursing; Weaning and Mixed Feeding; Selection of Wet Nurse 100 CHAPTER XIII. Principles of Substitute Feeding. Difficulties Encountered; Principles that Apply to All Infants; Many Forms of Proteins, Fats and Carbohydrates 110 CHAPTER XIV. Materials Used in Substitute Feeding. Cow's Milk: One Cow's Milk; Influence of Breed on Composition; Bacteri- ology of; Production of Sanitary Milk; Market Milk; Pasteurized and Sterilized Milk; Composition of Market Milk; Cream; Condensed Milk; Evaporated Milk. Cereals: General Properties of Carbohydrates of Cereals. Eggs: Proprietary Infant Foods; Classification of; Analyses of . 113 CHAPTER XV. Rise and Development of Scientific Infant-Feeding. Historical; Fundamental Errors Made; Classification of Methods of Modifying Milk; Laboratory Demonstrations to Illustrate Effects of Methods of Modifying Milk; Infants tend to adapt themselves to their Food; Infants differ in digestion and assimilation efficiency; Assimilation most Efficient in Early Infancy 126 CHAPTER XVI. Practical Feeding. Basis of; Percentage Milk Mixtures; Top Milk; Percentage Cereal Gruels; Composition of Milk and Gruel Mixtures; Outline of Feeding Directions; Food for Healthy Infants; Directions for Making Gruels; Adaptation of Food to Infant; Food for Infants Previously Badly Fed; Feeding History; Management; Food for Infants of Feeble Constitution; A Wet Nurse Unobtainable; Food for the Acutely 111; Management of Cases when All Attempts at Adding Fresh Milk Fail; Laboratory Feeding; Calorie Feeding; Directions for Mother and Nurse; How to Interpret Results; Feeding in Hot Weather; Feeding when Traveling; Feeding when Away from Home; Feeding Among the Poor; Infant's Food Dispensaries; Making Feedings on a Large Scale; Making Food at the Feeding Stations . 136 CHAPTER XVII. Diet During the Second Year. Dietary Twelfth to Eighteenth Months; Eighteenth to Twenty-fourth Months; Two to Three Years; Diet List for Children's Hospitals; Diet Lists for Day Nurseries and Creches; Diet During Later Childhood 174 CONTENTS. SECTION V. Diseases of the Digestive System. CHAPTER XVIII. Diseases of the Mouth. Page General Considerations; Desquamative Glossitis; Simple Stomatitis; Aphthous Stomatitis; Bednar's Aphthae; Perleche; Mycotic Stomatitis (Thrush); , Ulcerous Stomatitis; Gangrenous Stomatitis (Noma) ; Elongated Uvula . 181 CHAPTER XIX. Diseases of the Digestive Tract. Corrosive Esophagitis; Congenital Occlusion of the Esophagus; Acute Gastric Indigestion (Acute Gastritis); Chronic Gastritis; Dilatation of the Stomach; Stenosis of the Pyloris and Pyloric Spasm; Recurrent or Cyclic Vomiting; Infant's Stools; Colic; Acute Gastroenteritis; Acute Enterocolitis; Chronic Gastrointestinal Indigestion; Congenital Dilatation of the Colon (Hirschprung's Disease) ; Cholera Infantum; Constipation 189 CHAPTER XX. The Animal Parasites. Parasitic Protozoa; Oxyuris Vermicularis ; Ascaris Lumbricoides; Tenia Mediocanellata; Tenia Solium; Uncinaria Duodenalis; Trichina Spiralis. 211 CHAPTER XXI. Diseases of the Liver. The Liver; Examination of the Liver; Jaundice; Inflammation of the Biliary Ducts; Inflammation of the Portal Vein; Congestion of the Liver; Fatty Liver; Amyloid Liver; Cirrhosis of the Liver; Abscess of the Liver . . . 219 SECTION VI. The Infectious Diseases. CHAPTER XXII. The Infectious Diseases. Measles; German Measles; Scarlet Fever; Variola; Vaccination; Varicella; Table of Exanthemata; Diphtheria; Pertussis; Mumps; Typhoid Fever; Influenza; Syphilis; Cerebrospinal Meningitis; Anterior Poliomyelitis; Epidemic Paralysis in Children; Acute Articular Rheumatism; Chronic Articular Rheumatism; Malaria (Paludism) Erysipelas 225 CONTENTS. XI CHAPTER XXIII. Page Disinfectants; Disinfection 312 CHAPTER XXIV. Tuberculosis. Etiology; Tuberculous Adenitis; Thoracic Tuberculosis in Children; Pul- monary Tuberculosis (Acute and Chronic); Acute Miliary Tuberculosis; Tuberculous Meningitis; Tuberculous Peritonitis; Tuberculosis of Bones and Joints; Tuberculosis of the Vertebrae; Tuberculous Disease of the Hip; Tuberculous Disease of the Knee; Treatment of Tuberculosis in General 316 SECTION VII. Diseases of the Respiratory Tract. CHAPTER XXV. Diseases, of the Upper Respiratory Tract. Acute Rhinitis; Epistaxis; Foreign Bodies in the Nose; Examination of the Infant's Throat; Pharyngitis and Tonsillitis in Infants; Acute Pharyngi- tis; Acute Follicular Tonsillitis; tJlcero-membranous Tonsillitis (Vincent's Angina) ; Chronic Tonsillar Hypertrophy; Adenoids; Peritonsillar Abscess; Retropharyngeal Abscess; Acute Laryngitis (Spasmodic Croup); Edema of the Glottis; Laryngismus Stridulus; Congenital Laryngeal Stridor; New Growths in Larynx 341 CHAPTER XXVI. Diseases of the Lungs and Pleura. Acute Bronchitis; Chronic Bronchitis; Pulmonary Collapse; Emphysema; Bronchial Asthma; Acute Bronchopneumonia; Hypostatic Pneumonia; Lobar Pneumonia; Pleurisy, Dry, Serofibrinous; Empyema; Pneu- mothorax; Pulmonary Abscess; Gangrene of the Lung; Bronchiectasis; Foreign Bodies in the Respiratory Tract; Subphrenic Abscess 359 SECTION VIII. Diseases of the Circulatory System. CHAPTER XXVII. Diseases of the Heart. The Heart; Congenital Heart Disease (Cyanosis); Endocarditis; Septic Endocarditis Myocarditis 3S2 XI 1 CONTEXTS. CHAPTER XXVIII. Chronic Valvular Disease. Page Mitral Regurgitation; Mitral Obstruction; Aortic Obstruction; Aortic Regur- gitation; Tricuspid Regurgitation; Functional Cardiac Disorders . . . . 389 CHAPTER XXIX. Diseases of the Pericardium 395 SECTION IX. Diseases of the Blood and Ductless Glands. CHAPTER XXX. Diseases of the Blood. Glossary; The Blood; Anemia; Simple or Secondary Anemia; Chlorosis; Pernicious Anemia; Leukemia ; Pseudo-leukemia of Infants (von Jaksch's Anemia); Table of Anemias; Treatment of the Anemias; Purpura; Purpura Simplex; Purpura Hemorrhagica; Henoch's Purpura; Schonlein's Purpura; Hemophilia 398 CHAPTER XXXI. Diseases of the Ductless Glands. The Thymus; Enlargement of the Thymus; Status Lymphaticus; Diseases of the Spleen; Inflammation of the Spleen; Chronic Passive Congestion of the Spleen; Disorders of the Adrenals; Addison's Disease; Hodgkin's Disease (Lymphadenoma) ; Acute Adenitis; Chronic Adenitis; Exophthal- mic Goiter; Achondroplasia; Infantilism; Cretinism 414 SECTION X. General Diseases of Nutrition. CHAPTER XXXII. Nutritional Disorders. Rachitis; Congenital Rachitis; Scorbutus; Marasmus; Diabetes Mellitus . . 431 SECTION XL Diseases of the Uropoietic System. CHAPTER XXXIII. Diseases of the Urixe axd Kidneys. The Urine in Infancy; Character of the Urine; Formation of the Kidney: Anuria; Polyuria; Diabetes Insipidus; Renal Calculi; Hematuria; Hemo- CONTENTS. Xlll Page globinuria; Functional Albuminuria (Cyclic or Physiologic Albuminuria); Indicanuria; Acetonuria and Diacetonuria ; Congestion of the Kidney; Chronic Congestion (Passive Hyperemia) of Kidney; Nephritis, Acute, Chronic; Pyelitis; Perinephritis; Tumors of the Kidney; Hydronephrosis; Enuresis r . . 445 SECTION XII. Diseases of the Genital Organs and Bladder. CHAPTER XXXIV. Diseases of the Genital Organs. Phimosis and Paraphimosis; Balanitis; Urethritis; Vulvovaginitis, Mastur- bation; Hydrocele; Undescended Testicle; Differential Diagnosis of Swellings in the Inguinal Region 472 CHAPTER XXXV. Diseases of the Bladder. Cystitis; Vesical Spasm; Vesical Calculus 480 SECTION XIII. Diseases of the Nervous System. CHAPTER XXXVI. General Nervous Diseases. General Considerations; Paralysis in General; Characteristics of the Various Types; Convulsions; Chorea; Hysteria; Epilepsy; Headaches (Migraine); Insomnia; Pavor Nocturnus; Tetany; Congenital Myotonia (Thomsen's Disease) ; Paramyoclonus Multiplex; Angioneurotic Edema; Tics . . . . 482 CHAPTER XXXVII. Diseases of the Peripheral Nerves. Multiple Neuritis; Diphtheritic Paralysis; Facial Paralysis 503 CHAPTER XXXVIII. Diseases of the Spinal Cord. Myelitis; Multiple Sclerosis; Hereditary Ataxia (Friedrich's Disease); Primary Myopathies 507 XIV CONTENTS. CHAPTER XXXIX. Diseases of the Brain. Page Meningitis; Encephalitis; Abscess of the Brain; Tumors of the Brain; Cerebral Palsies; Hydrocephalus; Microcephalus ; Idiocy; Imbecility; Feeble- mindedness; Mongolian Idiocy; Amaurotic Family Idiocy 518 SECTION XIV. Congenital Malformations and Deformities. CHAPTER XL. Congenital Malformations and Deformities. Tongue Tie, Hare-lip; Cleft-palate; Branchial Cysts; Malformations of the Esophagus; Malformations of the Rectum and Anus; Hypospadias; Extrophy of the Bladder; Congenital Dislocation of the Hip; Congenital Absence of Bones; Talipes; Webbed Fingers and Toes; Meningocele and Encephalocele; Spina Bifida 535 SECTION XV. The Commoner Surgical Diseases. CHAPTER XLI. The Commoner Surgical Diseases. Anesthesia; Hernia; Circumcision; Appendicitis; Intussusception (Including Intestinal Obstruction); Peritonitis, Acute, Newly-born, Early Life, Pneumococcic; Ascites; Ischiorectal Abscess; Rectal Polypus; Fissure of the Anus; Prolapse of the Anus and Rectum; Malignant Tumors in Childhood 549 SECTION XVI. Diseases of the Ear and Eye. CHAPTER XLII. Diseases of the Ear. General Consideration; Otoscopy; Otitis; Mastoiditis; Infective Cerebral Sinus Thrombosis 565 CONTENTS. XV CHAPTER XLIII. The Commoner Diseases of the Eye. Page Foreign Bodies; Blepharitis; Conjunctivitis, Diphtheritic, Chronic, Granular; Chalazion; Strabismus; Keratitis; The Diagnostic Significance of Ocular Affections; Diagnostic Hints 570 SECTION XVII. Diseases of the Skin. CHAPTER XLIV. Diseases of the Skin. Ichthyosis; Nevi; Dermatitis Exfoliativa Neonatorum (Ritter's Disease); Pemphigus Neonatorum; Impetigo Contagiosa; Seborrhea Capitis; Erythema Multiforme; Acute Exfoliative Dermatitis; Eczema, Acute, Subacute, Chronic; Psoriasis; Miliaria; Urticaria; Furunculosis ; Angio- neurotic Edema; Herpes Zoster 575 CHAPTER XLV. Parasitic Skin Diseases. Pediculosis; Scabies; Tinea Tonsurans; Tinea Favosa; Alopecia Areata . . . 588 Index 593 DISEASES OF CHILDREN. SECTION I. THE NEWLY-BORN. CHAPTER I. THE MANAGEMENT AND CARE OF PREMATURE INFANTS. When a premature infant is born it is suddenly deprived of a very important organ, namely, the placenta, which has a selective action for the developing fetus. Three and sometimes four factors mitigate strongly against its extrauterine existence. These factors are in the order of their importance: (1) Undeveloped heat and respiratory centers; (2) increased susceptibility to infection; (3) patent umbilical vessels with a tendency to putrefaction; and (4) sometimes possible congenital disease from its progenitors. The temperature of a premature babe at the time of birth varies from 98.6° to 100° F. It is often suddenly introduced into, and examined in a room temperature of 74° F.; that is, with a variation of 24° or 26° F. A subnormal temperature undoubtedly often results, from which the child's undeveloped heat centers fail to assist it. A lowered temperature, then, is the first evil to combat. Brothers has shown that more than one-half of all deaths under four weeks are attributable to prematurity. We believe that many premature infants that help to swell the mortality statistics may be saved by timely and appropriate directions from their medical attend- ants. More viable under-term children are born now than formerly, owing to better methods at the time of birth and to such surgical measures as Cesarean section: The records of those born and reared in a maternity hospital show a high percentage saved; for example: Maygrier, at the Charite in Paris, has saved 516 out of 548 cases which weighed 4^ to 5^ pounds at birth, or a percentage of 96.58 per cent. Voorhees, from the Sloane Maternity, has an average of 79.5 per cent., but these cases had never been exposed to chilling and transportation and had the advantage of woman's milk as a pabulum. It must be remembered, however, that our maternity hospitals have no facilities for caring for outside cases, and these are sent after a variable time to an institution which has an incubator. 1 I DISEASES OF CHILDREN. The natural solution seems to be incubator life, and this apparatus will maintain the body heat, if properly managed at 90° F., but it will also necessitate that the babe respire this superheated air, often vitiated and liable to germ contamination. Constant and eternal vigilance is required to keep the apparatus — even the best obtainable — in proper working order. If the temperature rises suddenly, a heat stroke results, and if the gas pressure falls or the wind changes, Fig. 1. — Incubator with outside ventilation and automatic regulation of temperature. a subnormal temperature may follow. The premature infant de- livered at home should therefore be placed in a padded basket or crib, (see Fig. 2) and surrounded with hot-water bottles or kept warm with an electric heater. The room must be quiet and a sunny one; it should be kept at 78° to 80° F., preferably heated and ventilated by an open fireplace. The supply of fresh air should be constant. If unavoidably the infant's temperature has fallen to subnormal, a warm bath and gentle friction are indicated before supplying the swaddling blankets made of cotton which are to serve as clothes. The importance of conserving this body heat may be THE MANAGEMENT AND CARE OF PREMATURE INFANTS. 6 emphasized by the statistics of Budin in France. Ninety per cent, of the premature infants died who had a temperature between 90° and 92° F. It is a significant fact that the great majority of cases brought to us at the hospital had a subnormal temperature. The weight and length must next be considered in its relation to viability and to. feeding. If the weight is below 2\ pounds, the premature are rarely saved, while those with birth weights between 2i and 5 pounds are to be regarded as congenitally feeble. The Fig. 2. — Padded basket-crib suitable for premature infants. length of time in utero is, however, of greater importance than the birth weight in establishing the prognosis. Moore saved a premature infant born at the sixth month of gestation which was nine inches long and weighed one and one-half pounds (this babe weighed 19 pounds at the end of fifteen months). Therefore, if the child is born alive, it should be given every chance to live. The obstetrician should immediately place the babe in a warmed blanket or in warm cotton wool and have hot bottles close to its body and beneath it. Swad- dling clothes are later used. The next problem will be that of nutrition. An undeveloped digestive tract with a minimum amount of secretions and an over- active liver will demand careful consideration. The breast milk of a woman whose child is about ten days old is the ideal food; this should be diluted with water three times in the beginning, and later twice, and finally undiluted breast milk is allowed, especially if the infant is strong enough to suck. The quantity given should approximate 4 DISEASES OF CHILDREN. h r 4 6 one-fifth of the baby's weight, if it is above four and a half pounds; but very small amounts, one dram every hour, should be ordered for the first few days, and very gradually increased. The mother's own milk should be pumped, mas- saged, or nursed out by another stronger child, but should not be used for a week or ten days, as the colostrum at this period of gesta- tion, as shown by Adriance, is too rich in proteids. A wet nurse for a short period or a small amount of breast milk (often one ounce will suffice for twenty-four hours) should be otherwise obtained. If this is impossible, a 4 per cent, lactose solution is fed for a few days, followed by plain whey, and then dram-feedings of modified milk, beginning with 0.5 per cent. fat, 0.25 per cent, proteids, and 4 per cent, sugar are given, gradually increasing the proteids to 0.4 per cent, and later to 0.8 per cent. Sodium citrate, one grain to the ounce, will assist in modifying the curds. These small percentages are best obtained from the laboratories, or with the Deming percentage modifier. Peptonization is indi- cated if the stools show feeble di- gestion. The weaker infants are fed with a dropper, while those capable of making sucking efforts are fed with a modified Breck feeder. This can be made from a piece of glass tubing with dropper the one being perforated by three small holes 4). Gavage is dangerous. We have found milk and bronchi of premature infants at autopsy which reached there via the tube. The medical attendant must not be discouraged to note a falling off in weight for some time. It is often three to four weeks before the birth weight is regained. The fc Fig. 3.— Breck feeder for prema- ture infants. nipples applied, (see Figs. 3 and in the trachea Fig. 4. — Home- made feeder. THE MANAGEMENT AND CARE OF PREMATURE INFANTS. 5 nurse must be ever watchful for attacks of cyanosis, which must be combated with two- to five-drop doses of diluted brandy, or cam- phor, gr. I, in sterile olive oil hypodermatically. The icterus which is not uncommon and which is usually associated with constipation, often produces fatal results. It is best treated with one- or two- twentieths of calomel. Daily inunctions of liquid petrolatum (albolin) are given in lieu of baths for cleanliness after the usual diapering. After the first year these premature infants are not necessarily weak and puny, but on the contrary are often indistinguishable from the full-term infant. The prognosis, however, should always be considered as unfavorable, as the undeveloped digestive tract, the possibility of sepsis, and the defects in the heart all mitigate against its existence. The importance, however, of obtaining breast milk cannot be overestimated, for it is almost impossible to raise them without its help. In our experience, which includes over one hundred premature cases, we prefer the open method of treating premature infants to the use of the incubator, and all kinds have been tried. If an incubator is used, only the kind having connection with the outside air should be employed, as these infants are exceedingly susceptible to a lack of fresh air. CHAPTER II. INJURIES DURING BIRTH. Deformity of Head. A certain pointing toward the occiput and elongation of the head are noted in most labors. This may be extreme in cases where a long or difficult labor has resulted in excessive molding of the presenting part. Fortunately, little damage is done by this distortion and the head usually takes on its natural shape in a few days. Caput Succedaneum. The swelling on the presenting part of the head resulting from pressure is known as caput succedaneum. It consists of trans- uded serum and extravasated blood located between the scalp and pericranium in the loose connective tissue of this part. It has a soft, boggy feeling. Prolonged or difficult labors produce this effu- sion from pressure on the portion of the head that presents. No special treatment is required, as the absorbents of the connective tissue will cause its disappearance within a day or so. Cephalhematoma. Cephalhematoma is an effusion of blood between the bone and the periosteum covering it. It usually appears within one to three days after birth. Its seat may be any portion of the cranial vault. Most, commonly it occurs in the parietal region, sometimes over the temporal or occipital bones. The overlying integument presents no discoloration. A bony ring is soon developed around the base from the secretion of the periosteum. The effusion is, in most cases, limited by a suture. The effused blood, as a rule, undergoes absorp- tion within the first three months of life. In rare cases suppuration ensues, and even caries of the subjacent bone may occur. The fact that the tumor does not communicate with the brain cavity, which fact can usually be readily made out by palpation, serves to distinguish this affection from encephalocele. To differentiate caput succeda- neum and cephalhematoma it may be borne in mind that while the former is nonfluctuating and disappears in a few days, the latter is 6 INJURIES DURING BIRTH. / soft and fluctuating, presenting a marginal ridge, in the center of which the skull is felt, and disappears in a few months. Treatment. — In most cases no treatment is called for. Should the tumor grow it may be strapped with adhesive plaster, the head first being shaved. Incision, while generally condemned, has been practised with success. It offers the advantage of immediate relief and leaves no permanent deformity. The effused blood can usually be removed through a small opening. A firm compress is worn for several days to prevent refilling. It is needless to say that the strictest asepsis must be observed. If suppuration occurs the usual surgical treatment of abscess must be carried out. Injuries to Bone and Muscle. (a) Bone. — The soft and partially*' developed condition of in- fantile bone renders it liable to injury if subjected to much mechan- ical violence during delivery. The cranial bones are especially liable to indentation and fracture when the forceps is employed, yet such accidents may occur in spontaneous labor. Fracture of the cra- nial bones is most frequent in the parietals. When the brain is not injured the fracture is not apt to result seriously. Rupture of intra- cranial blood-vessels may lead to fatal hemorrhage. Simple inden- tations apparently cause little if any damage to the brain structures. Gentle efforts at reduction may be attempted, and thus the normal shape be restored. Fracture of the inferior maxillary bone may result from traction with the fingers in unskillful delivery of the after- coming head in breech presentations. Injuries may be inflicted upon the vertebra? or the spinal cord, with resulting paraplegia, and they are almost invariably fatal. Fracture of the humerus not uncom- monly occurs in forcible delivery of the arm in breech births, or sepa- ration of the epiphysis from the shaft of the bone may take place. Fracture of the clavicle usually results from violent use of the fingers in extracting the after-coming head. The femur may be fractured from misdirected traction with fingers or fillet in breech delivery. (6) Muscle. — Hematoma of the sternocleidomastoid muscle may result from artificial interference in breech extractions. A hard tumor about the size of a pigeon's egg may be seen developing in this muscle, usually on its anterior border. It is noticed between the ages of one and six weeks, and usually disappears by absorption in a month or so. The muscle fibers are sometimes torn. Hematoma of the sternocleidomastoid may lead to contracture of the injured muscle and torticollis. As a rule, the blood is spontaneously ab- sorbed in a few weeks. DISEASES OF CHILDREN. Birth Palsies. Injuries to the nerves during birth may be central or peripheral. The latter are fortunately the most common and the usual types are the facial and upper-arm paralysis. (_/a) Facial Paralysis. — Pressure upon the seventh or facial nerve at the stylomastoid foramen by the blades of the forceps is usually responsible for facial paralysis. The affection is, in most cases, unilateral, and will not be noticed when the infant is at rest. When^nursing or crying, the palsy of the affected side is apparent. Recovery usually takes place spontaneously in a few weeks. If the paralysis does not disappear promptly, faradism may be employed. In rare cases the palsy is permanent. Fig. 5. — Erb's paralysis. (b) Upper-arm Paralysis (Erb's or Duchenne's Paralysis. — The next most frequent peripheral palsy is seen in the arm. Various conditions during birth may produce compression and injury of the nerves about the shoulder, such as severe pressure of the obstetrician's finger or the blunt hook in the axilla, hematoma of the sternocleido- mastoid, or fracture of the humerus with displacement of the frag- ments. The greatest number of upper-arm paralyses, generally known as Erb's or Duchenne's paralysis, occur after breech deliveries. The injury usually results from traction made upon the shoulder in the delivery of the head, or in bringing down the arm when it is found above the head or upon the head in vertex deliveries, and is due, as a rule, to stretching of the fifth, sixth, and seventh cervical nerves. Dragging the head or the trunk strongly to one side is INJURIES DURING BIRTH. 9 usually responsible for the excessive traction upon the nerve trunks of the injured side. The deltoid, biceps, brachialis anticus, and supi- nator longus are the muscles oftenest affected. In mild cases the paralysis may not be noticed for some weeks, while in severe ones it will usually be apparent at once. Diagnosis. — The position of the arm is characteristic. It hangs helpless at the side and is rotated inward. As the triceps is not af- fected, the child can extend the forearm, but cannot flex it. After a few weeks the affected muscles show more or less atrophy, but the child will generally begin to use the forearm. The diagnosis of Erb's paralysis is not, as a rule, difficult when seen during the first year. The peculiar position of the arm and the group of muscles involved are rarely met with in any other affection at this early age. Prognosis. — The prognosis will depend upon the severity of the symptoms and the time when the treatment is begun. Spontaneous recovery takes place in some cases within two or three months. If there is but little improvement after this length of time, spontaneous recovery is not to be expected, and the case demands active treat- ment. In some cases partial paralysis may remain for several years or be permanent. Treatment should be begun as early as the third month, and should consist in frictions or massage and the persistent use of elec- tricity. If the muscles react to the faradic current, it may be used; but if not, the galvanic current must be employed. The treatment must be continued for several months, or until recovery is nearly complete. The foregoing treatment applies also in facial paralysis. (c) Central Paralysis.- — Meningeal apoplexy, followed by various paralyses, is one of the untoward results of prolonged and difficult labor. This is more apt to occur with the first-born child owing to the unyielding character of the maternal parts. While hemiplegia is the rule, from the distribution of the hemorrhage over the surface of one side of the brain, there may be less diffused local hemorrhages resulting in paralysis of the .face or of one arm or leg. In eleven autopsies following this injury, as reported by Dr. McNutt, the hemor- rhage was principally at the base of the brain in the vertex presen- tation, whereas it was largely on the convexity in the breech pres- entations. It has been supposed that the use of forceps is largely responsible for this accident, and the rough and careless use of instru- ments is doubtless a competent cause. The writer believes, however, that too long delay in the application of the forceps when the head is being subjected to prolonged pressure is oftener responsible for this unfortunate accident. The careless use of ergot before delivery, by 10 DISEASES OF CHILDREN. inducing a tetanic contraction of the uterus, also favors congestion of the fetal brain. Symptoms and Prognosis. — The symptoms induced by men- ingeal extravasation depend, of course, upon the seat and extent of the effusion. The extravasation is frequently located over the motor convolutions, and if not extensive the hemiplegia may disappear with the absorption of the blood. If more extensive, however, the infant may be stillborn or, if living, it may soon die from asphyxia or in a comatose condition. The voluntary muscles in such cases may be in a spastic condition or, more rarely, in a state of complete relaxation. The respiration is more apt to be depressed and irregular than the pulse. Convulsions may occur shortly after birth, followed by coma. If death does not ensue the prognosis for the extremities affected is good, as the paralysis gradually improves, often undergoing complete recovery. The brain, however, may be irreparably injured, as shown by subsequent epilepsy or even by various degrees of idiocy. Treatment. — The treatment must be preventive. This consists in avoiding as much as possible prolonged pressure upon the fetal head, in a careful use of the forceps, and in seeing that the infant cries immediately after birth, thus being assured that the lungs are inflating. It is of great importance that the transition from the fetal to the post-natal circulation should at once take place at birth, as otherwise great damage may be done, particularly to the brain; the vessels here are fragile and easily ruptured. If the infant cries the expanding lungs draw off the excess of blood that may do damage elsewhere. The physician should give his first attention to the infant until this happens, as a short period of asphyxia may do incalculable harm. If the lungs do not act, it is well to let the cord bleed to the extent of a few drams to prevent severe congestion of other vital organs. Asphyxia. The accidents during labor that induce asphyxia are: sudden death of the mother, constant pressure upon the umbilical cord, severe compression of any part of the fetal body, especially the head, as noted above, and more or less complete detachment of the placenta. In consequence of the air-hunger induced by these conditions, a vigorous infant may by inspiratory suction take in secretions of the birth-canal, which may cause suffocation after birth or induce pneu- monia later. Very feeble infants may fail to establish respiratory movements after birth, owing to weak or defective muscles and nerves. In partial asphyxia there is congestion and suffusion of the skin, with INJURIES DURING BIRTH. 11 blueness of the mucous membranes, full pulse, and moderate action of the reflexes. As the symptoms of carbon-dioxid poisoning become more marked, the pulse grows feebler, the skin paler, and the mucous membranes assume a grayish-blue color. The reflexes are likewise lost. The prognosis in the latter condition is exceedingly bad. In the milder degrees of birth-asphyxia recovery usually ensues. The Preventive Treatment consists in measures addressed to the acceleration of tedious labors and the prevention of prolonged pressure upon the fetal parts, especially the head. During descent of the head malpositions of the cord, especially prolapse, or winding tightly around the neck, must be looked for and, if possible, corrected. One of the possible causes of asphyxia will be removed if as soon as the head is born it is so turned that the face shall not lie in a pool of blood and liquor amnii. At the same time the mouth and fauces can hastily be cleaned of mucus with a moist rag drawn over the finger or by means of a soft rubber tube with a rubber bulb attached. In moderate degrees of asphyxia the stimulus of the cool external air and allowing a dram or two of blood to escape by the cord will be sufficient. Should this not suffice the chest may be sprinkled with cold water to stimulate the reflexes, while the infant is held suspended by the feet for the purpose of allowing mucus to gravitate from the air-passages. The child may be plunged alternately into hot and cold water. The hot water should have a temperature not exceeding 105° F. When these external stimuli fail to excite respiratory movements, resort must be had to artificial respiration. The child's pharynx should first be cleared of mucus and other liquid material that may have been drawn into it by premature efforts at respiration. The simplest and most effectual method of inflating the lungs is by direct insufflation — the mouth-to-mouth method. Direct Insufflation. — The child is placed upon its back with the head extended by means of a small pillow or roll of clothing placed under its neck; the mouth is well cleansed and a towel or hand- kerchief is spread over the face. With one hand closing the nose, and with the other making pressure upon the epigastrium, to prevent the inflation of the stomach, the physician forces air from his own gently into the child's mouth and inflates the lungs. The air is expelled by gentle pressure upon its chest, and the process then repeated. When properly performed, this method is safer than passing a catheter or other instrument into the trachea, as is sometimes practised. Care should be taken lest injury be done to the air-cells by too forcible expansion. 12 DISEASES OF CHILDREN. Various methods of artificial respiration may be employed. Schultze's method is most commonly employed. The operator holds the infant suspended, face to the front, his index-fingers being hooked in the axilla?, the thumbs resting on the front of the chest and the fingers upon the infant's back. The lower portion of the child's body is now swung outward, upward, and finally toward the operator's face, inverting the position. Care should be taken that the trunk is most strongly flexed in the lumbar region. .In this position the thorax is compressed — expiration. The child's lower extremities are now swung outward away from the operator's body and downward till the child hangs suspended by its axillae in the position first described. In this position of the child, hanging by its upper extremities, the abdominal contents fall and the diaphragm sinks — inspiration. To assist the respiratory movements the pressure of the operator's thumb is relaxed during inspiration and increased during expiration. This method is not to be recommended in feeble children. Laborde's method is easy to apply in the case of very feeble infants. It consists in making rhythmical traction upon the tongue, eight to ten times to the minute. After the respirations have been started, the infant must be watched to see that they continue. It may be advisable in some cases to administer hypodermatically ten to twenty drops of whisky combined with 1 minim of the tincture of belladonna or -g-J-g- grain of strychnin. In most cases it will be necessary after resuscitation to apply dry heat by a hot-water bag or other means. In asphyxia pallida a rectal injection of water at a temperature of 110° F. is of marked service. Congenital Atelectasis. Closely allied to asphyxia, and often associated with it, is a per- sistence of the fetal condition of the lungs, either of one or both in whole or in part. It is due to failure of the infant to completely inflate the lungs, and may persist for a considerable time. Sometimes it results in death, even after respiration has apparently been fully established. This is more apt to involve the lower lobes than the upper ones. It is frequently seen in premature infants with feeble respiration. The cause may also be injury to the brain from pressure. The symp- toms are those of deficient respiratory action, such as pallor, feeble cry, and poor circulation, with very little expansion of the chest- walls over the affected area. Deep inspiration may be encouraged by artificial respiration, and the vitality conserved by the external INJURIES DURING BIRTH. 13 application of heat and the judicious administration of nourishment and stimulants. Fetal Death. Death may take place at or before birth, which must sometimes be differentiated from asphyxia. In the former the heart pulsations cannot be felt and respirations and reflexes are absent. In the latter the heart is pulsating, reflexes are present, and there may be feeble attempts at respiration. We should not refrain from efforts at resuscitation because the heart-sounds are absent or no pulsations can be felt in the precordial region. The distinction between a dead- born and a still-born infant can usually be made by the rapid fall of rectal temperature in the former to ten or fifteen degrees below nor- mal and by the widely dilated condition of the pupils in the dead-born. In the still-born, artificial respiration may be employed, and the hypo- dermatic injection of a few drops of whisky and gr. -g-ro °f sulphate of strychnin may be given. CHAPTER III. DISEASES OF THE NEWLY-BORN. Acute Infectious Disease. While the newly-born infant seems to bear a sort of natural immunity to the common infectious diseases of childhood, it is pos- sible for an infant to be infected through the placenta before birth or by the usual methods soon after birth. While the symptoms of mea- sles, pertussis, pneumonia, scarlatina, or influenza are largely the same as when seen later on, the prognosis in the newly-born is bad. Sepsis of the Newly -born. An infection induced by pus-forming organisms such as the streptococcus pyogenes and the staphylococcus pyogenes aureus and albus may be seen in the newly-born. The umbilicus is the most vulnerable spot for the entrance of septic poisons during or shortly after birth. Upon ligation of the cord the blood that remains in the umbilical veins forms small thrombi that should gradually harden and in time become calcified, forming a fibrous cord in the same manner as in the ductus arteriosus and ductus venosus. In these latter structures the formation of thrombi is never accompanied with grave consequences, since their internal situation prevents the access of infectious agents. Pyogenic organisms, however, can readily gain access to the umbilical vein and give rise to umbilical phlebitis and septicemia. There is a constant alteration after birth in the blood-pressure in the umbilical vein, due to the action of the heart and lungs, by which a sort of flux and reflux is produced. This favors infection of the system when the contents of this vein become septic. This grave accident is liable to occur when the mother is in a septic condition. The poison may be produced by the same agents that have caused the puerperal fever. In these cases of sepsis there is a puriform or yellow softening of the thrombi that fill the umbilical vein. The softened matter consists of pus-corpuscles and finely granular matter containing micrococci. This sets up an inflammation not only in the vessel itself, but also in the surrounding tissues. In- 14 DISEASES OF THE NEWLY-BORN. 15 fective emboli may be carried to various parts of the body. As the micrococci enter the umbilical vein from the umbilical fossa, owing to the perviousness of this vessel, the structures near at hand, espe- cially the liver, bear the first brunt of the septic inflammation. The latter organ is usually found much diseased or degenerated. There is jaundice, with constant elevation of temperature and other symp- toms of general septic infection. If the infant lives long enough peritonitis will probably develop, and sometimes empyema, pleuro- pneumonia or even meningitis. In all cases evidence of severe illness and prostration are present. Cutaneous, mucous, or visceral hemor- rhages may supervene at any time. The abdomen is generally swollen and tender, and dirty-looking pus may be seen oozing from the navel; slight pressure about the umbilicus will often cause pus to exude if it is not otherwise apparent. The fecal discharges may be of natural appearance, but the urine is usually highly colored. The infant refuses nourishment, and there may be vomiting of greenish matter. Severe nervous symptoms, such as convulsions or coma, supervene before death. While the umbilicus is the most common seat of septic infec- tion, any sore or abrasion elsewhere may afford entrance to germs. Erysipelatous eruptions on the abdomen, chest, or other parts, are the most frequent manifestations of such infection. Multiple joint inflammation and suppuration may appear as evi- dences of a general pyemia, and a few cases of osteomyelitis have been reported. Treatment. — The prophylactic treatment of sepsis consists in the careful antiseptic management of labor and proper attention and cleanliness in reference to the navel. Localized sepsis may be com- bated by the topical use of peroxid of hydrogen, bichlorid of mercury solution, or other strong antiseptic agents. The remedial treatment of systematic infection consists in full stimulation and general support and the judicious use of external re- frigerant measures. In the latter condition, however, treatment is generally futile. Empyema, pleuropneumonia, erysipelas and any other local effect of infection must be treated symptomatically. Umbilical Hemorrhage. Hemorrhage may take place from the stump of the cord shortly after birth from insecure ligation, from shrinkage of the funis, or from slipping of the ligature. Laceration of the cord between the abdomen and the ligature may also be responsible for hemorrhage. Secondary hemorrhage, usually between the fifth and fifteenth days, may occur, 16 DISEASES OF CHILDREN. even though the cord has been securely ligated and properly watched. The trouble may be due to changes in the walls of the minute blood- vessels, allowing transudation, or to imperfect coagulability of the blood. In the latter case the hypogastric artery and the umbilical artery and vein have not been tightly occluded by the usual fibrinous plug. The hemorrhage is ac- counted for by syphilis, jaundice, hemophilia, or by depraved health on the part of the parents. Treatment. — The great majority of cases are fatal from the impossibility of controlling the hemorrhage. In the milder ones a com- press of gauze tightly ap- plied with adhesive strips may be sufficient. Adrenalin (toW) m &y also be used to moisten the compress. In the most obstinate cases it may be necessary to transfix the umbilicus by two needles placed at right angles with a figure-of-eight ligature placed tightly around them. Umbilical Vegetations. Fungous granulations at times appear, arising from the floor of the um- bilical fossa, shortly after the falling of the cord. They may attain the size of a pea, and they usually exude a bloody serum, which may induce excoriations in the sur- rounding skin. The granulations may gradually atrophy after weeks or months of sluggish existence. The constant moisture and dis- charge is, however, a source of irritation, and it is best to destroy the Fig. 6. — Adhesive plaster dressing for umbil- ical hernia, made with two pieces overlapping. (Pisek's method.) DISEASES OF THE NEWLY-BORN. 17 growths. This can be accomplished by repeated cauterization with the solid stick of nitrate of silver or, better still, by passing a ligature around the base of the mass and amputating the exuberant granula- tions with scissors. A dry dressing of boric acid or subnitrate of bismuth may then be applied. Umbilical Hernia. There is a tendency, especially on the part of badly-nourished in- fants, for the gut to protrude a little at the umbilicus. It is hence desirable to keep a firm abdominal binder in place for the first two or three months. After this time if a protrusion persists, the hernia may be retained by long strips of adhesive plaster. It may be necessary to keep up this support for several months. The dressing may be examined and changed every few days to be sure the pressure stays in the right place. If the skin is irritable from frequent pulling off of the strips of plaster, part of the plaster may only be removed and the new plaster applied over the ends of the old strips and thus tightened over the hernia. The skin must be kept scrupulously clean and fre- quently dusted with powder. In older infants, an abdominal truss may occasionally do good service. It is rare for this form of umbilical hernia to last through childhood. In exceptional cases when the rup- ture increases rapidly in size operative interference may be considered. Epidemic Hemoglobinuria. (WinckeVs Disease.) This form of hemoglobinuria is very rarely seen in the newly-born and then usually in institutions. It begins a few days after birth in healthy infants with constitutional symptoms of depression shown by a weak rapid pulse and general asthenia. An icterus soon develops that becomes very marked and is noted over the whole body. The urine is soon lessened in amount, contains traces of albumin and hemoglobin in large amounts. Casts are occasionally also found. The color of the urine may be dark or smoky. The disease pro- gresses rapidly,often terminating in one or two days. There may be marked cyanosis with convulsions or coma before the close of life. The disease is evidently an outcome of some sort of infection, but the microbe has not yet been isolated. Treatment does not seem to be of much avail. 2 18 DISEASES OF CHILDREN. Fatty Degeneration of the Newly -born. (Buhl's Disease.) This is a very rare disease that acts like some form of pyogenic infection. It is characterized by fatty degeneration of the heart, liver, and kidneys with hemorrhages from any of the mucous membranes or into the various serous cavities or viscera. The spleen and liver are both usually enlarged. The disease is accompanied by great prostration and may last one or two weeks. Icterus may be present. The treatment is supporting and symptomatic, but not able to save life. Icterus Neonatorum. This is a common affection of the newly-born. Two distinct varieties are recognized, differing widely in cause and prognosis and known as the mild and grave forms. (a) Mild Form. — Two divergent theories have been advanced to account for this form. The first considers the jaundice to be purely hematic; the second theory regards it as hepatic in origin. Bile is first formed in the liver and then carried into the circulation, the resorp- tion being due either to congestion or to edema of the hepatic tissue. It seems highly probable that both these theories may apply in different instances, and doubtless many cases of icterus neonatorum are to be satisfactorily explained only by taking into consideration a morbid condition of both the blood and the liver, thus combining the hematic and hepatic theories. The intense congestion of the skin observed during the first few hours of life often produces a yellowish coloration that cannot be con- sidered jaundice. It is of the same nature as the discoloration of the skin following an ordinary cutaneous bruise. The yellow tint is at first seen only on deep pressure, but as the erythema fades the yellow- ness increases. The conjunctiva? are not colored, and the urine appears normal. This yellowness is usually first noticed on the second day, and may continue a few days or a week. The term "true icterus" can be applied only to those cases in which the yellow discoloration of the skin is caused by a staining by the bile pigments. This more often occurs in cases of prolonged or difficult labor, in children born asphyxiated or before term, and in generally feeble infants. It is very frequently seen in foundling asylums. It may appear as early as a few hours after birth, but usually is not marked until the second or third day. In very mild cases the yellow color may appear only on the face, chest, and back, the conjunctiva? being DISEASES OF THE NEWLY-BORN. 19 but faintly tinted and the urine and feces normal in appearance. In severer forms the urine may be high colored enough to stain the linen, and the jaundiced hue may extend to the arms and abdomen. Some infants present a yellowish discoloration of the whole body, with typical clay-colored stools. In most cases the jaundice has disap- peared by the eighth or tenth day. It may persist for several weeks. In rare cases, after having much diminished, it reappears with renewed intensity. No matter how extensive this form of jaundice may be, it causes very little constitutional disturbance. The liver may be slightly enlarged, and occasionally there are symptoms of intestinal indigestion. A few small doses of calomel or mercury with chalk will be all the medication required. (b) Grave Form. — This form is, fortunately, rare, and may be produced by several different conditions. Defects in the bile-ducts will first be mentioned as among the commonest causes. In some cases all the large bile-ducts have been absent; in others the ductus communis choledochus has been narrowed, obliterated, or entirely absent. Sometimes a fibrous cord has been found in place of the gall-duct. The cystic duct has been absent and the gall-bladder in a rudimentary condition. Accompanying an obliteration of the gall-ducts cirrhosis is usually found in the liver, which will be more or less marked, according to the length of time the infant survives. The liver is generally enlarged. Jaundice that is due to obstruction or obliteration of the biliary passages may appear a few hours after birth and soon acquire a marked intensity. It often, however, does not appear for one or two weeks after birth. The yellowish discolor- ation of the skin may vary from day to day, at times being much more intense than others. The conjunctivae are yellow. The fecal discharges lose color and have an offensive odor, while the urine stains the napkin a yellow or greenish-brown. The spleen, as well as the liver, is usually enlarged, which partially accounts for the increase in size of the abdomen. Umbilical hemorrhage is a grave and not infrequent symptom in this form of jaundice. The bleeding is not sudden and profuse, but begins as an oozing shortly after the separa- tion of the navel string. It is apt to commence at night. Death is always hastened by this accident, and exhaustion from loss of blood is added to that induced by indigestion and malassimilation. There may also be a species of general purpura, bleeding taking place from the nose, mouth, or stomach. Infants may live for several months with impervious or defective bile-ducts, though death usually takes place earlier from failure of nutrition. Another form of grave icterus neonatorum is observed in connec- 20 DISEASES OF CHILDREN. tion with certain inflammatory changes in the liver, usually taking the form of an interstitial hepatitis, with which may be conjoined in- flammation of the biliary canals. This lesion is apt to be one of the results of congenital syphilis, as is likewise perihepatitis, which may cause a complete obliteration of the biliary passages. The latter form of inflammation often involves the connective tissue surrounding the common duct, the portal vein, and the hepatic artery on the under surface of the liver. These cases, however, may not always be of syphilitic origin. Perhaps the commonest manifestation of the grave form of icterus in the newly-born is seen in connection with septic poisoning that is generally accompanied with phlebitis. This has been noted under the head of sepsis. Later researches seem to prove that the bile itself may carry the infective agent. Tetanus Neonatorum. Although this disease is distributed through a wide geographical area, it is most apt to be found in filthy surroundings. Something beside filth, however, is necessary; there must be a specific cause. This consists in the tetanus bacillus, sometimes called Nicolaier's bacillus which produces tetanotoxin, a most virulent poison. It may exist in straw or dust from hay, which explains the fact that horses are subject to tetanus and that traumatic tetanus is often seen among laborers who are employed about farms and stables. The disease usually begins during the first ten days of life, and the onset is apt to be preceded by great fretfulness. Disinclination to nurse is soon followed by rigidity of the voluntary muscles, usually starting in the masseters. The rigidity increases, reaching its maxi- mum in from twelve to twenty-four hours. The head is thrown back, and there is a general flexion of the extremities. One peculiarity of the disease is that while the toes are flexed the great toes are adducted. There may be some relaxation at times, especially during sleep, but there are constant exacerbations, provoked by any peripheral irrita- tion. Respiration and circulation may be extremely embarrassed, and opisthotonus may be present during these exacerbations. The temperature is irregular, but usually high. Toward the end the pulse becomes rapid and feeble and death takes place from exhaustion. Treatment. — While the specific cause of the disease may gain entrance at any point of the body w T hen the necessary lesion exists, the umbilical wound is undoubtedly the seat of infection in the great majority of cases of tetanus neonatorum; hence the utmost cleanliness DISEASES OF THE NEWLY-BORN. 21 must be observed in cutting the cord and in dressing it. The scissors, the ligature, and the entire management of the navel, cord, stump, and the umbilical wound must be rigidly aseptic. The excess of the gelatinous matter should be stripped from the cord, and a dry, anti- septic dressing applied. Speedy mummification of the stump is the best safeguard against infection. Special care must be exercised in the umbilical dressings where the dwelling is easy of access to stable- yards containing horse-manure or loose earth. When the disease is once established it is almost invariably fatal. In cases of suppuration at the umbilicus, frequent cleansing with a solution of mercuric bichlorid of suitable strength should be employed. With reference to drugs, the two most valuable are potassium bromid, gr. iv every two to four hours, and chloral hydrate, gr. j every hour. The extract of calabar bean from T V to T ^- grain may be given hy- podermatically. While these are administered the infant must be given nourishment frequently, and stimulants should be freely em- ployed. The difficulty of swallowing, however, is a source of embar- rassment in satisfactorily carrying out these measures. Nourishment may be given by the rectum or by a nasal tube. A tetanus antitoxin is now produced by several manufacturing chemists, but so far the experience reported in the serum treatment of tetanus neonatorum has been rather negative. Conjunctivitis. The conjunctival membrane in the newly-born is very sensitive, and frequently the seat of inflammation. A mild inflammation is often seen, unattended by swelling of the lids, the inner surface being reddened and covered with a slight viscous secretion. The eyes must be kept cleansed by frequent bathing or irrigation with a saturated solution of boric acid. A little vaselin may be applied to the lids to prevent retention of the secretion by adhesion of their edges. Ophthalmia Neonatorum. This form of purulent conjunctivitis may be due to infection by the gonococcus in the severer cases or by various pyogenic cocci in the milder ones (Koch-Weeks bacillus). If the disease manifests itself by the second or third day, the infection probably took place during birth. When there is a delay of a week or more, however, the virus has probably been conveyed by careless attendants, by soiled fingers or other infected objects. The inflammation is of an intensely 22 DISEASES OF CHILDREN. virulent type, involving both the ocular and palpebral conjunctivae. The sac is filled with a grayish mucopurulent secretion, and there is intense chemosis. The subconjunctival connective tissue and skin are much swollen, so that the eye can only with difficulty be opened. There are photophobia, pain in the eye, and rise of temperature. Unless the symptoms quickly subside, the eye is irreparably damaged by ulceration and partial destruction of the cornea. The inflam- mation begins in one eye, but soon attacks the other unless it is effectively protected. The Prophylactic Treatment consists in employing antiseptic vaginal douches in the parturient woman when there is any muco- purulent discharge, and dropping two or three drops of a 2 per cent, solution of silver nitrate into each eye immediately after birth, after the method proposed by Crede. Curative Treatment. — When the inflammation has actually begun the eye must be kept as free of pus as possible by constant wash- ings with a saturated solution of boric acid. The swelled and puffy lids should have applied to them every few minutes gauze com- presses that have been kept upon a cake of ice, and the pus must be removed every hour or two. Constant cleansing and cooling of the surface will require the services of a careful nurse night and day. A 2 per cent, solution of nitrate of silver or of bichlorid of mercury, one or two grains to the pint, may be instilled between the lids every two or three hours, according to the severity of the case. As this affection so frequently results in blindness, it is well, if possible, to have the advice of an oculist. Protargol in 5 per cent, or argyrol 10 per cent, solution can be recommended as a substitute for nitrate of silver. It has the advantage of being less painful, and is equally efficient. If the disease is limited to one side an effort should be made to protect the sound eye from infection by applying a compress moistened with an antiseptic. The pupil must be dilated with sulphate of atropin if the cornea is attacked. Mastitis. The mammary glands of the new-born infant often secrete a milk-like substance, which appears between the fourth and tenth days after birth. During this time there may be swelling of the glands, which gradually abates with the subsidence of the secretion until, usually by the twentieth day at the latest, both secretion and swelling have disappeared. In some cases, however, the glands may remain DISEASES OF THE NEWLY-BORN. 23 engorged and tender, and suppuration ensue. This implies infection, and is exceedingly rare when proper antiseptic precautions have been observed during and after labor. Treatment. — When there is simple swelling the parts may be cleansed with soap and water and bathed with a weak antiseptic solution, either of carbolic acid or bichlorid of mercury. Gentle support with absorbent cotton and a bandage will also be indicated. If, in spite of this, suppuration occurs, there will be rise of temperature and the local signs of abscess. Then early incision, under proper antiseptic precautions, constitutes the treatment. Spontaneous Hemorrhages in the Newly-born. In addition to the accidental hemorrhages during the process of delivery caused by pressure effects, we may occasionally have spon- taneous hemorrhages during the first week of life that are independent of birth. These hemorrhages may occur in connection with various forms of sepsis, with congenital syphilis or from unknown causes. A general predisposing cause doubtless exists in the great alteration in the circulation induced by the transition from fetal to extrauterine life, from the rapid changes taking place in the blood at this time, and the fragile state of the walls of the blood-vessels. The blood may ooze from the mucous membrane of the nose, mouth, gastrointestinal tract, umbilicus, or vagina. The skin may also be affected, especially at the occiput, along the back and wherever pressure is apt to be exerted. There may likewise be small extravasations in the various viscera, but these are not usually recognized during life. The hemor- rhage takes the form of slow, continuous oozing and is not apt to last more than one or two days. While the actual loss of blood may not be great, a large number of the cases die from exhaustion, as losses of blood are not well tolerated at this time. The bleeding is apt to start from the intestinal tract, called melena neonatorum, when the infant may be restless or somnolent, with bloody stools, and occasion- ally vomit hemorrhagic masses. The umbilicus may begin to show oozing a few days later and hematuria is sometimes noted. Where the hemorrhage is limited to the nose, congenital syphilis is probably the cause. While the etiology of some of these cases is obscure, the condition is different from hemophilia, and the hemorrhages usually stop spontaneously in a few days. The prognosis is bad, the infants succumbing to exhaustion. Among 709 cases collected by Townsend 79 per cent. died. The treatment consists in trying to keep up the strength by careful feeding 24 DISEASES OF CHILDREN. and stimulation and by employing adrenalin in connection with the bleeding surfaces when they can be reached. Various diseases and affections that are often seen in the newly- born, but not confined to this period, will be discussed in their appro- priate sections. Among these may be noted tuberculous infection, congenital syphilis, thrush or sprue, colic and indigestion, edema, and pemphigus. SECTION II. HYGIENE OF INFANCY. CHAPTER IV. HYGIENE OF INFANCY. After birth a careful inspection of the infant should be made to discover any defects that may be present. The body should then be thoroughly oiled, and, if the infant is cold or gives evidence of poor vitalit} r , it may be wrapped in cotton batting and put in a warm place for rest. Vigorous children may be bathed in water at 100° F. shortly after the oiling and then dressed. The first bath must always be given expeditiously in a warm room. A dry dressing is best for the cord, which, after a thorough powdering, may be wrapped in sterile gauze. A daily sponging of the body with castile soap and warm water will take the place of the bath until after the cord separates. A pad of sterile gauze may be applied over the umbilicus for several weeks and kept in position by the abdominal binder. The eyes can be cleansed with a saturated solution of boric acid or a 2 per cent, solution of nitrate of silver where a purulent vaginal discharge has existed in the mother. The mouth may be gently wiped out with boiled water and a teaspoonful of tepid water given to swallow. Clothing. The clothing consists of an abdominal binder of flannel, which, in a few months may be changed in vigorous infants to a knitted band with shoulder straps. The binder should not press so tightly as to re- tard the free expansion of the lungs in breathing. Next will" come a shirt with a little extension below to which the diaper may be attached by pinning and then a flannel petticoat. Finally a dress of some light material will complete the raiment. Care must be taken to have the clothing neither too tight nor too loose. In the former case, the free movements of the chest, abdomen and legs are interfered with, while in the latter instance the clothing creases or works up and down in a manner to cause much discomfort. Long, warm stockings, with knitted bootees will keep the lower extremities protected in cold weather, and in the warm season, short, thin socks may be substituted. In early infancy the clothing is made long enough to well cover the 25 26 DISEASES OF CHILDREN. feet, but it is not necessary to have dresses and petticoats unduly long so as to drag on the feet. The Gertrude patterns are excellently adapted to the dressing of infants as the several pieces may be put on at one time, obviating unnecessary handling. Diapers may be made of linen, cotton, stockinet, or canton flannel, according to the season, care being taken to have them snugly applied and warm. Watchfulness of the nurse is required to have them quickly changed after being soiled. The Nursery. This should be a large well-ventilated room with a sunny ex- posure. The temperature should be kept constant — from 68° to 70° F. during the day and at night from 65° to 55° F., according to the age and vitality of the infant. An intake of fresh air without a draft may be accomplished by fitting a board under the lower window sash. If possible heat the room with an open fire on account of the ventilation. When furnace heat is employed, a thorough airing twice a day by widely opened windows is desirable. Bathing. After the cord has separated, a daily bath may be given. For the first six months the temperature of the water may vary from 98° to 100° F.; from six to twelve months, 95° to 98° F., and after one year it may be as low as 90° F. A good grade of soap— French or castile — may be used, and the lather removed by plunging the infant in the water. The skin must be thoroughly but gently dried without undue friction, and the folds of the skin and genitals powdered. The prepuce is to be retracted to prevent the collection of smegma. Finally, the eyes and mouth may be cleansed with a warm solution of boric acid. When the skin is thin and irritable, or the seat of eczema, bran baths may do well. In severe cases of eczema, the skin may be cleansed by rubbing with sweet oil or vaselin. Exercise and Fresh Air. When awake, the infant should not be allowed to lie continuously in its crib, as the gentle exercise of being held or carried about is bene- ficial. They should always be taken up for feeding. The arms and legs must not be so constricted by the clothing as to prevent easy move- ments and, when undressed, a little time for free play of all the muscles is beneficial. In warm weather, the infant can be taken out of doors as early as the second' or third week, in spring and fall at from four to six weeks, but if born in winter, unless the weather is mild, it may be wiser to give it its airings in the house until spring. In cold weather HYGIENE OF INFANCY. 27 it is best to give the outing between 10 a. m. and 3 p. m. when the sun is out, but the face and eyes must be carefully protected from the sun's rays. Never expose an infant to wind. When the temperature of the air is below 30° F. it is better to stay at home, except in the case of very strong infants. The baby can sleep out of doors, but care must always be taken to see that it is sufficiently warm during the winter months. In very cold weather or when there is melting snow, the infant may get fresh air by being warmly clothed, put in a room with a sunny exposure and have the window opened. The room must then be otherwise closed to prevent a draft. It is possible in this way to avoid the dust of the streets in windy weather. It is like- wise safer to take the fresh air in this manner in damp, foggy weather when there is no sun. General Habits. It is well to start early in training the infant to habits of regularity. Sleep is encouraged by putting the infant in its crib with a firm mat- tress, but with the head low, resting on a folded pad, darkening the room, and attending to proper ventilation. Rocking as a preliminary or accompaniment of sleep is undesirable. If feeding-time comes during sleep the infant can be awakened for this purpose, as he will usually sleep again after nursing or learn to wake at the proper time. The nurse need not hasten to take a baby up the moment it arouses and cries, as it will frequently go to sleep again after a few moments of rest- lessness. During wakeful hours, and especially late in the day, the infant must not be excited by too much playing and attention, as this induces delayed and disturbed sleep. The very young infant should sleep most of the time, from eighteen to twenty-two hours daily during the first months. At six months the baby usually sleeps two-thirds of the time, and at one year over half the time. Much can usually be accomplished by an early training of the bowels. As early as the third month the infant can be placed at regular times on a small commode for this purpose, taking care to support the baby in the proper position. At a year, efforts may be made to train the bladder by encouraging the young infant to indicate his desire for urination. After many trials progress will be made in this direction. The greatest regularity in feeding must be entailed from the first, but the necessary details will be considered in the chapter on feeding. Water must always be regularly given, even the newly-born getting a few teaspoonfuls daily. The young infant must always be kept quiet, as the rapidly grow- ing nervous system suffers from romping and too much attention. This must especially be enforced late in the day. CHAPTER V. WEIGHT AND DEVELOPMENT. It is important to have a record of the birth weight in every case. The male infant usually weighs a little more than the female. In a series of 200 cases examined by the writer the males weighed from 6 to 8 pounds and the females from 5^ to 7 pounds. As many of these were born in institutions the averages of light weight were fairly large. Seven pounds may be considered a good average birth weight. As far as initial weight may be considered a gauge of vitality, 6^ pounds will Fig. 7. — Platform scale for weighing the baby. show a good vitality, 5^ pounds a rather poor vitality and from 4 to 5 pounds a very poor vitality at the start. During the first few days there is generally a loss of from four to six ounces after which there should be a steady gain. It must be remembered, however, that babies are apt to gain irregularly at short intervals. One day the infant may show a gain of an ounce and the next day a quarter of that amount while doing perfectly well. Again, the weight may remain stationary 28 WEIGHT AND DEVELOPMENT. 29 for a day or so, and then jump up two ounces in twenty-four hours. According to Rotch, there should be an average daily gain from birth to five months of 20 to 30 gm. (two-thirds of an ounce to an ounce), and from five to twelve months of 10 to 20 gm. (one-third to two-thirds of an ounce). This would mean an average weekly gain during the first five months of about four and a half ounces to seven ounces, and from five to twelve months of from about two and a half to four and a half ounces. The infant should double its birth weight at five or six months, and treble it at from twelve to fifteen months. The weighing should be done by the same person either on grocer's scales or those specially Fig. 8. — Normal infant. Typical attitude. constructed for infants. Daily weighings . are deceptive and undesir- able. During the first six months, once a week is sufficient, and, in the second six months, once in two weeks is often enough in cases that are doing well. Careful records should be kept, and charting is con- venient for reference. The length of the new-born baby is slightly greater in the male than in the female. In the series already noted that was examined by the writer, the males averaged 50 cm. (19.6 inches) and the females 48.6 cm. (19.1 inches). In private practice, with healthy parents, the length will average about 20 inches. Growth in length is most rapid during the first month, a little less so during the second, the rapidity decreasing with each month. The following figures are taken from Rotch : The average increase for the first month is about 4.5 cm. (If inches); for the second month about 3.0 cm. (H inches); for the third to the fifteenth month about 1 to 1.5 cm. (£ to J inch); 30 DISEASES OF CHILDREN. for the first year about 20 cm. (8 inches); for the second year about 9 cm. (3J inches) ; for the third year about 7.4 cm. (3 inches). Just after birth the trunk, arms, legs, and head have peculiar con- formations. The body is of an elliptical shape, with the widest part at about the center over the liver, in the region of the lower ribs. The two ends of the ellipse, represented by the thorax and pelvis, are small and not well developed. The arms are stronger and better developed than the legs. During intrauterine life the baby is placed in a sort of squatting position with the legs drawn up and curled inward. This explains why the legs of the young infant are not straight, but show a decided bowing of the tibia and fibula. The soles of the feet also tend to point inward. The head is larger than the chest at this time, with a very short neck, and the baby assumes a position of general flexion. While infants at birth may vary in size, each individual should develop in proper proportion, the various parts of the body bearing a symmetrical relationship to one another. The circumference of the head is greater than the circumference of the chest at birth, and re- mains so up to the middle of the first year, when they begin to approxi- mate in size; at the end of the first year the chest expands to a greater circumference than the head. If later than this time the circumfer- ence of the head remains greater than that of the chest, it is an indica- tion of rickets or hydrocephalus. The following diagrams done in scale from 200 measurements will show to the eye the average relation- ships found at various ages. The Head. — The sutures of the skull should be ossified by the sixth month; the posterior fontanel closes at the end of the second month and the anterior fontanel from the sixteenth to the eighteenth months. Any deformities of the head due to prolonged pressure in difficult labors are usually overcome during the first few weeks. After birth and with increase in age, there is noted a gradual and steady enlargement of the great circumference of the skull, and, from this, of its estimated volume. Although no intellectual growth can be said to take place under two years, there should be an active evolution of the front of the brain, with increase of the perceptions. The first rapid growth of the brain after birth is more in bulk than in the size and com- plexity of the convolutions. Hence in early infancy the higher centers have but a slight development and function. With proper evolution, the convolutions grow and become arranged in functional groups, which groups, by their growth, alter and modify the shape of the in- fantile skull. If the skull is small or improperly shaped in any part, the brain in such area is imperfectly developing. A certain amount WEIGHT AND DEVELOPMENT. 31 of asymmetry is, however, found in all skulls as in other members of the body and, unless very marked, has no great significance. The principle of biology that the development of the individual reproduces on a small scale the development of the race, is well shown in the infant's brain. The higher centers and the association fibers are developed late in the child; they are likewise the latest acquirements LENGTH 20.7 LENGTH WEIGHT 7 LBS.12 0Z. NEWBORN 26.2 LENGTH WEIGHT 15.4 LBS. 6 MOS. 27.7 WEIGHT 18 LBS. 9 0Z. Fig. 9a. 12 MOS. -Diagrammatic table of relative measurements. of the race. The lower and more fundamental animal traits are trans- mitted by inheritance in greater degree than the higher ones. The skull changes considerably in its proportions during the first years of life, and then more slowly up to the end of the seventh year, when it has very nearly attained its full size. At birth, the circum- ference of the head averages from thirteen to fourteen inches, at the end of the second year about eighteen inches, at the seventh year about twenty and a half inches, and at the completion of growth twenty- two or more inches. 32 DISEASES OF CHILDREN. Just after birth the brain and nerve centers act only automatically, or by reflex action. Touch and taste are present at birth, but the baby is deaf for the first few days and it will not follow an object with its eyes until the third week. The eyes should never be exposed to bright lights. By the third month the baby reaches out its arms for LENGTH 29. LENGTH WEIGHT 22 LBS. 2 OZ. 18 MOS. WEIGHT 24 LBS. 24 MOS. Fig. 96. — Diagrammatic table of relative measurements. objects and may recognize individuals. The rudiments of memory are now developed, and by the fourth or fifth month a few people may be remembered and recognized. It is not until the third year, however, that memory develops very rapidly. Efforts at speaking usually begin at the end of the first year when single words may be uttered, and at the close of the second year short sentences may be tried. WEIGHT AND DEVELOPMENT. 33 The Spine. — The spinal column is curved but very flexible. In early infancy the so-called normal curves are not developed above the sacrum, but there is one long curve in the shape of a convexity above the latter bone. With the strengthening of the spinal muscles, and when the child begins to stand and walk, the normal cervical, dorsal, and lumbar curves begin to develop. As the child grows older the spine becomes less flexible and more rigid with increased power in the spinal muscles. There is, however, much more flexibility all through childhood than in adult life; when the spine loses its mobility, and especially when it is stiff or painful on motion, caries may be suspected. At birth the spinal cord extends as far as the third lumbar verte- bra, while in the adult the lowest portion of the cord is opposite the second lumbar vertebra. The spinous process of the fourth lum- bar vertebra is about on a level with a line drawn between the highest points of the crests of the ilia. Glands and Viscera. — The lacrimal glands are usually not developed sufficiently to shed tears for three or four months. The di- astase-forming organs — the salivary glands and pancreas — act very feebly during the first two or three months. The sebaceous glands are early active, as seen just after birth in the vernix caseosa and later in dry seborrhea. The thymus is large at birth, increasing slightly in size to the end of the second year and then remaining uniform in size until puberty, when it undergoes atrophy. The stomach is somewhat like a vertical sac at birth, but gradually develops in a horizontal direction; the intestines are relatively long with a sigmoid flexure that is accentuated and with sharper curves than in older subjects. The intestinal muscles are weak, which ex- plains the ease with which the bowel becomes distended with gas. The appendix is very long and narrow in lumen. The liver is large, reaching a little below the free margin of the ribs. The bladder is well developed and usually extends up into the ab- dominal cavity on account of the smallness of the pelvis. In female infants the bladder may be mistaken for the uterus at autopsy. The testicles should be located in the scrotum at birth, but they may re- main undescended in the abdomen or caught in the inguinal canal. The Muscles. — In the musculature, the greatest relative strength is shown in the hands and arms for a time after birth, At about three months the muscles of the neck have developed sufficiently to allow the infant to hold up its head in an uncertain way. At the seventh or eighth month the muscles of the back have become strengthened so that the baby can sit up, and shortly after this it may be allowed to 3 34 DISEASES OF CHILDREN. creep. Free play should be given to the muscles of the arms and legs from the first, as muscular and bony development are thereby encour- aged. The bones of the legs thus grow and straighten out, but this will be checked if the infant is made to sustain the weight of the body too soon. The average baby should not be encouraged to stand before the twelfth month. Efforts to walk may be started from then on to the fifteenth or sixteenth months. When walking has been established, the legs should be straight. Dentition. — The process of dentition begins early in intrauterine life, and the cutting of the temporary or milk-teeth should be completed at the end of infancy. At birth, although nothing but smooth gums are to be seen, the alveolar processes enclose the twenty temporary teeth in embryo. When beginning to come through the gums, they usually appear in groups. Even in healthy infants there is often some varia- tion in the order and time of the eruption of these first teeth, but the earliest to be cut are usually one or both of the middle lower incisors at the sixth or seventh month. The rest are gradually evolved, generalty in the following order: upper central incisors, upper lateral incisors, lower lateral incisors, four anterior molars, four canines, and finally the four posterior molars. The following table may serve as a general guide: Middle lower incisors, sixth to eighth month. Upper central incisors, eighth to twelfth month. Upper lateral incisors, tenth to twelfth month. Lower lateral incisors, twelfth to fifteenth month. Four anterior molars, fourteenth to sixteenth month. Four canines, eighteenth to twentieth month. Four posterior molars, twentieth to thirtieth month. As in other functions there is more or less variation within the limits of health; such irregularity as the lateral incisors being cut be- fore the central incisors may occasionally be seen. In rare cases in- fants are born with teeth, but these are poorly developed and lost early. Certain unusual cases of rickets, contrary to the common rule, may show very early dentition, perhaps beginning as early as the third month, but such teeth are poor. Delayed Dentition. — Much delay in teething is an evidence of faulty nutrition or constitutional disease, principally rickets. If an infant has cut no teeth by the end of the first year there will nearly always be marked evidences of rickets present. The latter disease is the commonest cause of delayed dentition. The teeth of rickety chil- dren are often poorly developed and prone to decay, even the second dentition may be similarly affected by this disease. Cretinism is WEIGHT AND DEVELOPMENT. 35 another cause of very slow dentition. In general, bottle-fed babies are slower in cutting teeth than those brought up on the breast. Disturbances of Dentition. — Many bodily disturbances for- merly attributed to teething are now known to have other causes that have been revealed by more accurate diagnosis and pathology. This is a period of rapid growth and instability, especially of the digestive and nervous systems. Many troubles at this time are due more to faulty care and feeding than to any normal physiological activity and growth. Still a certain number of infants do show disturbances at this time that are apparently due to the eruption of teeth, as careful ex- amination fails to show other cause. There may be evidences of ner- vous discomfort shown by constant restlessness and fretfulness, dis- inclination to take food, and various grades of indigestion. There is drooling with swollen gums, and the infant keeps putting its hands into its mouth. As light, irregular temperature may also develop that will be aggravated by indigestion if food is forced in too great amount or strength. In a few cases the infant seems much sicker, with high fever and severe nervous symptoms, such as semi-stupor or convulsions. Rickety babies are prone to the latter. Most cases, however, show the disturbances of dentition rather by an aggravation of any existing trouble that otherwise might hardly be noticeable. The treatment consists in careful regulation of the diet, which will usually take the form of temporarily weakening the food, and in giving a sedative, such as sodium bromide. Incising the gums is not advised. Any diarrhea at this time must receive prompt and careful attention. Care of Temporary Teeth. — The teeth must be cleansed twice daily by gently rubbing up and down with a very soft, wet tooth-brush. The health and preservation of the temporary teeth are necessary to favor a good set of permanent teeth. Any pyogenic germs allowed to lodge in the roots may injure the permanent teeth; milk-teeth must accordingly be filled if carious and preserved as long as possible. They also tend to preserve the alveolar shape. Permanent Teeth. — There are thirty-two in the complete set. The first molars are usually the earliest teeth to appear in the second dentition, at the sixth or seventh year. Then the central and lateral incisors, from the seventh to the ninth year; the bicuspids from the ninth to the tenth year; the canines from the twelfth to the fourteenth year; the second molars from the twelfth to the sixteenth year; and the third molars, or wisdom teeth, from the seventeenth to the twenty-first year, or even later. The proper development of the permanent teeth may be interfered 36 DISEASES OF CHILDREN. with by malnutrition or repeated attacks of stomatitis which may cause a poor formation of dentine and enamel. The ends of the incisors and molars may show constrictions and erosions. Carious teeth frequently cause earache, neuralgia, adenitis in the neck, and poor nutrition from chronic indigestion due to imperfect mastication. Hutchinson's Teeth. — Congenital syphilis will sometimes induce a change in the upper central incisors of the permanent teeth only, known by the name of their discoverer. They are small and peg- shaped, with scooped-out grinding edges, usually deflected inward; occasionally they are deflected outward. Growth during Childhood. The increase in weight and height depends upon race and climate as well as on the size and physique of the parents. It is thus evident that no absolute rules can be given for comparison that will apply to all children. We have already given data as regards infanc} r , when growth is steady and rapid. After the period of infancy, growth is not relatively so rapid and takes place more in cycles. It depends very largely upon good heredity, and a healthy well-nourished state during the first years of life. Biological researches have shown that favorable embryonic conditions and good nutrition during the earliest years have the greatest influence in determining the full height and development of the individual. If a child is fortunate in its birth and well nourished up to its fifth or sixth year, there will probably be a normal growth thereafter, as, even if there are poor conditions later on, nature will probably be able to compensate for them. Each individual has a certain normal size to attain which will usually be reached if the first years have been favorable. It is difficult to make up, however, for early unfavorable conditions. The two principal periods of acceleration of growth occur during the second dentition and at the period of adolescence. This roughly corresponds, first, with the period from six to nine years in boys and girls, and second, from eleven to thirteen in girls and from fourteen to sixteen in boys. This cycle of increase in height should precede and be shortly followed by an increase in weight. There also tends to be some variation in growth at different seasons. In a series of cases quoted by Tanner, the period of most rapid increase in height among seventy boys, from seven to fifteen years of age, was found to be from April to August, and the least from August to December, while the greatest increase in weight occurred from August to December, and the least from April to August. WEIGHT AND DEVELOPMENT. 37 a Q d a Q d >> a Q 6 3 >. Q d >> Q d 1 P d nS Q d Mo. Day. Mo. Day. O Q +3 "55 -4-3 a o DQ 03 -a O © d 0) Cm a p o *6 >> •+■3 a £ GO a> o 03 o d c a d o s- O T3 s go -G O o d o> 03 S O 5 bp ^d 03 § a s- c 1 1 s "5 o aT o d 03 6 d o a tn o a & oT t> d 03 S-c 03 d o 3 s u a 03 t-, o cT o d a> 0) s o O o o & u d a; 38 DISEASES OF CHILDREN. Whenever there is a rapid increase in height, the child is apt to grow thin and anemic, as the making of bone particularly uses up the red blood-corpuscles. The children then become nervous and table, requiring extra care at home and school. lrri- lbKyrs. 12 ki yrs. 9fcyrs. §Yz yrs. 43.9 inches 50.0 inches 45.2 lbs. 55.4 inches 59.6 lbs. 62.9 inches 76.9 lbs. 107.4 lbs. Fig. 9c. — Diagrammatic table of relative measurements. In order to present a guide of average growth, the following tables have been combined and compiled from the studies of Boas on the rate of growth in height and of Burke on the weight of American children: Table of height and weight of American boys. Fears Average height (Boas) Average weight (Burke) 6* 43 . 9 inches 45.2 pounds 7* 46.0 inches 49.5 pounds 8^ 48.8 inches 54.5 pounds 9§ 50.0 inches 59.6 pounds 12J 55.4 inches 76 . 9 pounds 15i 62.9 inches 107.4 pounds m 67.4 inches WEIGHT AND DEVELOPMENT. 39 Table of height and weight of American girls. ^ears Average height (Boas) Average weight (Burke) 6i 43.3 inches 43.4 pounds 7* 45 . 7 inches 47 . 7 pounds 8i 47.7 inches 52.5 pounds 9i 49 . 7 inches 57.4 pounds 12J 56 . 1 inches 78.7 pounds 15£ 61.6 inches 106.7 pounds 18J 114.9 pounds Mental and Moral Growth. — The mental development of the child must be carefully watched from the beginning. Just as the human embryonal life represents various upward stages of animal de- velopment; so the child's mind reproduces in miniature the earlier stages of the growth of the race. It is early necessary to recognize the vari- ous tendencies that manifest themselves in a growing child, so that they may be guided aright. It must be remembered that the child exhibits the elemental human forces and instincts. Just as the emotions are developed in the race before the reason, so it is with children, who can be moved by their sympathies long before they can be influenced by their intellect. Love is a surer guide for them than reason. This is the secret of success of many mothers and of some teachers. The most lasting impressions of childhood come through the feelings. At the end of infancy, and during early childhood, the imitative faculties are especially dominant. The acts of older children, of adults, and even of animals are faithfully copied without much idea of their significance. Up to the age of seven years much of the training and education of the child must come from imitation. Before this age nearly all the playing of children is imitative, shown by the delight in toys representing articles in real life, but after this, especially in boys, the games take on a more competitive form involving muscular exercise. There exists in some children a touch of barbarism that is merely an evidence of underdevelopment. Apparent cruelty, shown in a callousness to suffering, is sometimes seen, but this is rather due to a lack of experience as to the meaning of pain than to defective moral sensibilities. The conduct of the child is largely influenced by the tone and temper of those around him, in the intellectual as well as in the moral sphere. A cultivated home will do more for the proper devel- opment of the child than the formal education of the finest schools. Adolescence. — The beginning of this period is a most interesting and critical time for the child. Up to this time, as already noted, the 40 DISEASES OF CHILDREN. child has lived "the race life, but he now begins to develop individual characteristics, and family traits come out more strongly. There is a rapid growth of all parts of the body, especially marked in the reproduc- tive organs and the heart and lungs, with increase in blood-pressure and in general glandular activity. The appearance of hair on the pubes is considered characteristic of the period. The peculiarities of sex now begin to manifest themselves; boys and girls cease to mingle in such an indiscriminate way as in earlier childhood. Up to twelve years there need not be much differentiation of the sexes, but after this they must be separately considered. Vague aspirations and a general restlessness show the stirring of new life in the child's mind. Both the emotional nature and the imagination become very active. If any trait is entirely absent at this time it is not apt to be seen later in life. As growth and development are so rapid during adolescence, nothing must be allowed to conflict with the physical nature at this time. Overstrain in school must be guarded against. It has been proven from examinations of many school children that, as a rule, the heaviest and tallest, or those with the best physique, stand highest in their classes. Hence if a child is poorly nourished or undeveloped, the best thing, even for his intellectual growth, is to focus attention on his body for a time and let his mind be temporarily neglected. Appar- ent stupidity or bad mentality in school children is often the result orphysical causes that may and should be removed. Deafness, defect- ive eyesight, enlarged tonsils and adenoids, and poor nutrition from lack of proper food may be especially mentioned in this connection. SECTION III. THE EXAMINATION OF THE SICK CHILD. CHAPTER VI. THE EXAMINATION OF THE SICK CHILD. If the physician unaccustomed to the care of children will first learn what to expect to find in the normal child, he will better appre- ciate the variations in disease. He must first of all learn that a proper examination will take time, and that a hurried examination often leads to grievous errors. Having once made up his mind to be systematic, thorough, and painstaking, the bugbear of pediatric practice will begin to disappear, and diagnoses will be made where formerly there was dis- appointment and confusion. The younger the infant or child, the greater are the peculiarities from the adult type in its relation to disease. History. — If possible obtain the anamnesis outside of the nursery. It should preferably be obtained from the mother or attendant who has been in closest attendance upon the child. First — elicit a natural story as to the change from the healthy child to the sick one. If digres- sions are made they can be guided back to the proper channels. This will give a clue to the nature of the illness, and the further questions will be modified considerably thereby. For example, if the disease be one of malnutrition, most careful details of previous feeding from the time of birth will be pertinent, and the dietary life traced to the present time. Heredity and environment are inquired into, and previous illnesses recorded on properly prepared history blanks. The accompanying history card, as suggested by Dr. R. S. Haynes, is one that is convenient to carry, and tends to making recording systematic and of value without much waste of time and energy in writing. Inspection. — The child asleep. Trained observation is the most valued asset of the pediatrist. If possible, examine the child while it is asleep. Sit by its crib and watch it. Its general posture, if quiet or restless is to be noted. The breathing as to its character must like- wise be observed, and the number of respirations per minute counted. Respirations. Newborn, 35 to 45 First to second year, 20 to 25 First to the second month, 24 to 36 Second to sixth year, 20 to 23 Second to the sixth month, 20 to 32 Sixth to twelfth year, 18 to 20 41 42 DISEASES OF CHILDREN. W) < « to O -£ 11=3 I I u 03 tt) ^ QQ 03 03 rn ^ A g ^ O rC -1-3 -Q So u 3 «§ ^ PQ X o H CO »— i W 5 03 75 20 -d -^ ^ ? 3 «S £ s-. OT3 ^3 o > ho = QQ - H ■/. , w .5 +3 '3 03 6 03 13 ~ i o 03 h3 .2 d O a> 03 M GO o a* d s .fa o£ 00^ H el 550 bJD O .2 § ~ £ 22 o\S2 S3 si w a a) o3 co >> c3 *c3 _°, .2 eo - ai C-p •r« 03 d j?«. m 5g> ^S 03 ^ .£ ^ — « CUI? 03 S o >» d X -I •a « i U E i •'-- o it * s i °s 5 2" ' °3 ] - 1 S" ' •„ 8 "III 9" " *>„ ?. S ""a x ? ■" *_ s - •-."' ■* ! i CO =>" * *« - ui » ft 1 ^ -»--■-- i < »- ■j y^ ' w s ~ „ — I 5 " 4 \ j5 ■* =*" "_ ~ - ea~ \ V — \ ft " 1 ; ■ Hill * ~H~~ '' ■ • ■- .1 • .... 1 . . 1 1 y' j 51 *^ ? a? 1 » at|* i * • 1 Sf t |x; 3 *f 2 *S SCpt >»■; j x ; £ at 2« : - X 5* »a? : V^ "3 'SQNnOd Nl 1H0I3M tion is reversed for the left side of the body. Any abnormalities, new-growths, or diseased conditions of the structures and viscera in the lower abdomen can then be palpated and much information gained. In cases of tuberculous peritonitis the abnormal omental thick- 50 DISEASES OF CHILDREN. ening and the matting of the intestines can often well be made out, the diagnosis thus confirmed, and the prognosis made more definite. Enlarged mesenteric and retroperitoneal glands are palpable by a sweeping motion of the introduced finger without the necessity of changing hands. Intraabdominal sarcomata can be quite definitely located; calculi in the bladder or ureters palpated, malformations of the kidneys or enlarged kidneys, as in hydro-, or pyonephrosis may be distinguished. Therefore, in an abdominal case where the diagnosis is not abso- lutely clear and uncomplicated, the examiner should not pass judg- ment upon a given case without recourse to a thorough examination through the rectum. CHAPTER VII. SPECIAL EXAMINATIONS. A culture and a smear should be made for examination if the throat/e. g., shows a suspicious membrane or if there is a serosanguino- lent discharge from the nares. A sterile cotton applicator is swabbed over the area and gently wiped over the culture medium or upon a clean glass slide. A purulent secretion from the eyes may demonstrate on smear the presence of the Koch-Weeks bacillus or the gonococcus of Neisser. A similar test of a vaginal or urethral discharge will be necessary to determine the character of the contagion and the necessary precautionary measures. Sputum for examination can be obtained in younger children by means of a laryngeal applicator passed down the epiglottis, or by pass- ing a catheter partly into the esophagus. Fluid obtained by lumbar puncture should be collected into sterile tubes and allowed to stand until a coagulum forms. This is taken for examination. Centrifuging is then done, and a further search made for the causative agent and cell content. (For technic, see p. 52.) A drop or two should be allowed to flow over a culture medium for in- cubation and possible growth. Aspirated fluid from the chest when slightly clouded is microscop- ically examined for the presence of pus-cells, and operative interfer- ence is often based on their numerical estimate. (For technic, see p. 54.) Blood is best taken from the lobe of the ear or finger-tip. The part is well cleansed and the first drop obtained wiped away. No undue pressure should be used to obtain a blood flow. The pipette or the Tallquist scale is used for the hemoglobin estimation. A thin smear is made for malarial organisms. For the typhoid test (Widal) three droplets about the size of the head of a black pin are collected at different points on the glass slide. The differential count is made from a thin smear and stained. For details and technic see a labora- tory guide to diagnosis. The X-rays are of late assuming a greater importance in pediatric practice. Foreign bodies swallowed or aspirated, fractures and dis- locations, bone changes and tumors, estimation of anatomic age, dis- placed viscera, consolidations and exudations are conditions in which 51 52 DISEASES OF CHILDREN. we can obtain valuable aid. Short exposures should be made with the best tubes. An anesthetic is sometimes necessary for unruly children. Technic for Subdural or Lumbar Puncture. One of two positions may be selected: the sitting posture, or the child may be placed on its side with the spinal column well flexed. Cleanse the lower lumbar area until the parts are surgically clean. The operator, who has thoroughly cleansed his hands then takes the sterilized needle in his right hand, as one holds a pencil in writing, Fig. 16. — Method of performing subdural or lumbar puncture. and inserts the same at right angles to the body through the inter- vertebral disk between the third and fourth lumbar vertebrae (see Plate V). This point is conveniently located by placing the index- and third fingers of the left hand on the highest points of the respective iliac crests, the middle finger being placed on the vertebral spine which is on the same level as the crests above determined. This is the third lumbar spine, and the point of election is midway between this spine and the one immediately below it. The needle meets with onlv carti- PLATE I. It L — , / : II tree z SPECIAL EXAMINATIONS. 53 laginous resistance if properly inserted, and should be introduced about three-quarters of an inch. If bony resistance is encountered, with- draw slightly (not entirely) and change somewhat the angle of inser- tion. If the spinal canal is entered a free flow of fluid follows; then allow the fluid to escape into a sterile tube. At the same time collect two or three drops in a culture tube of blood serum. When 15 c.c. have been collected quickly withdraw the needle and seal the punc- ture wound with cotton and collodion. Estimation of Hemoglobin. (Tallquist Method.) After puncturing the tip of the finger or lobe of the ear, allow the filter-paper to slowly absorb the drop until an area the size of a dime has accumulated. Allow to stand until the humid gloss is lost, then compare with the scale provided pressing the color scale firmly against the blood stain, using daylight but not direct sunlight for il- lumination. This method w T hile a ready and inexpensive one compares very favorably with the Dare hemoglobinometer, above 50 per cent. Test for Indican. The simplest and probably the most accurate test for indican in urine is performed as follows: to a clean test-tube add four to six drops of a 1 per cent, solution of potassium permanganate, then 1 or 2 c.c. of chloroform, then 10 c.c. of concentrated hydrochloric acid C. P., and lastly 10 c.c. of urine. Invert the test-tube two or three times to thoroughly mix and allow to stand five minutes. The ethereal sul- phates in the urine are broken down by the hydrochloric acid and are oxidized by the potassium permanganate to indigo which is dis- solved by the chloroform, giving a deep blue color, the intensity of which when compared with the color scale (Plate I) deter- mines the extent of the putrefactive changes occurring in the intestine. Transudates and Exudates. Rivalta has recently perfected a test for accurately distinguishing between transudates and exudates. Add 2 drops of acid acetic (glacial) to 100 c.c. of water to make the test solution. Allow the exudate, a drop at a time, to make its way down through the dilute acid medium and it will leave a bluish trail in the water like a puff of cigarette smoke, each drop leaving a separate 54 DISEASES OF CHILDREN. trail. The fluid remains clear and unaltered if the added drop be that of a transudate. Technic for Aspiration of Pleural Cavity. Sterilize a needle and clean the chest wall over the site of election, in all cases observing strict surgical asepsis. Place the child in a sitting posture with both arms drawn well forward, then holding the needle at a right angle to the body, puncture in the midscapular or in the posterior axillary line (preferably the former), the point of election being the interspace just below the angle of the scapula. Insert the needle about three-quarters of an inch. From the fluid a culture is made and the remainder is collected in an empty sterile tube for further examination. Seal the puncture wound with cotton and collodion. Tuberculin Tests (also see p. 324). One of three tests may now be selected for use in suspected tuber- culous children. The skin test was superseded by the eye test and inunction test, but to-day it has the greatest number of advocates, since it is the most reliable and at the same time least annoying to the patient. Skin or Von Pirquet Test. This is made by scarifying three small areas on the arm, as for vaccination, and inoculating the central one with a drop of Koch's old tuberculin (obtainable in the market), using the upper and lower areas as controls. In from twelve to forty-eight hours (occasionally even longer) a reaction will be observed in tuberculous individuals. At first a reddened blush appears which soon becomes inflamed and resembles the first stages of a successful vaccination. The controls should show no reaction. In advanced cases the reaction usually fails, due to the presence of numerous antibodies in the blood of the child. The Calmette or Eye Test. In selected cases in which we are positive that the eye is normal, one drop of a one per cent, solution of tuberculin for older children and a one-half per cent, for infants, is dropped on the lower lid of one eye and the eyelid held down for a moment before allowing the eye to close; the closure should not be spasmodic, but gentle; it is better to gently massage the eyelids over the eyeball for a moment. PLATE II. The ocular, percutaneous and cutaneous tests, (a) ocular reaction; (b) inunction or Moro reaction; (c) cutaneous or Yon Pirquet reaction. SPECIAL EXAMINATIONS. 55 A positive reaction is indicated by a feeling of annoyance in the eye which ensues in from six to twenty-four hours, or even after two days. The palpebral or ocular conjunctiva becomes injected, later the caruncle is swollen, and, in intense reactions, an exudate is observed. The patient complains of having a '• cold in the eye." The symptoms soon diminish, so that in four to five days the eye is quite normal again. The indiscriminate use of this test has led to reports of corneal ulceration. The severity of the reaction is no criterion for the in- tensity of the infection. Severe reactions may follow in incipient cases. As in the skin test, active and latent cases will react, but those far advanced may give a negative test. It should be remembered that no immunity to tuberculin is produced by these tests; the other eye will react; a skin test or inunction test can be subsequently made in the same individual. The Inunction or Moro Test. The Moro reaction is obtained by using a 50 per cent, tuberculin and lanolin ointment, and vigorously rubbing a piece the size of a split pea for a few moments over the site selected; this may be, for example, the axillary or the interscapular region. A maculopapular eruption is produced in the tuberculous at the annointed area in from twelve to tw r enty-four hours. It may persist for five days to over a week, and in neurotic children may appear on the opposite side of the body. The test is simple, easily performed and commends itself for use with intractable children. Thread Reaction in Pyelitis. Pf aundler demonstrated " that a bouillon culture of bacilli grown on urine and mixed with the blood serum of the same patient will produce, even when considerably diluted, an agglutination" such as occurs in other bacillus coli infections. The bacteria to be examined are grown on agar-agar, a twenty- four hour culture being employed. Three drops from the (water of condensation) culture are added to a bouillon tube. This emulsion is mixed with the patient's serum in the proportion of one to thirty or one to fifty, and then examined in the hanging drop. After twenty- four hours if the reaction is positive the following appearances develop: "The small rods grow out into delicate extremely long threads which appear claw-like and interwoven, and form lump} r groups under slight magnification. The groups are either isolated or else are connected ,")(') DISEASES OF CHILDREN. by extremely delicate filaments. Between the single filaments the liquid is perfectly free from form element. The threads and filaments do not present the least indication of mobility. Under high powers the threads appear partly articulated, granular and sometimes thick- ened with clubs. The threads are greatest in length, and the filaments are densest in the reaction where the serum dilution is the least." To produce this reaction the necessary conditions are: "the employment of a serum of microbes from the same patient and the nee of fever during the infection as an indication of the general disturbances, the reaction, however, fails not only in light cases of brief duration, but in serious cases which end in death." The Wasserman Test for Syphilis. This reaction has proven to be of distinct value in the diagnosis of suspected cases of syphilis. It can be used, however, only in lo- calities where there is a well-equipped laboratory which has the spe- cial apparatus required for its performance. In spite of the many attempts which have been made to simplify the test, it still requires a special training and much time if reliable results are to be obtained. Fox, in a recent communication from which this is freely drawn, describes the technic and explains the principles upon which this is founded. He concludes that the reaction must be considered as a union taking place between certain lipoid substances and the antibodies existing in syphilitic blood. The reaction requires that five substances be carefully secured by following a certain method and laboratory technic: (1) Antigen — made from the liver of a syphilitic fetus or from crude lecithin. (2) Antibody — serum from the patient's blood. (3) Complement — serum from the blood of a guinea-pig. (4) Hemolytic amboceptor — inactivated, standardized serum from the blood of a rabbit previously injected with sheep's corpuscles. (5) Sheep's corpuscles. These five substances are added to the serum of the suspected patient, and also to the serum of a known positive and a negative case. Ample controls are made to insure that complete hemolysis takes place and that neither the antigen nor the patient's serum does not bind the complement. Complete hemolysis denotes a negative result, while inhibited hemolysis is classed as positive and graded according to the degree of intensity as strong-positive or weak-positive. CHAPTER VIII. SIGNS OF ILLNESS IN INFANCY. As it is by no means easy in every case to tell exactly when or how an infant begins to be ill, a close observation of symptoms and their proper interpretation becomes highly important. Slight causes often produce very marked and sudden effects at this time of life. This is explained by the active growth of infants and especially by the rapid development and irritability of the nervous system. Thus a really slight indisposition may present the appearance of severe dis- ease, while the converse of this is sometimes true, as serious illness may so blunt this delicate nervous susceptibility as to cause the true gravity of certain cases to be overlooked. Attention may be called to various conditions that are evidences of some disturbance, and to note what they usually signify. Irritability of Temper. — In the absence of speech, the infant shows discomfort or suffering principally by cries and restlessness. If watched closely, it may by certain signs indicate to some extent the seat of the trouble. In headache, the hand will be frequently raised and held beside the head; in earache, the hand will be carried to the ear, and often pull upon that organ; in difficult and painful dentition, the fingers will be constantly inserted in the mouth, as if to pull out the cause of distress; irritation of the stomach and bowels may be accom- panied by a continual rubbing of the nose. During an attack of colic, the legs are drawn up over the abdomen, which feels hard, and there is likewise a writhing motion of the body. Crying is a very constant accompaniment of all kinds of illness. Constant, uninterrupted cry- ing is usually caused by earache, hunger, or thirst. If, after giving the baby suitable nourishment or a drink of water, it still keeps up a continuous, almost automatic cry, there is probably severe pain in the ear. This may be confirmed by pressing in front and behind this organ, when the baby will wince. Where there is some disease in the head, a sudden, piercing cry is uttered at certain intervals, between which there will probably be no fretting. In pneumonia, there is crying only during spells of coughing and a short time after; in pleurisy, there is likewise crying only during coughing, but it is shriller and shows more suffering than in pneumonia, and is also produced by mov- 57 58 DISEASES OF CHILDREN. ing the child and pressing over the affected side. Crying just before or after a movement of the bowels, with a twisting of the pelvis, gives evidence of intestinal pain. Where the hand is tightly shut, with the thumbs thrust deeply into the palms, and the toes strongly bent, there is much nervous irritation, which may eventuate in a convulsion. Restless Sleep. — Much may be learned by a careful inspection of an infant during sleep. A well child always sleeps quietly, but, when ill, sleep is fitful and sometimes only possible when the infant is rocked or patted or carried about in the arms. If there is a constant kicking off of the bedclothes, so that the child will not long keep covered even in cold weather, it is a pretty sure indication of rickets. When it is impossible for a child to sleep unless the head and shoulders are raised high upon a pillow, there is usually some disturbance in the ac- tion of the heart or lungs. If a child sleeps with its mouth wide open and the head thrown back, there is enlargement of the tonsils or ade- noid tissue at the vault of the pharynx interfering with natural quiet breathing through the nose. A persistent boring of the back of the head into the pillow points to cerebral irritation. When sleeping with half-open eyes, there is apt to be moderate pain present, and, if there is a constant movement of the lips, the discomfort is located in the gastrointestinal canal. Changes in the Features. — When illness is present, it is quickly shown in the countenance of the infant, which, during health, is in a condition of easy repose. In general, it can be stated that the upper part of the face is involved in diseases of the head, the middle part in affections of the chest, and the lower part in disturbances involving the abdominal organs. Thus in disease of the brain, the forehead and eye- brows will be sharply contracted, and the eyes sensitive to light with various changes in the pupils. Puffiness and swelling about the eye-lids point to dropsy, which is usually caused by diseases of the kidneys following scarlet fever or other infectious process, but occasionally by severe anemia. In pneumonia and pleurisy the nostrils are sharply defined, and dilate and contract with the movements of respiration which will appear more or less labored. The mouth is the feature most affected in abdominal disease, shown by a drawing of the upper lip and other movements indicating pain. State of the Discharges. — A careful examination of all the organs opening upon the surface of the body must be made to detect any abnormal discharges. The ears, eyes, nose, mouth, urinary and rectal regions must thus be carefully inspected. The upright position of the stomach during infancy renders vomit- SIGNS OF ILLNESS IN INFANCY. OV ing a frequent and easy symptom when this organ is distended. In such a case there may be a regurgitation of some slightly curdled milk after each feeding. The infant shows no distress from this act and c< >n- tinues in a good condition of health; the stomach simply rejects any excess of food above that which it can readily hold. But sudden and profuse vomiting, without any error in diet, may constitute the beginning of severe illness, such as scarlet fever, diphtheria, or some brain disease. Acute illness in early life may begin with vomiting in place of the chill seen in older subjects. Vomiting may simply be a sign of local disturbance in the stomach, as when mucus is ejected in cases of gastric irritation. Where tough curds are vomited with the milk very sour, there is evidence of fermentation of the milk and an overacid condition of the stomach. If this persists, the mouth will become red and sore from a direct continuity of the irritation. Much can be learned by investigating the number and character of the discharges from the bowel. During the first two months there are usually three or four stools in the twenty-four hours, and during the first two years, two stools a day on an average. The stools are homogeneous, of a soft, semisolid consistency, and of yellowish color. In cases of diarrhea or inflammation they may be green, or contain hard, lumpy curds, or have an admixture of mucus and blood, or be of very watery consistency. Abnormal stools will be considered more at length in the section devoted to diarrhea. The urine is passed many times in the twenty-four hours, and the diaper may have to be changed as often as every hour. Infants vary in this, however, as they may go six or eight hours without voiding urine. If twelve hours pass without it, a careful examination must be made in order to reveal the cause of retention. In some cases where the urine is highly acid, it may be expelled when a few drops collect in the bladder, and, as this amount quickly dries in the diaper, there is no evidence from wetting that urine has been passed. A dark, smoke- colored urine may indicate nephritis, and thus be of great significance. Scanty urine, loaded with uric acid and the urates, may leave a red deposit upon the napkin simulating blood. CHAPTER IX. GENERAL THERAPEUTICS. Under this heading will be described methods and means of treat- ment that are ordinarily employed in pediatric practice. As these various measures are used in a number of conditions, it is advisable to discuss them at some length and later refer to this chapter when outlining the treatment for a certain disease. Drug Administration. Never prescribe a drug without a good and sufficient reason. Prescribe so that the dose will be small in amount and as agreeable as possible. Heavy syrupy mixtures may be agreeable, but are apt to give rise to fermentation from excess of sugar. Pills and capsules are not intended for children who rarely can swallow them. Pre- scriptions should be simple and if possible contain but one or at most two drugs. Powders made up with sugar of milk are mixed with water and given from the teaspoon. Tablet triturates form an easy and accurate method of giving drugs (except nitroglycerin). If the child is unwilling, the medication on the spoon is quickly slipped on to the tongue and the spoon held in position well back until swallowing takes place. In this way the child cannot regurgitate it. Begin with small doses in early life and increase if the desired effect is not obtained. Heroic doses, however, may be used in emergencies where rapid and active stimulation is required. Hypodermatic in- jection of the stimulant is often required to produce physiological effects. The rule that an infant up to a year should receive one-twentieth of, and at one year one-tenth of the adult dose, is to be followed in the majority of cases. The stimulants, however, are exceptions to this rule. At the fifth year one-fifth, and about the tenth year one-half the adult dosage is usually to be given. Castor oil should be administered ice cold on a wet spoon. The taste of quinine in solution may be disguised with syrup of verba santa, extract of licorice or syrup of wild cherry, but it is not unusual to find children who take bitter medication better than adults. Tasteless quinin in the form of euquinin, tannate of quinin, or saccharated 60 GENERAL THERAPEUTICS. 01 quinin is now obtainable. Sweet chocolate disguises the taste ad- mirably. Opium or its derivates, with the exception of codein, are to be largely avoided. The coal-tar derivatives, combined with caffein are used at times to control pain. They should be given in small doses, and not as a routine measure for the control of pyrexia. The drugs or preparations of drugs most frequently used internally with the greatest advantage in pediatric practice are: (1) Calomel. Castor oil. Fowler's solution. Basham's mixture. Bismuth subnitrate. Bromids. Cascara sagrada. Cod-liver oil. Strychnin sulphate. Digitalis. Sweet spirits of niter. Syrup of iodid of iron. Tincture of nux vomica. Salicylates Alcohol. Potassium iodid. Ammonium compounds. (2) . Atropin. Camphor. Nitroglycerin. Chloral hydrate. Codein phosphate. Dover's powder. Hexamethylenamin. Hydrochloric acid. Liquorice powder. Phenacetin. Rhubarb. Salol. Iron compounds. Asafetida. Santonin. Aspidium. Ipecac. TABLE OF AVERAGE DOSAGE. Drug- Aconite Tinct. (10 per cent.) gtt. | Ammonium Chloride gr. ] Ammonium Carbonate .... gr. { Ammonium Acetate Sol. (Spirit Mindererus) gtt. 10 Ammonium Aromatic Spts. gtt. 3 (Liq. Ammonii Anisatis) . gtt. 1-2 Antipyrin gr. \ Antitoxin . Diphtheritic Immunization 500 units Pharyngeal Type 3,000 units Laryngeal Type 10,000 units Arsenic Fowler's Sol. (Liq. Pot. Arsenitis) n\ £ Arsenious Acid gr. ,.,',„ Dose, Dose. I Maximum F equency in 24 hrs. Age 5 yrs. q. 4 hrs. dr. 3-6 q. 1-4 hrs. dr. ^-lh q. 1-4 hrs. gtt.30-d~r.l t.i.d. gr. 5-10 500 to 1,000 units 5,000 units 10,000 units »ll 500 to ] Repeat 1,000 units | or double the dose 5,000 units fin 12 hrs. 10,000 I if neces- units sary. to effect j n 2-3 gr. t.i.d t.i.d. n\ 10, or to effect 62 DISEASES OF CHILDREN. TABLE OF AVERAGE DOSAGE.— Continued. Drug Dose, Age 6 mos. Dose, Age 2 yrs. Dose, Age 3 to 5 yrs. Dose, Frequency Dose, Maximum in 24 hrs. Age 5 yrs. gtt • i gr- i gr. 1 gr. o RT. 2-3 gr. 5-10 gr. i-1 gtt . 5-10 Asafetida, Milk of, by rectum only dr. 1 Aspidium Oleoresin Aspirin gr. 1 Atropin gr. ^ Basham's Mixture Belladonna Tinct Beta-naphthol Benzoic Acid Bismuth Subcarbonate Bismuth Subgallate (Dermatol) Bismuth Subnitrate . . . Bismuth Salicylate .... Brandy (Cognac) Bromide, Ammonium ] Bromide, Potassium Bromide, Sodium Bromide. Strontium Brown Mixture (see Lico- rice Comp. Mixt.). Caffein Citrate Calcium Chlorid Calcium Sulphid Calomel Camphor, Pulverized Camphor Spts. 10 per cent. Cascara Sagrada, Ext Cascara Sagrada, Fluid Ext Castor Oil dr. 1 Cerium Oxalate '. Chalk, Prepared gr. 2 Chalk Compound Mixt dr. 1 Chloral Hydrate gr. £ Chloroform Spirits gtt. 1-2 Cinchona (see Quinin). Codein gr. sV Cod-liver Oil dr. \ ate Creosote Carbonate Digitalis, Tinct gtt. \ Digitalis, Infusion gtt. 10 Digitalin gr . ,fo Dover's Powders (see Opium Powders of Ipecac). Dionin gr. ^r Ergot, Fluid Extract gtt. 2-3 Ether, Compound Spts. (Hoffman's Anodyne) . . . gtt. 2 Ether, Nitrous Spts. of (Sweet Spirits of Niter) . . gtt. 2 dr. 1-2 try 10 gr. 1-2 dr. i gtt. 1 gr. h gr. 2 gr. 10-15 dr. 1-2 ra 30 gr. 3-5 gr- d>o dr. 1 gtt. 2-5 gr. 1 gr. 3-5 gr. 15-30 pro doso once q. 4 hrs. q. 4 hrs. t.i.d. q. 4 hrs. t.i.d. q. 4 hrs. p.r.n.' gr. 5-10 gr. 5-10 p.r.n. gr. 10-15 gr. 10-30 p.r.n. gr. 1-2 gr. 2-3 p.r.n. gtt. 10-20 gtt. 20-30 q. 3 hrs. dr. 2 r^ 10-30 gr. 15-20 gr- in) oz. ^ t. l 5-10 gr. 3 gr. 5-10 dr. 2-3 dr. 2\ oz. \ gr. 5-15 dr. 1-oz. \ gr. 1-3 gr. 3-5 gr. 5-8 gr- \~\ gr. \ gr- ~h gr- T V-i gr- h gr. \-\ gr. 1 gr- io gr- i-1 gr- I gtt. 5 gr- h gtt. 5 dr. 1-2 gr. 1-2 gr. 3 dr. 1 gr. 1-2 gtt. 2-3 gr- h dr. \ gtt. 1-2 gtt. 1-2 gtt. 1-2 dr. \ gr- T?o gr. ,V gtt. 5 gtt. 5 gtt, 5 q. 4 hrs. gr. 25-40 gr. \ gr. 2 gr- to gr- t-2 gr- i gtt. 5-10 gr. 1-2 gtt. 5-10 dr. 1-4 2-3 5-8 1-2 2-3 5-10 gr- dr. gr- gtt. gr- tV dr. 1-2 gtt. 2-3 gtt. 2-3 gtt, 2-3 dr. 1-3 gr- dro gr- tV gtt. 10-15 gtt. 10 gtt, 10 q. 4 hrs. t.i.d. t.i.d. in divided doses q.2 to 4 hrs. t.i.d. t.i.d. t.i.d. pro doso t.i.d. q. 4 hrs. q. 3 hrs. q. 4 hrs. q. 4 hrs. q.4 hrs. t.i.d. t.i.d. t.i.d. q. 4 hrs. t.i.d. p.r.n. t.i.d. t.i.d. gr. 2 gr. 4-6 gr- tV-4 gr- i-2 gr. 1-1 ra 10-30 gr- 2-5 dr.^ oz. i gr. 5-10 gr. 20-30 oz. 1 gr. 5-10 dr. \ gr. i-f oz. $— 1 gtt. 5-10 gtt. 5-10 gtt. 5-15 dr. 3-oz. 1 gr- to gr. i dr. \ p.r.n. dr. \ q. 1-2 hrs. dr. 1£ GENERAL THERAPEUTK 9. TABLE OF AVERAGE DOSAGE.— Continued. 63 Drug Dose, Age 6 mos. Dose, Age 2 yrs. Dose, Age 3 to 5 yrs. Dose, Frequency Dose, Maximum In 24 hrs. Age 5 yrs. Ferric Prep, (see Iron). Fluoroform (2.8 per cent. sol.) Fowler's Sol. (see Arsenic Liq. Potass.). Glauber's Salts Glonoin (Nitroglycerin). . . Glonoin (Spts. of) Guaiacol Carbonate Heroin Hydrochlorid Hexamethylenamin (Uro- tropin) Hoffmann's Anodyne (see Ether Spts. Comp.). Hydrochloric Acid, Dilute Hyoscyamus Tinct Hydrargyrum (see Mercury). Iodid, Sodium, and Potas- gtt. 1 gr. *ta gtt. i gr. i gr- lU gr. \ gtt. \ gtt. * gtt. 2 gr. 30 gtt. 6 gr- *U gr- iAo tO TTTTT q. 2-4 hrs gtt. i gtt. 1 q. 2-4 hrs gr. 1 gr. 5 q. 4 hrs. gr- rh gr- tV q. 4 hrs. gr. 1 gr. 2-5 t.i.d. q. 2 hrs. gtt. 18 gtt. 4-8 gr. 20 gr- A sium gr. 1 Iron. Iron. Oxid Saccharated. . . Ferric Chlorid, Tine Liq. Ferri et Ammonium Acetatis (see Basham's Mixt.). Soluble Citrate of Iron (Ferri et Ammonii Citras) Syrup of Iodid of Iron gr. 1 gr. i Pyrophosphate of Iron, (Soluble) Elixir of Reduced Iron Liq. Ferri Peptonati (N.F.) . Ipecac, Wine of (Emesis) . . Ipecac, Syrup of (Expector- ant) Jalap, Powdered Licorice Compound Mixt. (Brown Mixture) Liquorice Compound Pow- der Magma Magnesia (N. F.) Milk of Mag Magnesium Citrate (Liq. Magnesia Citrate Effervescent) Magnesium Sulphate Male Fern, Oleoresin (see Aspidium). Mercury Bichlorid itl 5 gtt. 5 gtt. 2 gr. h gtt. 15 gr. 10 ^ 10 oz. £ gr. l.~> gtt. 2 gtt. 2 gr. 2 gr. 2 m_i gr. 1 gtt. 5 n\ 5 gr. h \xi 10 dr. \ gtt. 3 gr. 2 gtt. 5 gtt. 3 gr. 3 gr. 5 rri 3 gr- 3 gtt. 5-10 m 15 gr. 1 in 30 dr. \-l gtt. 5 gr. 3 gtt. 20-30 gtt. 30-40 gr. 20 dr. £ t.i.d. t.i.d. t.i.d. t.i.d. t.i.d. t.i.d. t.i.d. t.i.d. t.i.d. t.i.d. q. £ hrs. to effect q 4 hrs. once q. 3 hrs. gr. 5-15 gtt. 15 gtt. 10 gr. 5-10 gr. 3-15 in io gr. 3-10 gtt. 15- dr. \ x\\ 45 gr. 3 dr. H dr. 3 gr. 40-dr.l bed time dr. 1 t.i.d. oz. 2 oz. 4 gr. 30 gr. 60 gr. -As gr. T fo gr. ', 111 A. M. in \. if. t.i.d. dr. \ gr. 3 dr. 2-o*. \ dr. h-1 dr. 3 oz. 6 dr. 1 gr. 15 64 DISEASES OF CHILDREN. TABLE OF AVERAGE DOSAGE.— Continued. Drug Dose, Age 6 mos. Mercury Mild Chlorid (Calomel) gr. T V~£ Mercury Biniodid gr. T Ao Mercury with Chalk (Gray Powder) gr. \ Morphin Sulphate Niter. Sweet Spirits of (see Ether Spts. Nitrous). Nitroglycerin (see Glonoin) Nux Vomica Tinct gtt. 1 Novaspirin gr. 1 Opium Tinct. (Laudanum) Opium, Camphorated Tinct. gtt. 3-5 Opium, Power of Ipecac and (Dover's Powder) gr. |-J Peppermint Water (Aqua Mentha Piperita) dr. \ Pepsin Powdered gr. 1 Pepsin Essence of (N. F.) . . gtt. 20 Phenacetin (Acetpheneti- din) Phosphorus Syr. Calcii Lactophos. . . Phosphoric Acid Dil Syr. Hypophosphites . . . Potassium Acetate Potassium Bitartrate Potassium Bromid Potassium Citrate j Potassium Chlorate Potassium Iodid (Expec- torant) Potassium Iodid (as Anti- syphilitic) Quinin, Sulphate and Bi- sulphate Rhubarb Powdered Rhubarb Syrup Arom Rhubarb and Soda Mixture Rhubarb and Anisated Magnesia Pulv. (N. F.) . . Salicin Sodium Salicylate Methyl Salicylate Aspirin gr. 1 Oil of Wintergreen gtt. 1 Salol gr. \ Santonin i , Serum Antidiphtheritic ( Antitoxin). Serum Antimeningitic .... 15 c.c. Sodium Benzoate gr. 1 Dose, Age 2 yrs. gr- \ gtt. 10 gtt. 1-2 gtt. 15 gr. 1 dr. \ gr. 1-3 gr. 1 gr. \ gr. \ gr. 1 gr. \ gr. 1 gtt. 15 gr. 3 gr. i-1 gr- -h gr. \ gr- -so gtt. 2 gr. 1-2 gtt, 1-2 gtt. 15 gr. I dr. 2 gr- 2 gtt. 30 gr. 1 gtt. 30 gtt. 5 gtt. 30 gr. 3 dr. 2 gr- 3-5 gr. 2 gr- 2 gr- h gr. 2 gr- 1-2 gr. 3 dr. 1-2 dr. i-1 gr. 5-10 gr. 1-2 gr. 2 gtt. 3 gr. 1-2 gtt. 3 gr. 1-2 gr. i 15 c.c. gr- 2 Dose, Age 3 to 5 yrs. Dose, Frequency gr- *-2 gr. h gr- h-1 gr. 53 gtt. 3-6 gr. 3-5 gtt. 2-3 gtt. 20 gr. 1-2 dr. 4 i gr. 3 ! dr. 1 gr. 2 dr. 1 gtt. 10 dr. i-l gr- 5 dr. 4 gr- 5-8 gr- 5 gr. 3 gr. 1 gr. 3 gr. 2-3 gr. 5 dr. 1-2 ! dr. 1-2 gr. 10-20 gr. 2-3 , gr. 3-5 gtt 5 gr. 3-5 gtt. 5 gr. 2-3 \ gr. h 30 c.c. gr- 3 Dose, Maximum in 24 hrs. Age 5 yrs. in divided gr. \-2 doses t.i.d. gr. \ t.i.d. p.r.n. t.i.d. q. 4 hrs. p.r.n. q. 4 hrs. p.r.n. t.i.d. t.i.d. t.i.d. gr. 3 gr. t'c gtt, 5-15 gr. 15-20 gtt. 10 dr. 1-2 gr. 1-5 oz. 1-li gr. 5-10 dr. 3 q. 4 hrs. gr. 4-8 dr. 3 dr. \ dr. 3 gr. 15 oz. | t.i.d. t.i.d. t.i.d. t.i.d. once q. 4 hrs. q. 4 hrs. t.i.d. q. 2-4 hrs. t.i.d. q. 4 hrs. t.i.d. t.i.d. t.i.d. b.i.d. q. 3 hrs. q. 3 hrs. q. 2-3 hrs. q. 4 hrs. q. 2-3 hrs. t.i.d. q. 4 hrs. gr. 25-40 gr. 15-30 gr. 10 gr. 10 gr. 10 gr. gr. oz. oz. 5-15 15 gr. 40 gr. 24 dr. \ r^ 20-30 gr. 15-20 gtt. 30 gr. 10 gr. 1-2 daily for 4 pro doso days q. 4 hrs. gr. 10-15 GENERAL THERAPEUTICS. TABLE OF AVERAGE DOSAGE.— Continued. 65 Drug Dose, Age 6 mos. 1 Sodium Bicarbonate gr. 2 Sodium Bromid gr. 1-3 Sodium Iodid gr- 1 Sodium Phosphate gr. 15 Sodium Sulphate Spartein Sulphate .... Strophanthus Tinct . . . Strychnin Sulphate Tanalbin Tannigen Tartar Emetic Terpin Hydrate Thyroid Ext. Desic. . . . Thymol Urotropin Veronal Whisky gr. gtt gr- gr- 1 gr. 1 gr- -iho gr. i-1 gr. i gtt. 10 Dose, Age 2 yrs. gr. 3 gr- 3-5 gr- 2 gr. 30 gr- 30 gr. A-t Abdomen. General Enlargement or Prominent Abdomen. (a) Distention with Gas. — Dyspepsia, gastritis, pyloric stem intestinal indigestion unci dysentery, intestinal obstruction, constipation, tuberculous and septic peritonitis, pneumonia, typhoid, congenital dilatation of colon, obstructed hernia, intestinal perforation. (b) Fluid (1) Peritonitis (chronic, serofibrinous, tuberculous, septic (from umbilicus), gonorrheal, pneumonic. (2) Heart disease (uncompensated heart and chronic adhe- sive pericarditis). (3) Kidney diseases. (4) Hepatic diseases (cirrhosis, true tumors, degeneration). (5) Portal obstruction (enlarged glands, adhesions). (6) Grave anemias. (c) Constitutional Diseases. — (Usually from weak spine.) Rickets, cretinism, syphilis, marasmus. (d) Miscellaneous. — Pott's disease, curvature, congenital dis- location of hip. Hysteria. (e) Enlarged liver and spleen. Enlarged Liver. (1) Hyperemia in Sepsis. — Cardiac and pulmonary affections. (2) Toxic. — (a) Alcohol, phosphorus, santonin. (6) acute infectious diseases. (3) Constitutional Diseases. — Tuberculosis, syphilis, rickets, ath- repsia. (4) Cirrhosis. — (Acute yellow atrophy.) (5) The Anemias. — Leukemia, pseudoleukemia, splenic anemia, Banti's disease, primary splenomegaly. (6) Abscess, cysts and true tumors. Enlarged Spleen. (1) Acute infectious diseases. (2) Constitutional diseases (as above). (3) Hepatic, cardiac and pulmonary (as above). (4) The anemias (as above). (5) Abscess, cysts and neoplasms. Localized Tumors. (a) Kidney. — Floating kidney, hydronephrosis, pyelitis, peri- nephritis, neoplasm, cystic kidney, tuberculosis. (6) Stomach and Intestines. — Pyloric stenosis, intussusception, 86 DISEASES OF CHILDREN. appendicitis, impacted feces, worms, neoplasms, congenital dilatation of colon. (0) Miscellaneous. — Thickened omentum (tuberculous peritoni- tis) mesenteric glands, psoas abscess, encysted peritoneal abscess, distended bladder. Tumors of Abdominal Wall. Abscess, hematoma, hernia (muscular). Umbilical Region. (1) Hernia (of omentum, intestines, bladder). (2) Fungus (granulations). (3) Periumbilical abscess. Inguinal Region. Tumors or Enlargements. Hernia, hydrocele of tunica vaginalis and cord. Undescended testicle. Orchitis, mumps, syphilis, tuberculosis, influenza, trauma. Neoplasms. Varicocele. Delayed Growth. (a) Improper feeding and digestion, starvation, pyloric stenosis, marasmus. (b) Cretinism, rachitis, idiocy, infantilism, osteomalacia, micro- melia. (c) Tuberculosis. (d) Syphilis. (e) Valvular heart disease. (/) Progressive paralysis. Hemorrhages. 1. General Causes. (1) Acute Infectious Diseases. — Pyemia, septicemia. (2) Toxic. — Iodids, mercury, ergot, belladonna, phosphorus, antipyrin, chloral, arsenic, food poisoning, snake bites. (3) Constitutional Diseases. — Syphilis, scurvy, Bright's disease, tuberculosis, athrepsia, cachexia. (4) Purpura. — Purpura simplex, fulminans, hemorrhagica rheu- matica, Henoch's purpura. (5) Blood Diseases. — Hemophilia, leukemia, pseudoleukemia, splenic anemia, Banti's disease, severe secondary and perni- cious anemia. (6) Mechanical. — Injury, pertussis, epilepsy, at birth. SUGGESTIVE SCHEME FOB DIAGNOSIS. s < 2. Special Causes. (a) Of New-born. — Asphyxia, obstetrical operations, deficient expansion of lungs, sepsis, syphilis, hemophilia, congenital disease of liver and bile ducts. (b) From Nose. — (1) In new-born as above. (2) Affections of mucous membrane. Traumatism, foreign body, acute and chronic rhinitis, adenoids, polypus, diph- theria, measles, worms. (3) Congestion, prolonged cough. Cardiac and pulmonary affections. Overheating, nephritis, sinus thrombosis. (4) Prodromal, in acute infectious diseases. (5) Vicarious menstruation. (6) Fractured skull. (c) Of Stomach. — Gastric ulcer, chemical erosions, worms, foreign body. Occlusion of intestines, swallowed blood, general causes as in 1. (d) Rectum. — General causes and new-born. Severe enteritis, gastric and intestinal ulcer, follicular and membranous enteri- tis, worms, intussusception and strangulation, hemorrhoids, polypus, anal fissure, condyloma, prolapse rectum, injury with enemata, etc., typhoid, tuberculosis. Extremities. 1 . Disturbances of Motion. (a) Paralysis or Pseudoparalysis. — Anterior poliomyelitis, scurvy, syphilis, rickets, postdiphtheria, cerebral palsy, neuritis, birth palsy, meningitis, fracture, epiphyseal suppuration, osteo- myelitis, spina bifida, transverse myelitis, progressive mus- cular atrophy. Landry's paralysis. (b) Inability to Walk or Walk with Limp. — (Any of the above pa- ralyses cited in (a) ),. Delayed walking. Tuberculosis of the •hip, knee, ankle, Pott's disease, osteomalacia, congenital dislocation of the hip, rickets, coxa vara, rheumatism, mental deficiency, idiocy, hydrocephalus and microcephalus, cretin- ism, weakness after disease or poor nutrition, progressive muscular atrophy, flat-foot, improperly fitted shoes. (c) Spastic Extremities (rigidity). — (Normal in early infancy.) Gummata, cerebral hemorrhages, sclerosis, tumors, spastic paraplegia, acute encephalitis. Little's disease, hydrocephalus. meningitis, lateral sclerosis, hereditary ataxia, tetany, cata- lepsy, tetanus. ss DISEASES OF CHILDREN. 2. Swellings. (a) Joints. — Chronic and .acute polyarthritis. (Rheumatic, puru- lent, gonorrheic, following scarlet fever and pneumonia). Tuberculosis of the joints, simple effusion, bursitis. (b) Bones. — Rickets (epiphyseal), syphilis, scurvy (subperios- teal). Osteomyelitis, neoplasms. (c) General Enlargement. — Anasarca, angioneurotic edema, sepsis, hydremia, acromegaly, elephantiasis, erysipelas, cretinism. 3. Hands. (a) Dactylitis. — (Simple, tuberculous, syphilitic.) (6) Clubbed Fingers. — Heart disease, chronic cough, hepatic cir- rhosis. (c) Claw Hand. — Ulna paralysis, progressive atrophy, lesions spinal cord, ischemic paralysis. (d) Purposeless Involuntary Movements. — Chorea (infectious and hereditary, Huntington's). Organic brain lesions (hemi- plegia, tumors, abscess brain, sclerosis after meningitis). Friedrich's ataxia, habit spasm, idiocy, hysteria. SECTION VI. INFANT FEEDING. CHAPTER XL THE INFANT FROM THE NUTRITIONAL STANDPOINT.* Introduction. — It is coming to be an important part of a physician's work to look after the feeding of infants, and as much if not more knowl- edge is required to do this successfully than is called for in writing prescriptions for drugs for diseases. No one can become a good infant feeder who is not well-grounded in the principles of nutrition, partic- ularly as they apply to infants, or who has not served an appren- ticeship under a successful feeder and learned the art of infant feeding, even if he has not mastered the science. As a principle may oftentimes be applied in different ways and as methods that are ap- parently contradictory may produce essentially the same results, a section will be devoted to the elementary principles involved in the management of all infants, so that confusion will not be caused by the apparently contradictory statements of other authors. The essential sameness of many substances and procedures which are to all appear- ances diametrically opposed to each other will then be recognized. The Infant. — To thoroughly understand the management of in- fants one must fully realize the position of the infant in the life history of a human being. A normal life history, from a biological standpoint, commences at conception and ends at death due to old age. The prob- lem of nutrition begins when the fertilized ovum starts to divide and form additional cells, and from this time on until death there is an un- ceasing demand for food. During a life history the food is supplied in many different forms, and as the organs of nutrition change in the earlier stages of development, the physical properties of the food change also. Fig. 25 is intended to show the different forms of food utilized by the human being during its life history and the organs of nutrition used at different stages of development. In the earliest stages the food is supplied from the yolk of the ovum; as development progresses, the villi of the chorion appear and act as organs oi nutri- * For greater details in reference to the biology of this Bubject, see "Theory and Practice of Infant Feeding," by Dr. II. D.Chapin. Third edition. William Wood & Co. 89 90 DISEASES OF CHILDREN. tion; these gradually merge into the placenta which derives food from the maternal blood; at birth the breasts supply food in the form of colostrum for a few days, which is gradually displaced by milk. When the milk supply naturally fails, toward the end of the first year, the child is capable of digesting some forms of semisolid food such as its parents eat, and continues its development on this food. FIRST NUTRITIVE PERIOD 1 ST 2ND 3RD 4-TH OVUM CHORION PLACENTA BREASTS YOLK YOLK AND SERUM MATERNAL BLOOD COLOSTRUM AND MILK SECOND NUTRITIVE PERIOD © 5TH MILK, BREAD, CEREALS, EGGS 6TH SOUP. FISH, MEAT, VEGETABLES, FRUIT, NUTS Fig. 25. — Nutritive life history. Life Divided into Two Nutritive Periods. — From the illustrations in Fig. 25 it will be observed that the life of a human being is sharply divided into two parts : First, that which is marked by the food being derived entirely from the mother; second, that in which none of the food is supplied by the mother. It will also be noticed that during the period in which the food is supplied exclusively by the mother, there is a rapid change in the form and complexity of the organization of the fetus or infant, and that the form in which the mother furnishes the food, the organs through which she supplies it, and the organs of THE INFANT FROM THE NUTRITIONAL STANDPOINT. 91 nutrition of the fetus and infant undergo great changes. In a word, the mother changes the food to suit the condition and organs of the developing infant, and not until the digestive tract is developed suffi- ciently to be able to utilize semisolid food does the normal mother cease to nourish her offspring with special forms of food. The second nutritive period begins when the child is able to secure enough nutriment from semisolid food, and this period is marked more by general increase in size than by profound structural changes or the development of new nutritive functions. Table Showing Derivation of Tissues of Man Weighing 180 Pounds. (Schematic.) Conception to weaning (first nutritive period): Ovum 1 Chorion \ supply 8 pounds (birth weight). Placenta J Breasts supply 12 pounds 20 pounds (weight at weaning). Weaning to maturity (second nutritive period): Milk, eggs, cereals, meat, 1 , 1cn fish and vegetables / SU PP^ -M Total 180 pounds (weight at maturity). Essential Unity of Foods. — When all forms of food, including mother's milk, are subjected to chemical analysis they are found to be composed of ingredients which fall into five groups : Proteins, often- times termed proteids, which form the tissues; mineral matter which is necessary for bone formation, and also in lesser quantities to replace metabolic waste; fats and carbohy- drates which supply the energy; and water. The great difference in foods at different ages Nv *^k^§r^£ is not one of composition, but of form. | A 1 Foods of the First Nutritive Period. — The 1L m V, mother supplies food to her offspring in six M^.^1 different forms: First, the yolk of the ovum; next the fluid in which the ovum is bathed; then that which is supplied in a form suited for assimilation by the chorion; and then t *£. f TangVrooT'life by blood which circulates through the pla- size. (Parker and Has- centa. When birth occurs, the food is sup- we plied through the breasts in two forms, at first colostrum and finally as milk. Each of these forms of food is specially adapted to the infant at the time it is furnished, and as soon as the infant outgrows one form of food another is supplied. 92 DISEASES OF CHILDREN. The Infant a Mammary Fetus. — While the infant is looked upon as a fetus until birth, it is, in a broader sense, a fetus until it is capable of subsisting on soft food, or, in other words, until its digestive appa- ratus is developed. Fig. 26 shows the fetus of the kangaroo. This animal has no placental connection with its mother; it is born in an exceedingly rudimentary state of development, and then grows fast Fig. 27. -Head of mammary fetus, hemisected to show adaptation of teat to mouth. {From a specimen, Columbia University.) to the nipple, at which it develops from the size of a young mouse to a weight of about seven pounds, when it is able to secure food for itself and becomes independent of its mother. In the early stages of the mammary development of the kangaroo the mother ejects the food into the esophagus which at this time has no connection with the air passages (Fig. 27). As the development advances the fetus ceases to be adherent to the nipple and obtains nourishment by THE INFANT FROM THE NUTRITIONAL STANDPOINT. 93 sucking. At one time this type of animal predominated, but now placental forms so far outnumber them that they have become rare. If the infant was born about the time the placenta develops and then became adherent to the nipple it would be nourished much like the young kangaroo, and the importance and place of breast-feeding would be self-evident. The young of implacentals are still in the fetal stage at birth, and also after the mouth ceases adhering to the nipple, which corresponds to the time of birth or when the placenta separates from the mother in placental animals. For some time after- ward they depend upon the mother for nourishment. Therefore from a nutritive standpoint the infant is as much a fetus as is an impla- Fig. 28. — Colostrum corpuscles. (Jewett.) Fig. 29. Normal human milk. (Jewett.) cental animal after it is developed sufficiently to suck, and this fact should be kept in mind. Breast Secretions : Specialized Foods. — From the illustrations in Fig. 25 it is plain that before birth the form of the food supplied by the mother and the method of furnishing it change to suit the state of development of the fetus; and as at birth the digestive organs of the infant are not fully developed, it may be concluded that in some way the breast secretions are peculiarly adapted for that part of the first nutritive period in which the digestive tract is developing. Composition and Properties of Breast Secretions. — The first secretion of the breasts or mammary glands after the infant or young animal is born is called colostrum. Chemical analysis shows it to be composed, like all foods, of proteins, mineral matter, fats, carbohy- drates, and water. Upon boiling, colostrum coagulates, owing to a large portion oi 94 DISEASES OF CHILDREN. the protein being in the form of albumin. It is also distinguished by the presence of colostrum corpuscles (Fig. 28). In the course of a few days after birth the character of the breast secretion undergoes a complete and radical change. The later secretion is milk, which is also composed of protein, mineral matter, fats, carbohydrates, and water, but it will not coagulate when boiled, showing there has been a change in the character of the protein, and the colostrum corpuscles are absent. From these facts it is evident that chemical analysis throws little light on the properties of either colostrum or milk, except to show that they are composed of the basic food elements. As the characteristic feature of nutrition during the first nutritive period is the adaptation of the form of the food by the mother to the Teeth and salivary glands Stomach. Intestines. Fig. 30. — Development of human digestive tract. (Allen Thompson and Wiedersheim.) organs of nutrition of the fetus, which are constantly undergoing change, it is evident that the way to acquire a knowledge of the proper- ties of the breast secretions is to study them in the relations to the infant's digestive organs. Development of the Digestive Tract. — At birth the digestive organs are quite different both anatomically and physiologically from those of the adult. Teeth are absent, which in the adult reduce the food to a state of fine subdivision, to fit it for the stomach, and the gastric secretions particularly are not like those of the adult, and in some animals the stomach is not fully formed. During the colostrum period there is little gastric secretion, but when the mother secretes milk, the rennet ferment or rennin, which is closely allied to pepsin, is secreted in the stomach. Rennin prepares the milk for stomach THE INFANT FROM THE NUTRITIONAL STANDPOINT. 95 digestion by the infant in much the same manner as teeth prepare the food for digestion later in life. That is, rennin acts upon a portion of the milk and changes it from a fluid into a semisolid which has on a small scale much of the physical property and texture of the chewed food of the adult. Until pepsin and acid are secreted, true gastric digestion does not take place and the solid remains very soft; but when acid appears it in some way combines with the solidified milk, rendering it more solid and fitting it for digestion by pepsin. Thus it is that the first solid food for the undeveloped digestive organs is produced from the specialized food supplied by the mother, and its digestive properties are altered or adapted to the stomach by the gastric secretions. Fig. 31. — Stomach of different milk secreting animals. (Wiedersheim.) Comparative Anatomy and Physiology of Digestive Organs. — When the digestive organs of the lower mammals are compared it is found they differ greatly both in structure and in the methods by which they carry on the digestive processes. All animals digest proteins, mineral matter, fats and carbohydrates, and the chemical changes that take place in digestion are essentially the same in all forms of animal life, but methods of digestion show wide differences. In the early fetal stages the digestive tracts of all mammals are very much alike, but as development proceeds, anatomical differences are observed which become pronounced as maturity is approached. There are as wide differences in the digestive organs of animals as there are in the forms of their limbs and feet, and these differences assume great importance when it comes to selecting food for different species. From 96 DISEASES OF CHILDREN. practical experience in feeding many kinds of animals at experiment stations the following principle has been deduced: the food must be adapted to the species. Comparative Mammary Secretions. — As far as known, all mam- mals secrete colostrum for a few days after birth takes place, and this secretion is followed gradually by milk, but the milks of different species show wide differences in their properties. When they are subjected to chemical analysis, it is found they all agree in being com- posed of proteins, mineral matter, fats, carbohydrates and water, al- though the proportions of these ingredients are not the same in all kinds of milk or in the milk of different individuals of the same species. To one who is not familiar with the methods of milk and food analyses it might appear from this that the differences between milks of different species were due merely to the varying proportions of the food elements present, and for a time this was the belief held by some of the foremost pediatricians. But, when it was known how little idea of the prop- erties of a food is shown by the report of its chemical analysis, the limited value of food analyses in infant feeding was appreciated. The terms proteins, mineral matter, fats, carbohydrates, and water are about as definite as the terms wood, stone, glass, and metal used in describing the construction of a house, and comparing foods accord- ing to the proportions of the elements present is about as useful a procedure as comparing buildings by their composition. However, it must not be supposed that a chemical analysis of food or milk has no value, for it is of great importance, but its true value should be recognized and not overestimated. The proper way to compare milks for infant feeding is to see how they react to rennin, pepsin, and acid, and how they compare in compo- sition. Milks of different species when so compared show great differ- ences, although they may have identically the same composition; that is, be composed of the same quantities of proteins, mineral matter, fats, carbohydrates, and water. Human milk is changed into a semi- solid, finely divided mass by rennin, pepsin and acid; cow's, goat's, and sheep's milk into a solid mass which is of the same volume as the milk; mare's and asses' milk into a fluid jelly. This results from the action of rennin on a portion of the proteins generically termed casein, or by some caseinogen. When the digestive organs of the various animals are compared it is observed they are not alike either in form or in the manner in which they perform the digestive function, and it is found that the mother's milk is digested in much the same manner as the food will be digested after weaning, so the reason for the differ- ent physical properties of the various milks after they have been THE INFANT FROM THE NUTRITIONAL STANDPOINT. 97 acted upon by the rennin ferment is apparent, and the fact that mother's milk is the ideal food for any young animal becomes self- evident. It is Nature's way of applying the rule — the food must be adapted to the species. If the peculiar adaptation of the milk to the digestive organs was not enough proof of the superiority of mother's milk, it would be found in the fact that the general composition of the milk of each species of animal is such that the milk is adapted to the rate of growth of the young. Animals that grow rapidly need larger quantities of proteins than those which grow more slowly and the mothers of animals whose growth is rapid secrete milk much richer in proteins than mothers of animals whose growth is slower. In practical feeding it is found that milks of different species are not interchangeable from a digestive standpoint, although they are all highly nutritive, but the reason was not discovered until infant feeding was studied from the standpoint of milk as a specially adapted food, and the subject was considered from a biological stand- point. Chemical and Biological Standards in Infant Feeding. — In the early days of scientific infant feeding it was believed that the differ- ences between all milks lay in the relative quantities of proteins, mineral matter, fats, carbohydrates, and water of which they were com- posed and in their reaction to litmus-paper, and that milks could be made interchangeable by readjusting their percentage composition and altering their reaction to litmus. For a long time this teaching was thought to be correct, but it began to be observed that it was often not followed in practice, and it was then taught that the great differ- ences between milks lay in the relative proportions of casein and albu- min which made up the proteins of milk. For a time this teaching was accepted by many, but it was found that caseins differed and that the term casein was about as definite as the term wood. By a play on words all milks could be made alike on paper, but actually they were different. There have been used from time to time various methods of making cow's milk agree with infants, such as adding lime-water, bi- carbonate of sodium, citrate of sodium, and peptonizing materials, which have produced chemical changes, each of which has been claimed to make cow's milk like human milk. These methods have been confusing and contradictory and have made the whole subject chaotic. The aim has been to make human milk by chemical means and the standards used in feeding until recently have been purely chemical. But as the effects of the different methods in practice have 7 98 DISEASES OF CHILDREN. been studied it has been found that they do not make human milk, but either change the character of the proteins of cow's milk, or alter the action of the digestive secretions of the infant on the milk, so in reality while the theory has been that chemical changes were utilized to make human milk of cow's milk, practice has been along the line of adapting food to the infant. Theory and practice have been diamet- rically opposed and naturally great confusion was the result. Since the recognition of the fact that it is impossible to make human milk from other substances as yet, and that the practice is to adapt food to the infant, the biological standard of feeding has as- sumed greater importance and makes theory and practice coincide. This standard or principle may be stated as follows: At all stages of life the food must be composed of proteins, mineral matter, fats, carbohydrates, and water. These elements exist in a great variety of forms which are equally nutritious, but are not equally adapted for the digestive organs at all ages, or for all species of animals, as their digestive organs are not alike. The peculiarities of the digestive organs must be first considered, and after this has been done food must be selected that is adapted for the particular digestive tract. After such a food has been found its composition must be looked after so that enough of the elements necessary to produce proper growth and development may be assured. Under this standard any procedure is scientific, provided it is employed with the understanding of its purpose, but if it is not one that cannot be continuously used without danger to the general well being of the infant it must be looked upon as a temporary expedient and the patient not dismissed until on a proper diet. In the treatment of practical feeding this plan will be followed, and the prominent position heretofore given to the supposed chemical differences between human milk and other foods will not be found in this work. The chemical side of feeding will be subordinated to the physiological aspect, for in practice all that the chemical composition of a food shows is its possible nutritive value, its actual value for each infant being a subject for determination by experiment with the infant. Recapitulation. — The main points to be kept in mind in infant- feeding are: The infant should be looked upon as a mammary fetus. The mother's breast secretions are specialized forms of food, adapted to the developing digestive organs. Milks of lower animals and table food are as nutritious as mother's THE INFANT FROM THE NUTRITIONAL STANDPOINT. 99 milk, but are not adapted to the undeveloped condition of the infant's digestive tract. The chemical composition of a food shows nothing concerning its suitability for any animal and is not of first importance. The value of foods for individuals cannot be judged by comparing their chemical composition. Foods ma}' be " chemically right but practically wrong." The food elements required by all infants are the same, but the form in which they are to be presented must be determined for each infant by experiment. No jnfant is a law unto itself except concerning the form in which it prefers its food. CHAPTER XII. BREAST-FEEDING. Importance of Breast-feeding. — Reference to Fig. 25 on page 90 will show that the breast secretions are the last of a series of specially suitable forms of food supplied by the mother during the period in which the organs and their functions are developing in the infant. The breast secretions are furnished during the time the infant's diges- tive apparatus is developing, and serve a purpose in addition to supply- ing nourishment. The secretions of the breasts adapt themselves to the increasing strength of the digestive organs, and, instead of these organs finding their work easier as they become stronger, they find the digestive work increases as their digestive capacity becomes greater. This is brought about by an alteration in the physical properties of the mother's milk in the stomach by the infant's gastric secretions before true digestion commences. The rennin, pepsin and acid of the stomach, as they successively appear, produce pro- found changes in the physical condition of the milk. When rennin acts alone, as it does in very early infancy, the milk becomes a fluid jelly; but later on when pepsin and acid appear the milk is changed into a mass having much of the consistency of well-chewed food, and which should be looked upon as its prototype. It is thus that the digestive organs are prepared to digest semisolid food about the twelfth month, when weaning naturally takes place. In addition to this interesting and important property of the mother's milk, it generally contains the food elements in the proportions and forms best suited for proper nutrition of the infant. It is not a difficult matter to bring together the food elements in the same quantities as are found in any specimen of breast milk, or colostrum, but even when derived from milk of lower animals the food does not have the delicate properties of the breast secretions, and it is often contaminated or has undergone bacterial changes. While many infants are successfully fed on substitutes for breast secretions, such feeding should not be attempted until every effort to secure breast-feeding has failed. An infant that is fed artificially is in reality a premature infant, for breast-feeding belongs in the same category as maternal feeding through the placenta. The death rate is much higher among artificially fed infants than 100 BREAST-FEEDING. 101 among those breast-fed, and in hot weather when bacterial changes in the food are greatest the loss of artificially fed infants is several times greater than during the colder seasons, while the increase in death rate among breast-fed infants is slight. Every consideration shows the advantage of employing the maternal method of nutrition while the infant's digestive organs are developing, and breast-feeding should always be advocated unless contraindicated (see p. 107). Preparation for Maternal Feeding. — For some months before delivery, the nipples should be treated so as to toughen them and thus prevent tenderness or fissure when the infant uses them. This is done by gently rubbing them between the thumb and fingers. De- pressed or misshaped nipples may thus be made usable, and the comfort of the mother will also be conserved. Management of Breast-feeding. — When the mother is enough rested after delivery the infant should be offered each nipple. If it does not seem satisfied and becomes fretful or restless, a teaspoonful or two of boiled water may be given. This will quiet the infant and helps to flush out the digestive tract and kidneys. For the first day or two the infant may be offered the breast every three hours during the day and twice during the night, at four- to six-hour intervals. After this it should be nursed every two hours during the day and once or twice at night. When the supply of milk is sufficient the infant will suck for fifteen to twenty minutes and then drop off to sleep. If after having the nipple twenty to thirty minutes the infant seems restless and unsatisfied it may be concluded that the milk supply is insufficient. A weighing before and after nursing may also help to determine whether the amount has been sufficient. After the first few weeks such a test should show an increase in weight of between two and three ounces. If under such management the infant has soft yellow stools with no pronounced signs of indigestion and gains steadily in weight, it may be considered as doing well and requires no further attention. Regularity of Feeding Important. — One of the most fruitful causes of indigestion in breast-fed infants is feeding at irregular, and especially at short intervals. Sometimes a fresh feeding is taken into the stomach before the previous meal has been digested which is bad enough; but in addition to this, the irregularity in nursing has a profound effect on the composition of the mother's milk. If the intervals between nursings are long there will be a large quantity of rather poor milk; but when the milk is drawn at short 102 DISEASES OF CHILDREN. intervals it has the effect of reducing the quantity and greatly in- creasing the percentage of fat, the other ingredients not being affected to any great extent. An excess of fat in the food is apt to produce vomiting, and an abnormal gastric secretion may follow, causing the milk to curd or solidify abnormally; hence it is not difficult to see why frequent nursing causes digestive disturbance. When milk is drawn at regular intervals it has practically the same composition, unless the mother has been subjected to influences that derange her nervous system. These may profoundly alter the character and com- position of her milk and produce great disturbances in the infant. It is, therefore, of the greatest importance to have the mother regular in her own habits and free from excitement, and that the infant be fed at regular hours. It will be helpful if the mother is given direc- tions for feeding by the clock, as at 5, 7, 9, 11 A. M.; 1, 3, 5, 7, 9 P. M., and once during the night in occasional cases. Milk Agrees, Flow Scanty. — When the mother's milk agrees with the infant, but is not sufficient in quantity to cause it to gain in weight steadily, attempts should be made to increase the flow, and when these are not successful, mixed feeding, that is, part breast and part artificial feeding must be employed. If the mother is to secrete sufficient milk she must digest and assimilate a liberal supply of food herself, for unless she does this the milk will be produced from her own tissues and she will lose in weight. The diet of the mother should consist of simple, easily digested food in liberal quantity milk, eggs, and thoroughly cooked cereals being the mainstay. Tea and coffee should be withheld or used sparingly, cocoa or chocolate being given in their place. Southworth, who has devoted much attention to this matter, recommends the use of cornmeal gruels to be taken between meals as a means of increasing and conserving a scanty flow of breast milk. When cornmeal gruel is not relished, oatmeal gruel may be substituted. The gruels are made as follows: Two to four heaping tablespoonfuls of yellow cornmeal or rolled oats are placed in one quart of cold water in a double boiler and the water in the boiler is kept boiling for two or three hours. The gruel is then strained through a coarse wire strainer and enough boiling water is added to make one quart of gruel. The gruel should be well salted. It is often advantageous to add an equal quantity of milk. A pint of such gruel is to be taken about ten o'clock in the morn- ing and again at about three in the afternoon. The gruel, when dex- trinized, supplies energy food in a form quickly assimilable, and the coarse particles of the gruel undoubtedly promote normal action of BREAST-FEEDING. 103 the bowels and thus promote the general well-being of the mother and incidentally that of the infant. When there is anemia iron should be administered. Elimination of Drugs and Excretory Products in Milk. — It is a well-known fact that some substances pass into the milk from the mother's system which may unfavorably affect the infant. Consti- pation of the mother will affect the infant unfavorably, and under cer- tain conditions urea in appreciable quantities finds its way into the milk. When the mother is constipated and the use of cornmeal gruel does not overcome the condition, cascara should be given. Great care must be exercised in giving drugs to nursing women, as they may be excreted in their milk. Morphin, mercury, quinin, iodid of potassium and similar preparations should be given cauti- ously and their effects watched. Milk Plentiful, but Disagrees with Infant. — As a general rule, the milk of the mother will agree with her infant. However, there are some women whose milk may at times be excessively rich in all of its elements or which may fluctuate widely in the amount of fat present or have properties that make it unacceptable to the infant. If the milk agrees with the infant for a time and then suddenly disagrees the probabilities are that the mother has been subjected to excitement of some kind; it may be worry, fright, anger, grief, or loss of sleep that has made her irritable. Such influences will produce sudden changes in the character of milk and alter its digestive proper- ties. It is well known that the milk of a cow that has been overheated, driven rapidly, or made irritable by flies or dogs will not react nor- mally to rennin and acid. The changes brought about by these nervous influences are more than variation in percentage composi- tion, and cannot be detected by chemical analysis. The remedy in this class of cases is to remove all causes of anxiety and nervous disturbance, and have the mother sleep in another room so that she shall not be disturbed by the infant's crying. Pleasant surroundings, and moderate daily exercise in the fresh air are also indicated. Sometimes the milk of one breast is perfectly satisfactory while that of the other causes disturbance. In such cases the remedy is to secure all of the feedings from the good breast if possible until the other one secretes normal milk. When the milk disagrees from the start and the mother seems healthy it is possible that the trouble is caused by the milk being too rich, the result of overeating on the part of the mother. At any rate it is helpful in all of these cases where the milk disagrees to make an examination of it, as will be explained in the next paragraph. 104 DISEASES OF CHILDREN. If it is found that the amount of fat and total solids in the milk is too high the diet of the mother should be restricted, and exercise to the point of fatigue, to divert the food supply from the breasts, may be advised. It may also be necessary to give saline cathartics. If there is an over-abundant supply of rich milk, the infant should be al- lowed to take only the first milk from each breast and thus avoid the extra fat "strippings" or the last milk secreted which contains a much higher percentage of fat than the first part of the secretion. If the infant has curdy stools and colic, a tablespoonful of barley water, lime- water, or water containing one grain sodium citrate may be given just before each nursing. If the methods of management suggested above do not overcome the difficulty, so that the infant gains from four to six ounces a week, with good digestion and normal stools, it will be necessary to resort to mixed feeding. Give a bottle every other feeding, using a formula suit- able for a younger infant at the beginning, as described on page 149. Examination of Breast -milk. — There are three ways of examining breast milk: (1) by having an analysis made showing its percentage composition expressed in proteins, mineral matter, fats, carbohydrates, and water; (2) by roughly determining these ingredients by means of the amount of cream that will rise on a given quantity of milk and the specific gravity of the milk; (3) by the use of the pioscope. The chemical analysis of milk is expensive, and its value is apt to be overestimated. It takes several days to get a report from the laboratory where it is made, and laboratories for this purpose are not always available. The second method of determining fats and specific gravity takes twenty-four hours, but can be utilized anywhere. A specimen of the milk is drawn from the breast, care being taken to get all there is, because the first portion contains little fat, while the last portion or " strippings" is very rich in fat. The milk is mixed and its specific gravity is taken with an ordinary urinometer. Ten cubic centimeters of the milk are then placed in a graduated ten c.c. tube or graduate and allowed to stand twenty-four hours for the cream to rise. Poor milk will have a small layer of cream and rich milk a much thicker cream layer. The amount of fat in the milk is thus estimated. The specific gravity of normal human milk is about 1.031. If the milk shows a layer of cream not over one c.c, and has this specific gravity, it may be looked upon as normal milk as far as percentage composition is concerned. If the specific gravity should be as low as 1.028, with more cream, it would indicate that the milk was rich in fat, as the fat being lighter than the milk serum reduces the specific gravity of the milk. BREAST-FEEDING. 105 This method is widely used in the dairy industry for calculating the composition of cow's milk, but the fat is accurately determined by the Babcock test (page 171), which may also be used with human milk. About half an ounce of milk is required for this test, but if this quantity cannot be obtained, what is available may be diluted with water two or three times after the specific gravity has been obtained and the result multiplied by the number of times the milk was diluted. If the specific gravity is above 1.03 and there is little cream, or fat shown by the Babcock test, the milk is poor in fat and normal in other solids, or all of the milk was not drawn from the breast and the portion containing the fat was left behind. A second specimen should be drawn and greater care taken to get all there is. The milk should be drawn at the regular nursing interval or milk extra rich in fat will be obtained, for, as stated before, milk drawn at short intervals is abnormally rich in fat. At one time great importance was laid upon the reaction of breast milk. It was supposed always to be alkaline or amphoteric in reaction. At present comparatively little importance is attached to the reaction of breast milk, for the same specimen of milk may be found to be acid, amphoteric, and alkaline, all depending upon how the reaction is determined. Litmus-paper was the substance used to determine the reaction of milk, a strip being dipped into the milk and its reaction judged by the change of color of the litmus-paper. Litmus and litmus-paper vary a great deal in sensitiveness, and all kinds of reactions can be obtained with milk by using different lots of litmus-paper. Phenolphthalein in 1 per cent, alcoholic solution is now used as the indicator in testing the reaction of both human and cow's milk, as it is many times more sensitive than litmus. Lime-water is usually employed in neutralizing acidity in milk, -and it takes about 10 per cent, to 20 per cent, to make human milk alkaline to phenolphthalein. With a better understanding of the chemistry of milk Fig. 32.— Pioscope and the process of its digestion, it is seen that ^ slze ^ undue importance was placed upon its reaction and composition, and simpler and better methods of clinically testing the suitability of breast milk are coming more into use. Fig. 32 is an illustration of the pioscope which is used for testing breast milk. It consists of two disks, one of hard rubber and the other of glass, which rests upon the rubber disk. The glass disk is divided 106 DISEASES OF CHILDREN. into sectors which are colored to represent milk of different qualities. The milk is drawn from the breast and a few drops are placed in a little depression in the rubber disk. The glass disk is then placed on the rubber one and the milk is compared with the different sectors of the glass disk. At a glance one can tell approximately the quality of the milk. The apparatus is about one-fourth of an inch thick and can be easily carried by the physician. Its great advantage lies in the fact that it enables the physician to know at once what the conditions he has to deal with are, and it requires no skill in using. The following case illustrates its usefulness. An infant which was being breast fed Fig. 33. — breast pump. Fig. 3i — Hoovei breast pump. and had previously been doing well suddenly suffered with digestive disturbance. The milk of each breast was tested with the pioscope, and it was found that the milk from one breast corresponded with " normal" on the pioscope, while that of the other breast did not, Directions were given to nurse from the normal breast and the infant had no further trouble. The difference in the milk was discernible by the eye. If the milk of both breasts had been mixed and analyzed, or its composition estimated from its specific gravity and cream layer, the fact that the milk of one breast was different from that of the other in all probability would not have been known, and the treatment might have been to stop breast-feeding and try artificial feeding, which as it proved was unnecessary. BREAST-FEEDING. 107 Nursing not Possible. — When the nipples are fissured it is impos- sible for the infant to nurse, and the milk should be drawn with a breast pump, two forms of which are shown in Figs. 33, 34. The Hoover breast pump (Fig. 34) will be found convenient and easy to use. Heating an empty bottle and placing the neck over the nipple will sometimes prove satisfactory in collecting milk. The milk may be fed through a medicine dropper or from a small nursing bottle. Pumps and bottle should be kept scrupulously clean. When there is but a slight fissure or abrasion which causes pain to the mother, a nipple shield (Fig. 35) may be used. It is best to fill it with warm water so that the infants will not have to exhaust the air it contains before obtaining any fluid. It is also well to massage the breasts to aid in secur- ing the milk. The nipples should be carefully washed with a solution of boric acid and dried after use. Contraindications for Nursing. — When the mother is anemic and is losing weight and shows signs of exhaustion, even after tonic treatment has been employed; or when she is nervous and excit- able to such an extent that her milk continually disagrees with the infant, breast-feeding should be FlG 3 u-T H Nipple discontinued. If when menstruation is resumed the milk disagrees, artificial feeding may be employed temporarily, and after the period has passed breast-feeding may be commenced. In the meantime the breast should be emptied with a breast pump at regular intervals to keep up the secretion. If the milk disagrees but slightly it may not be necessary to feed artificially. If pregnancy occurs it may be necessary to employ substitute feedings, but in the middle of a hot summer it will be better to con- tinue the breast-feeding, if it is not too much of a strain on the mother, than to risk the dangers of commencing artificial feeding in hot weather. Mothers affected with tuberculosis should under no cir- cumstances be permitted to nurse their infants. Diseases such as typhoid, pneumonia, and septicemia in which there is much pyrexia and prostration also are contraindications to nursing. Weaning and Mixed Feeding. — Whenever the mother's milk fails in quantity or quality, it becomes necessary to commence substitute feeding to make up the deficiency. It is a good plan to have one bottle a day given to a nursing infant about the third month so it shall be trained to its use and the mother trained in the preparation of food. This will be much appreciated in cases where sudden weaning becomes 10S DISEASES OF CHILDREN. necessary. The substitute feeding may alternate with breast-feedings, and as the breast secretion fails the number of bottles given may be increased one at a time. In this way the transition is gradual and digestive disturbances are avoided. During the first few weeks of life, when the nursing mother has little milk, a small amount may be given from the bottle immediately after nursing if the infant gets too little from the breast. Fig. 36. — Preferable type of breasts for wet-nursing. Whenever sudden weaning becomes necessary a wet-nurse should be employed if possible, as no substitute feeding can compare with good wet-nursing. Selection of a Wet-nurse. — In selecting a wet-nurse, we must consider her age, her general health and development, her probable nervous status, and the age and health of her infant. The preferable age for the nurse is between twenty and thirty years, and multipara? BREAST-FEEDING. 109 are apt to do better than primiparae on account of having had charge of the suckling and general care of infants. A careful physical examination of the applicant should be made by the physician. Constitutional taints, especially syphilis and tuberculosis, must be excluded by a painstaking history and thorough examination of the mouth, lymph-glands, skin, and other parts likely to show evidences of infection. If any vaginal discharge is present, it must be ex- amined for gonococci. The best breasts for satisfactory suckling are not the large, firm ones, but rather the more flabby and pendu- lous kind, as shown in Fig. 36. The nipple must be of good form and size and sufficiently protuberent for easy grasping by the infant, and free from fissures and abrasions. A woman of quiet, phleg- matic temperament, in good health, is to be preferred, as nervous instability has a quick effect on the composition of the milk. A woman whose infant is under six months can usually suckle a new- born baby, but a less disparity between the ages of the infants is desirable if it can be attained. A careful examination of the nurse's infant must be made to exclude any constitutional disease, especially syphilis. Such examination will also show how well the infant has thriven upon its mother's milk. The diet of the wet-nurse, when se- lected, should be as nearly as possible that to which she has been accus- tomed, avoiding a too great variety and quantity of food. If she is furnished a diet richer and more abundant than she is accustomed to, she will in all probability overeat and bring on either defective digestion or excretion, which will promptly disorder the digestion of the infant. Regular outdoor exercise must also be insisted upon. Several nurses will sometimes have to be tried before a breast that agrees with the baby is found. CHAPTER XIII. THE PRINCIPLES OF SUBSTITUTE FEEDING. Difficulties Encountered. — In attempting to feed infants artificially, one of the first impressions received is that the whole subject is chaotic. Methods that give brilliant results in some instances totally fail in other cases apparently the same. One infant will thrive on a quantity of food that is insufficient for another of the same age; another may gain in weight rapidly and still not be rugged and well-developed. The parents may be poor, ignorant, or careless, and great difficulty may be experienced in getting a supply of suitable food, or in having the food prepared and administered properly. Learning the formulas of a few food mixtures will never make a good or successful infant feeder. What is required is a clear conception of what are the essential prin- ciples involved in artificial infant-feeding in health and disease, and a working knowledge of how to prepare food so that these principles may be complied with under different conditions. Principles that Apply to all Infants. — All infants require a certain quantity of proteins and mineral matter to replace normal metabolic waste, and enough fats and carbohydrates to supply the energy needed to cany on the processes of life. A food that supplies exactly these quantities of the food elements is called a maintenance ration, and on such a food the infant would neither gain nor lose. Oftentimes in cases of illness it becomes necessary to put infants on such food, and the parents may feel the infants are being starved, but they are not on a starvation diet by any means; growth is suspended temporarily, but the infant is holding its own. After the portion of the food needed for maintenance has been ap- propriated, what remains, if any, may be utilized for growth or for causing gain in weight which does not necessarily mean that the infant is really growing. Growth consists in an increase in number of the cells of the various tissues, and as these are composed principally of proteins and water the food must contain a greater quantity of proteins than is required to replace waste, if growth is to be made possible, for cells cannot be formed from fats and carbohydrates. A rapid gain in weight may result if the food given contains only a little more protein than is necessary to replace waste, but considerable 110 THE PRINCIPLES OF SUBSTITUTE FEEDING. Ill fat and carbohydrates, as the excess of these ingredients is con- verted into body fat which causes increase in weight. To those not familiar with the principles of infant-feeding this gain in weight is strong evidence that the food is suitable for the infant, but not so much importance is attached to mere gain in weight as formerly. If the food is known to contain a liberal supply of proteins, and gain in weight follows its use, it is considered that the gain in weight is caused by true growth, as it is characteristic of young animals of all kinds to greedily assimilate and convert into tissues the proteins that the food contains in excess of that needed to replace waste, within reasonable limits. Proper growth hinges on the proteins of the food. If the food contains a relatively large proportion of proteins with a too small proportion of fats and carbohydrates the proteins will be used to supply energy which could just as well be furnished by fats and carbohydrates, and growth will not take place. If the quantity of fats and carbohydrates is increased and the amount of proteins decreased somewhat the infant will be able to make a satis- factory growth, therefore it is important to have the food elements present in the food in certain relative proportions if best results are to be obtained. It is possible to profoundly alter the character of the body by modifications of the diet during the early growing period. Much scientific work has been done along this line at the Agricultural Experiment Stations of the various States in the efforts to learn the principles involved in the production of meat for market, and how to select food so as to produce the most rugged animals. It was found that a liberal supply of protein in the early stages of growth produced larger animals, made their vital organs larger, gave them more blood, stronger bones, and about one-third more muscle than food poor in proteins, but rich in fats and carbohydrates. The essentials of artificial infant feeding are: a liberal supply of proteins and mineral matter- for the construction of additional tissue, which means growth; a sufficient supply of fats and carbohydrates to furnish energy, and all in forms that can be not only digested by the infant, but which permit the development of vigorous digestive organs. A strong digestive apparatuses of great importance in after- life, and by proper selection of food in infancy the foundation for good digestion later on can be laid. Many Forms of Proteins, Fats, and Carbohydrates Used in Feeding Infants. — Proteins for infants are obtained in cow's or goat's milk, from cereals, and from eggs, and in a few instances in the form of meat broths and meat juice. The cereals should be looked upon as vege- 112 DISEASES OF CHILDREN. table eggs, as they are composed of the embryo plant and enough food to nourish its protoplasm with proteins and carbohydrates until its organs for securing food are developed. Mineral matter which is a mixture of many salts is obtained in milk and the cereals, in com- bination with the proteins presumably, for it is never supplied in a separate state. Fats are taken in the form of milk or cream almost exclusively. Carbohydrates are utilized in the form of milk-sugar, granulated sugar, maltose and dextrin derived from starch, and cooked starch. CHAPTER XIV. MATERIALS USED IN SUBSTITUTE FEEDING. Cow's Milk. General Composition. — Chemical analysis shows the milk of all cows to be composed of proteins, mineral matter, fats, carbohydrates, and water, but the proportions of these ingredients are not the same in all specimens of milk from the same cow or from the cows of dif- ferent breeds. The composition of milk depends largely on the breed of cow, the individual peculiarities of each cow, and the time and manner of milking. One Cow's Milk. — It was formerly believed that the milk of one cow was preferable to the mixed milk of a herd of cows for use in infant- feeding, but as improved and more sanitary methods of handling herd milk have done away with much of the contamination which brought such milk into disrepute, it is now much better to use the mixed milk of a large number of cows, especially as it is more uniform in composition and less liable to sudden fluctuations and changes of properties. The range of composition of the milk of single cows has been found to be from 2.25 per cent, to 9 per cent, of fat, and 2.19 per cent, to 8.56 per cent, proteins (Van Slyke), while in mixed herd milk there is seldom much of a range of variation, the fats running almost never below 3 per cent, and very seldom over 5 per cent., except in the milk of high-bred Guernsey and Jersey cows; while the proteins will almost always run between 3 per cent, and 3.5 per cent. If a cow is affected witlr tuberculosis the danger of infecting the infant is much greater than if her milk is diluted by the milk of other cows which are free from tuberculous infection. Again, the com- position and properties of a cow's milk are seriously affected by fright, worry, teasing by a dog, or the annoyance of flies. The milk of a frightened cow has been known to kill her calf, so the use of one cow's milk is attended with greater risks than the milk of a herd of healthy cows that has been properly handled as it is not likely that all of the cows would be subjected to the same abnormal conditions. Influence of Breed on Composition of Milk. — The milk of different breeds of cows shows marked differences of composition and do 8 113 114 DISEASES OF CHILDREN. amount of effort will make the cows of one breed give milk of the same character as the cows of another breed. Holstein cows will give milk containing about 3 per cent, fat, 2.80 per cent, proteins, and 4 per cent, carbohydrates, while Jersey cows will give milk containing as high as 5.5 per cent, fat, 3.60 per cent, proteins, and 5 per cent, carbohydrates. Other breeds give milks which fall between these two extremes, but it is seldom that milk of pure-bred cows is offered for sale unless it is from the dairy of some " gentleman farmer" who is a cattle fancier. Bacteriology of Milk. — Milk as secreted by a healthy udder is practically sterile, but just inside the teat is a " milk cistern" to which bacteria from outside find access. For this reason the first three or four jets from each teat should be discarded and then the milk will be quite free from bacteria if received under proper conditions into sterile pails. But owing to the small profit or possibly no profit at all that comes to the milk producer, as most milk is sold at about the cost of production, he cannot take proper care of his cows or the utensils employed, and the milk becomes highly infected at times with all kinds of bacteria, some of them pathogenic. A visit to one of the barns in which cows were kept for the production of milk for market a few years ago would have shown a dark, poorly ventilated building, the beams covered with dust and cobwebs, the bodies of the cows plastered over with manure, and piles of loose hay and manure lying near the cows while the milking was being done. Milk from such dairies would contain hundreds of millions of bacteria to the cubic centimeter, but fortunately most of these bacteria were sapro- phytes, and the harm they did was chiefly in souring the milk by converting its sugar into lactic acid or decomposing the proteins. In hot weather the heat would favor development of new bacteria and the milk would not keep. This led to a demand for sterilization or pasteurization, but it has since been found that it is much better to produce milk under sanitary conditions and thus keep down the number of bacteria than to kill them by heat after they have been allowed to get into the milk and attack it. Another thing that would have been noticed at this dairy, possibly, is that the milkers did not wash their hands or wear clean clothes, and that the water used in washing milk pails and cans came from a well close to a water-closet. If there was an infectious disease, such as scarlet fever or typhoid fever in the family of any of those who handled the milk, the opportunity for infecting the milk was present, and there are many recorded instances where epidemics of typhoid fever particularly have been caused by milk infected by those handling the milk or by water used in washing utensils. MATERIALS USED IN SUBSTITUTE FEEDING. 115 Fortunately, this state of affairs is not as common as formerly, and the physician to-day does not have the problems to contend with in obtaining a good supply of milk that the physician of ten years ago had to deal with. The principles involved in the production of whole- some milk are now well understood, and are being applied more and more even in remote parts of the country, and good milk suitable for feeding infants can be produced anywhere by the exercise of care and cleanliness. Production of Sanitary Milk. — All that is needed to produce milk suitable for feeding infants are cows that are free from tuberculosis or other disease, a stable that can be kept clean — an ordinary barn will do — and careful attention to keeping the cows and utensils clean. The cows are to be cleaned daily and kept as sleek and clean as horses. The hair on the udder is to be kept cut short and the udder and belly are to be wiped off with a damp cloth just before milking. No loose hay or manure are to be left in the stable when milking is going on, as dust from them carries bacteria with it into the milk. All utensils are to be washed with boiling water, and steamed if possible. The milker should wear clean clothes, and his hands should be washed with soap and water just before milking. The first few streams of milk from each teat should be thrown away, not into the milk pail, but into the manure gutter, and the milking should then proceed into a small mouth pail. The milk should then be strained through a sterile cloth and cooled and iced and kept iced until ready for consumption. The bacterial condition of milk is of as much importance as its chemical composition and should never be left out of consideration. It is well also to remember that methods of milk production in America and Europe are totally different, and that European literature on this subject does not always apply to American conditions. Market Milk. — From a commercial standpoint milk may be divided into three grades: (1)'" Grocery milk," such as is sold at very low prices in city grocery stores, especially in the tenement districts, and dipped out of cans into the family pitcher; (2) bottled milk, such as is delivered to families in glass bottles in the more well-to-do sections; (3) sanitary, inspected, or certified milk, which is also sold in bottles. Grocery milk is produced at as low a cost as possible and con- tains enormous numbers of bacteria, as no more care is taken in its production than the health authorities insist upon. It is a poor food for infants, especially in hot weather, when it may be positively dangerous. 116 DISEASES OF CHILDREN. Bottled milk is generally produced under much better conditions than grocery milk and sells for about double the price of the grocery milk. It forms a satisfactory milk for infant feeding in a large number of instances. Sanitary, inspected, or certified milk is produced under the super- vision of a commission of physicians, usually appointed by a local medical society. Such commissions furnish standards of cleanliness and bacterial count which are to be complied with. Then if the milk when taken at random from the milkman's delivery wagon comes up to the standard, he is furnished with a label certifying that the milk is of the required quality, or "certified milk," as it is often called. The standards fixed by "milk commissions" in different cities are not all alike. In Philadelphia, for instance, the number of bacteria per cubic centimeter must not exceed ten thousand, while in New York the maximum number must be not over thirty thousand per cubic centi- meter. Certified milk is the safest and best milk obtainable for use in infant feeding, and can now be had in most large cities and in some small ones: There is no reason why it should not be obtainable any- where. Any progressive dairyman or farmer can produce it. The price of this milk is 50 to 100 per cent, higher than that of ordinary bottled milk. It is important that the certification be done by some competent medical authority and no milkman should be allowed to do his own certifying. Pasteurized and Sterilized Milk. — By heating the milk to about 160° F. for about twenty minutes the great majority of bacteria pres- ent are destroyed. Such treatment of milk is called pasteurization. If the milk is heated to 212° F. it is said to be sterilized, as all of the bacteria are destroyed. In both of these processes the bacterial spores survive, and if the milk is not kept below 50° F. they will germinate, and soon the milk will contain as many bacteria as it did originally, but the type or kind of bacteria will not be the same. Bacteria that convert the sugar of milk into acid and cause souring are the pre- dominating kinds in fresh milk and the acid they produce retards the growth of other types, until, when milk is nearly soured, 95 per cent, of all the bacteria present are acid producers. Heating the milk to above 150° F. destroys the acid bacteria and leaves a free field for bacteria that attack proteins. Therefore pasteurized or sterilized milk does not readily sour, but its proteins are often partially decomposed by bacteria produced from spores which escaped de- struction, and such milk may cause considerable digestive disturbance. Pasteurization or sterilization may be used to take the place of clean- MATERIALS USED IN SUBSTITUTE FEEDING. 117 liness in producing milk, but it is not to be advocated for this purpose. If the milk is suspected of conveying pathogenic bacteria, then it should be pasteurized, but this should be done if possible in the home when the infant's food is prepared, so that there shall be no opportunity for contamination between the time the milk is pasteurized and the infant receives its food, for pasteurized milk is just as liable to be un- healthful as fresh milk if it is not protected from reinfection. Ster- ilized milk is not used to any great extent because it has a cooked taste. Pasteurized milk tastes very much as fresh milk does, although a differ- ence is discernible. Heating milk in some way alters it so that it is not solidified by rennin as quickly as fresh milk, and this property is often taken advantage of in prepairing food for infants in whose stomachs fresh milk solidifies too rapidly. Heating the food may make it digest satisfactorily. Composition of Market Milk. — Nearly all of the States have laws regarding the composition of milk and cream. Most of them require the milk to contain 12 per cent, of total solids, of which at least one- fourth must be fat. A few States require the milk to contain 3.5 per cent, fat, and solids not fat 9 per cent, or slightly more. Since the introduction of bottled milk the public has become edu- cated to look for a layer of cream in the necks of the milk bottles. Milk containing but 3 per cent, of fat will not produce a satisfactory layer of cream, so either cream is added to milk containing but 3 per cent, fat, or the cream is allowed to rise on such milk, and a portion of the milk under the cream is drawn off thus increasing the percentage of fat in what remains. Milk for the general bottled trade will contain between 3.5 per cent, and 4 per cent, of fat, about 3.20 per cent, proteins, and 5 per cent, sugar and mineral matter. Some milk dealers with poor facilities will bottle 3 per cent, fat milk, but it will not pass with most purchasers of bottled milk. Bottled milk from fancy Jersey cattle will contain from 4.5 per cent, to 5.5 per cent, fat, 3.5 per cent, proteins, and 5 per cent, sugar and mineral matter. Certified milk generally contains 4 to 5 per cent, of fat, with the other ingredients about the same as in good bottled milk. Cream. — There are two kinds of cream sold by milk dealers: (1) Gravity cream, or that which rises naturally if the milk is allowed to stand; (2) centrifugal cream, or that which is separated by passing the milk through a centrifuge running at a high rate of speed. The percentage of fat in cream varies, running all the way from 16 per cent, up to 40 per cent. Some gravity cream may run as low as 16 per cent, and as high as 25 per cent. Centrifugal cream can be made of any desired percentage of fat by adjusting the centrifuge. There are 118 DISEASES OF CHILDREN. marked physical differences between gravity cream and centrifugal creams. Gravity cream will "whip" much better than centrifugal cream, and for some purposes in catering centrifugal cream cannot be employed. Centrifugal cream is much thinner than gravity cream , ■■■■,--„ ,-Q,[.-t - ■■'--■ 3 ^■•--v.*^J y -< > -^ Fig. 37. — Microscopic appearance of normal milk (Babcock and Russell.) Fat globules in clusters. of the same composition. Heating or pasteurizing milk or cream produces much the same effect as centrifuging, and to overcome the effect of these processes there has been invented a method of restor- ing the "body" to such milk or cream, which consists in adding a MATERIALS USED IN SUBSTITUTE FEEDING. 119 combination of calcium hydrate with cane-sugar, called syrup of lime or "viscogen." This substance will cause cream or milk to thicken perceptibly, and is sometimes used to make poor cream appear like richer cream. Figs. 37, 38 show the microscopic appearance of normal milk and milk that has been centrifuged or heated. Condensed Milk. — There are on the market, and widely used, a large number of brands of condensed milk. These are made by evaporating milk in vacuum pans, at a low tempera- ture, after it has been brought near the boiling-point. If it is to be sold in the fresh state it is then run into cans and shipped to market. Other- wise, granulated sugar is added and the milk is then put into small cans and hermetically sealed. Such milk is known as sweetened condensed milk. It is a one-sided diet contain- ing an excess of carbohydrates. It will make children very fat because they change its excess of sugar into body fat, but when it is diluted so they can digest it the percentage of proteins or blood and muscle-forming portion of the food is not much more than half that of mother's milk, and of course the infant cannot grow prop- erly on it. There is also a great de- ficiency in fat. Evaporated Milk. — There is also sold in cans what used to' be called "evaporated cream" but which since the passage of the "Pure Food and Drugs Act" in 1906 is called by its true name "evaporated milk." This is condensed milk which has been canned without the addition of sugar. It has a creamy consistency and when diluted with water is very much like sterilized milk. It does not sour readily, but is liable to putrefaction, and for this reason is put up in small cans that shall be used up soon after opening. It will not keep when opened as will the regular condensed milk. Fig. 39.— Obesity with lack of proper musculature, resulting from high carbohydrates and low protein. 120 DISEASES OF CHILDREN. Cereals. The various cereals play an important part in artificial infant- feeding, and when used intelligently are of greatest service. In feeding sick infants and for tiding over a period when milk is not tolerated, the cereals and products derived from them are the main reliance. But it should also be remembered that if used injudiciously they may cause considerable disturbance. General Properties of Cereals. — The cereals are essentially vege- table eggs. That is, they are composed of the plant germ and enough food to nourish this germ until it has developed organs for securing food from the soil and air. All cereals are composed of fats, car- bohydrates, proteins, and mineral matter in different proportions. The amount of fat in wheat flour is about 1 per cent., while the quantity in oat- meal is about 9 per cent. Barley flour may contain as high as 3 per cent, fat, while pearl barley will con- Lj _ . ' .',«,, N tain as little as 0.7 per cent. fat. Pig. 40. — Barley gram. (Goodale.) . x c, Protein layer; d, starchy portion. Proteins vary in much the same way. Barley flour may contain as high as 13 per cent, and as low as 7 per cent, proteins. These differences are largely due to the methods of preparing the cereals for use. Fig. 40 is an illustration of a cross section of a cereal in which it will be noticed that the proteins are found in the outer layers of the grain. In making pearl barley the outer layers are ground off, leaving the interior portion which contains a relatively high pro- portion of carbohydrates or starch. Accordingly, a sample of barley may contain 13 per cent, proteins and 74 per cent, carbohydrates, and after it has been "pearled" it will contain 7 per cent, proteins and 77 per cent, carbohydrates. The proteins of barley make an exceed- ingly sticky dough when the flour is mixed with water, and for this reason it is desirable to remove a portion of the protein for certain purposes in cooking and some flour is made from barley from which the protein layer has been removed. Such flour stirs into water very easily and for cooking purposes is very convenient. From a nutritive standpoint such flour is not the best, as in infant-feeding particularly, the main object is to give as much proteins as can be utilized, and cereals containing the full quantity of protein are to be preferred. MATERIALS USED IN SUBSTITUTE FEEDING. 121 Carbohydrates of Cereals. — The skeleton and tissues of plants are composed of carbohydrates, while in animals the tissues are mostly proteins. Naturally, then, the cereals are composed largely of car- bohydrates, the proteins which are only necessary for the formation of new protoplasm being present in smaller amounts. The carbo- hydrates may be in a number of forms, and the plant and its germ has the power to change one form into another as is needed. For for- mation of plant tissues they may be changed into cellulose, of which cotton is a good example. For storage of a reserve supply they may be changed into starch or inulin. When the reserve or starch is drawn upon, the plant secretes enzymes which change the starch into a soluble form. The starch first becomes soluble, it is then changed into dextrin and finally into maltose. These changes can readily be brought about in preparing food for infants, and this fact is of impor- tance, for oftentimes carbohydrates in the form of starch will not be acceptable, when by being converted into soluble starch, dextrin, or maltose they will not only be well digested, but will bring about a marked improvement in general conditions. Many of the proprietary infant foods are made in whole or in part of cereals which have been treated so as to affect the properties of their carbohydrates, or starch. The amount of cellulose in cereals is very small. Details for pre- paring cereals for infants will be found at page 151. Eggs. Eggs. — These are to the animal kingdom what the cereals are to the vegetable kingdom — a germ with material which it can use in form- ing an animal organism which is capable of digesting food from other sources. As the animal tissues are almost entirely made up of pro- teins and water, eggs naturally are likewise composed principally of proteins and water. They 'also contain fat, and lecithin from which nerve tissue may be formed, and organic iron for blood formation. Eggs of different animals vary in composition according to the devel- opment of the young when hatching takes place. Hen's eggs are the ones principally used and these contain enough of the food elements in suitable form to make all kinds of tissues, as the chick comes out of the egg fully formed, and its growth then consists almost entirely of enlargement. Eggs, therefore, are very useful additions to diet during the growing period, and especially when the infant is beginning to eat table food and needs easily digested proteins. 122 DISEASES OF CHILDREN. Proprietary Infant Foods. General Properties. — Before the subject of infant-feeding was as well understood as it is at present, many attempts were made to fur- nish artificial foods which should take the place of mother's milk and of cow's milk. For a time they served a useful purpose and when it was impossible to obtain a supply of good cow's milk they were of considerable value, as very often they were retained and saved the infants from starvation or serious digestive disturbance caused by contaminated milk. On them many infants gained in weight and thrived temporarily, but frequently these infants developed rickets and scurvy, or were poorly developed and of feeble constitution, and consequently were carried off by the first serious sickness. All of these foods are composed of proteins, mineral matter, fats, and car- bohydrates. In some the amount of fat is infinitesimal, the protein low in quantity and the carbohydrates very high. None of them are at all like mother's milk in properties. They often contain only enough protein to but little more than make up for metabolic waste, but the carbohydrates are in such a form that they are easily assimi- lated and converted into fat which causes increase in weight. All of the proprietary infant foods are composed of cereals, sugars, dried milk, and eggs, either singly or in combinations that have under- gone special treatments. Chemical analyses show little or none of their properties except their possible nutritive value. The most recent analyses available are given on page 123 and are taken from the 1908 report of the Connecticut Agricultural Experiment Station. Classification of Proprietary Infant Foods. — A clear idea of what the infant foods on the market are like will be obtained if they are classified according to the materials from which they are made, and according to this plan they will all fall into about three or possibly four distinct groups or classes, as follows: <-T to <-< cu +-> 03 cp 73 73 >> .,-d *- O CSX! b£u 3 03 02 O ^ e a a O -+3 * d i H cp o3 ^ cp CP « 2 s X o H£ 73 ^H 33 # > Ph*E 3 i2 OT3 O^ T C R a '+3 it J. 9 X X . 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If flour la used in making the gruel and none is removed by .-training, dividing the com- position of the flour by the number of parts of gruel made from one part of flour will give its composition; as, for instance, a gruel made with one ounce of flour to the pint would be one-sixteenth as strong as the flour. But when whole or granulated cereals are used, a large part of the proteins and considerable of the carbohydrates are removed by straining, as the cereal does not disintegrate while cooking and the composition of the gruel is not in proportion to the composition of the cereal employed. In using ordinary cereals in preparing gruels the following quan- tities will be approximated, when a tablespoon is used in measuring the cereals. 1 level tablespoonful of pearl barley weighs £ oz. avoirdupois. 1 level tablespoonful of barley flour weighs | oz. avoirdupois. 1 level tablespoonful of wheat flour weighs \ oz. avoirdupois. 1 level tablespoonful of rolled oats weighs i oz. avoirdupois. When the ordinary cereals are made into gruels they will have approximately the following composition: If all of the rolled oats had remained in the gruel made with one ounce to the quart, the gruel would have contained about 0.50 per cent, proteins, as these rolled oats contained about 16 per cent, proteins, but the gruel actually contained but 0.26 per cent, proteins, showing half of the proteins were removed when the gruel was strained. There can now be obtained through the drug stores a series of standardized flours for making gruels known as Cereo Gruel Flours. put up in tins the covers of which measure one ounce of flour. On the labels is given the quantity of flour to use to make a gruel of any desired composition. Gruels made from these flours contain more proteins than gruels made from ordinary cereals, as will be seen by comparing the composition of gruels in Table II with those in Table I. Percentage Composition of Milk and Gruel Mixtures. — When milk or top milk is mixed with gruel the percentage of fat in the mixture is not affected by the gruel, as gruels contain negligible quantities oi fat, but the percentages of protein and particularly those of the carbohy- drates, are much greater than when milk is mixed with water. The following table shows the amount of proteins and carbohydrates in various dilutions of milk and gruels made from the standardized gruel flours mentioned above are used. at Ih >» o Ih at J3 a CD Fh 73 C eg 'o (h o 5+-C O 73 c 5 & a (IJBnb oq anoy pruS jo sinjuoodsaiqB^pAajzi) -szo f OOOiOiOOO C© CO to 10 lO iC 10 (liBnb o% anojj pnj3 jo sjnjuoodsajqB} pA9j 8) *szo c CO "HH >0 10 C£> 00 O _ ■^ T^ "HH Tf ^ Tt 1 *0 (jjBnb 05. .moy pru3 jo sjnjuoodsajqB:). pAaj fr) zo i TtNO^COWtO CO Oi "* t-h t-1 (M (N CO CO thh xtures. Eh' H H o H h5 M < pq (l-iBnb oi Jnog pruS jo SJTlJUOOdS9iqBJ pA9J zi) -szo £ O CO thh t-h 00 ^O CO l>» CO CO CO to LO 10 in Milk and Gruel Mi gruel flours, page 14£ (qiBrib oq -mop pruS jo spajuoodsgjqB:; pA9j 8) -szo z 00X050000 rh ■* ■* Tr< 10 ^ to (qjBnb oj anop pruS jo sjnjuoodsajqB^. pA9{ P) -zo i NOONOMN C^ CO CO CO ^ ^ ^ (qjBrtb oq. Jnoy pruS jo jnjuoodsajqB} pA9j i) zo | rHNNMMO-* ^H ^H (N (N CO TJH THH £ .2 «S 73 u ^ '5 -4-> o u -^> b£ a CD «H -^> 02 73 03 13 u O o 73 a s P O h-H (qiBtib oq. -mojj pnj3 jo sjnjuoodssjqBi pA3j si) 'szo £ rtl 10 CD t> 05 O (N (N (N (N (N (N rfi 00 o ~& So o «S «-' Eh' H H Eh" o H < pq (qaBnb oq. .mojj piuS jo sjnjuoodsajqB* pAaj ji) -szo? w c; h co 10 n t-h ^-1 CM a Ih 0) (jJBnb 05. jnojj pruS jo sjnjuoodsajqB:). pA9j 8) 'szo z J0 CO -^ CO h "JOOCNOO^X ' t-h t-i CN CN CM pru3 jo uorqjodojj Hoc «*# ic?x Hf« c*o -+* H« 3^^XUI JO UOI^JOdOJ £ Hoc t** c*o Hin »=fac c** t-fao PRACTICAL FEEDING. 145 Illustrations of Use of Previous Tables. — Wide experience has demonstrated that there are certain percentages of each of the food elements more than which it is not safe to have in the food of most in- fants, and other percentages less than which the food should not con- tain as it will not be sufficiently nutritious. It is seldom advisable to have the food of infants contain over 5 per cent, of fat, 8 per cent, of carbohydrates, or 3.5 per cent, of pro- teins. The mineral matter in mixtures is generally sufficient, and as yet no attempt has been made to deal with the complex substances that make up this element of the food. For the great majority of infants the maximum percentages just mentioned should not be employed as they will cause disturbances, and it is only after a period in which the strength of the food is grad- ually increased that high percentages can be tolerated by any infants. However, many times infants are given as great or greater percent- ages inadvertantly by those who do not estimate the composition of the feeding mixture, and a great deal of unnecessary disturbance results. For instance, an infant is given a mixture composed of the top nine ounces from one quart of milk, nine ounces of water, and one ounce of sugar. It vomits a great deal and is not doing well. By reference to the key to composition of milk mixtures on page 141 it will be found that a mixture containing one-half top milk made by using the top nine ounces from a quart bottle and one-half water will contain 6 per cent, fat, 1 . 6 per cent, protein, and about 1.6 per cent, carbohydrates. The one ounce of sugar added would be a trifle over one-twentieth of the mixture, or 5 per cent., which would bring the percentage in the mixture up to over 7 per cent. The mixture would be looked upon as being composed of fat 6 per cent., carbohydrates 7 per cent., and protein 1 .6 per cent. As vomiting is often caused by too much fat in the food, the inference would be that as the percentage of fat was above that found to agree, with most infants it should be cut down. A glance at the key shows that if the top twenty ounces is removed from the bottle and mixed to make its composition uniform and is then diluted in the same pro- portion, that is, equal parts of the top milk and water, the percentage of fat in the mixture will be 3 per cent., which would be about what would be suitable for most infants. If this top milk was substituted for the top nine ounces and the infant had no more difficulty with its food, it would be conclusive that an excess of fat caused the trouble, especially if the stools were sour-smelling and frothy- Another infant might be seen who had sour, watery movements that irritated the skin. Its food might have been made as follows: Whole milk, eight ounces; wheat-flour gruel (two ounces flour to quart), eight ounces; granulated sugar. two level tablespoonfuls; total, sixteen ounces. Referring to the table on page 144, showing the composition of milk and gruel mixtures, it is found that a mixture half milk and gruel (two ounces flour to quart) contains 2 per cent, protein and 4.9 per cent, carbohydrates. From the key on page 141 it is found that two level tablespoonfuls of granulated sugar weigh one ounce, which would be one- 10 146 DISEASES OF CHILDREN. sixteenth of the mixture or slightly over 6 per cent. Thus, to a mixture containing 4.9 per cent, carbohydrates there is added 6 per cent, more, making a total of practically 11 per cent, carbohydrates in the food. Few infants can digest and assimilate much over 7 per cent, to good advantage, and the indications are that in this case the excess fermented and produced acid discharges. One-half a level tablespoonful of the sugar, 1^ per cent., is about all that should] have been added, as this would have made the total about 7 per cent. In the case of a very young infant suffering from colic, and with curds in the stools, a mixture containing three parts of milk to one part of water might have been given. Referring to key on page 141, it will be found that a mixture con- taining three-fourths milk will contain 2 . 4 per cent, protein, from which the curds are formed. Experience has shown that young infants should not at first have over 1 per cent, of proteins in their food, as their digestive organs are not suffi- ciently trained to digest more than this quantity, when not in the form of protein of breast-milk. If the proportion of milk was made one-fourth instead of three-fourths, in all probability the colic would disappear, as would also the curds in the stools. Of course sugar would have to be added to milk so highly diluted to save the infant from living on its own tissues. About one part of sugar to sixteen parts of food would be required. There was a time when it was firmly believed by many that all of the digestive disturbances of infancy could be successfully treated by thus altering the percentage composition of the food, but it is now known that other factors are involved, and that while adjustment of percentage composition is an important matter, still there are other points equally important to be taken into consideration. It is only a waste of time and energy for the physician to commit to memory lists of percentages suitable for different ages and con- ditions. If he will study each case as it presents itself and work out the composition of each food that is disagreeing, he will soon come to understand what percentages to use to get best results, and also to know what other methods besides changing percentages to employ under different conditions. Outline of Feeding Directions. — It is impossible to give explicit directions for preparing food for each particular infant, as infants differ in their digestive capacity and in their efficiency in assimilating food, as mentioned on page 135, and in their condition when the physi- cian is called in. However, all cases naturally fall under about four headings: (a) Well infants which cannot obtain breast-milk, and the control of which the physician has from the start, (b) Infants that are well except that they are suffering from bad methods of feed- ing, (c) Infants of feeble constitution whose digestion is easily deranged, (d) Infants that are acutely ill. Before attempting to PRACTICAL FEEDING. 147 feed an infant, its feeding history should be carefully taken to deter- mine in which class the infant belongs. The methods of feeding these different classes of infants vary considerably, and while the same general principles hold, they must be applied differently. In all methods attention must be paid to per- centage composition of the food. This is not a difficult matter, and can be readily learned, but the skill and ability of the infant feeder have a chance for display when it comes to adapting the form of the protein, fats, and carbohydrates to the infant; or to modifying the action of the infant's digestive secretions on its food by various additions to the food as explained on page 130. In the suggestive feeding mixtures given here the preparation of the food is sharply divided into two parts: First, adjustment of the quantitative or percentage composition.. Second, modification of the form of the food, or the action of the digestive secretions on the food. Food for Healthy Infants. The object in preparing food for healthy infants is to so modify or adapt the food that they will be well nourished and have their digestive organs so developed that the infants will become able to take whole cow's milk without digestive disturbance. It is generally about the ninth to twelfth month before this is possible, and if alkalies or antacids have been added to the food in too great quantities it may be later, as these substances seem to interfere with the normal development of the stomach. In reality the whole process amounts to a training of the infant's digestive organs, and it is important to commence in the early months with small quantities of the protein of cow's milk, as this causes the greatest amount of trouble, moderate quantities of fat, and a liberal supply of carbohydrates, as these cause little digestive disturbance when not given in too great excess. The fats are kept in the neighbor- hood of 3 per cent, during the whole period of artificial feeding, and the carbohydrates at about 6 per cent, or 7 per cent., seldom over these figures. But the protein is managed in an entirely different manner. At first the protein is given in as small a quantity as 0.4 per cent., or about one-eighth as much as is found in cow's milk, and about one-fourth as much as in breast milk. As soon as a tolerance is established the quantity is increased about 0.40 per cent, at a time until the infant is able to digest whole milk with its 3.20 per cent, of protein. These advances in strength of food are made about a month apart. There is no fixed rule, except to increase as rapidly as 148 DISEASES OF CHILDREN. the infant can stand it. With some the advance can be quite rapid, while with others it must be made slowly. By this process the heat and energy portions of the food are kept up to the highest point of efficiency, while the growth- producing elements are at first given in less quantities than is desirable; but gradually they are brought up to a point where proper tissue formation becomes possible. If the protein is given in too great quantities at first, indigestion results and a period of greater or less duration ensues in which little growth can be made. For this reason it is better in the long run to slightly underfeed with protein for a short time and avoid digestive disturbances. In increasing the quantity of protein in the food it is often the case that the more the haste the less the speed. The following table gives an outline of the quantities and composition of food which may be taken as a working basis in preparing food for healthy infants : The whole process of pre- paring the food is shown in an extract from pictorial directions for preparing food devised by Deming (Fig. 44). For those whose minds do not run to mathematics a percentage milk modifier will be helpful. This is a measuring glass graduated to percentages of protein and fat of cow's milk. Protein may be varied by 0.20 per cent, at a time and ■^QL> — «i"LU mm ^ CD MliiiMl 6 Warm the food slightly and give 1 bottle every hours dur- ing day. times at night 5 Pour iozs. into each of bottles. Pasteurize and keep on ioe. 4 Add level tablespoon- fuls of [a] Granulated Sugar [b) Milk Sugar Stir to dissolve. c a C o "1 •0 X < 5 logo M§5§. 2 Soso Is 2.2 "a a \$32 i O, III o N c 1 i 2% Add dipper- fuls or ozs. Limo Water. 2 Take of this mixed Top Milk dipperfuls or ounces s § a N « n c "" c 1 resh milk and 'when the cream has risen iip off the Top ozs. into a bowl and stir to mix. H f 02 02 02 1 ^ C3 N N sa si si SI S) 73 bD O o O o O O < 3 02 rH^ HC1 T-H T-H « H V-" 02 02 02 CO 02 02 02 T3-T 3 t£ o SJ N SI si SJ SJ o o o O CO O CO O CM O CO S- . Mg i— l CNJ CO <* CO CM ^ N 1—4 >— 1 (M CO r nJTJ 65 65 ^ ^ 65 65 65 65 i.2 o o o o © -+3 Pi' 00 -+3 Ph °J P J o °£ CO l> r^ t- 1^ i> i> i>- 65 65 ^ ^ 65 65 65 65 iO o CO o 10 1— 1 CO OQ CO CO CO CO TJH £ bfl a o3 _d 65 65 ^ ££ 65 65 65 65 P*"£ © -p3 O o o o o < s TJH 00 (M CO Tf 00 CM © S-i ^ ^ CM CM CM CO +3 -p3 -M 02" -(j -M pp pp .43 h-G a3 >3 ~>> - >> b/D^ ~ bfi bJO to bJD S w ^bfl ^ Oj tt oc! "2 Oj P C3 3 £ g§ ga p"a 5 'a 02 -ri u P e-S *T! ^^ P->3 ?^ 2^ ^-M P b£ O bD O bC s s O cj o m 43is ^"oj 2^ 2 p ^.S -^.s © ^s -^ © -P © r1|M CD -2 » rP © ■*»•§ w,2 Hc^'C CM o <^.2 (M O ^ © CO © CO P CO P +3 +3 o CM O p 73 73 73 73 ' 02 02 02 02 02 02* S 73 § g K 2 N KJ SI SI si SJ o O O O O -.£.2 § 02 CO "* • CO 00 O cu ^ TV, ° O o +3 o -1-3 SI O O -t-3 ■+3 O S © CtH CM l> CO CD 10 10 ^ 02 02 02 02 02 02 02" 02 S3 O 00 SI SJ SI SI S) SI S) '■si 3 ^ o o o 00 o CM (M 00 00 ° pd pd -r3 P O pd -p3 p a p a •+3 OS -f3 a © bfi <1 02 a 73 02 M © o B a a -*-3 CO O .p +3 CM O -t-3 pd -1-3 T-l O -r3 CO 1 T* T3 T3 -u -1-3 A 1— 1 CM CM CO +3 t^ O CN 73 9d « bX rt P b£ 75^2 © © 150 DISEASES OF CHILDREN. fat in small fractions of 1 per cent. In using it, milk or top milk is poured into the graduate up to the figures indicating the desired per- centages of protein and fat and the glass is then filled with a diluent. The percentage of fat obtained with each percentage of protein when whole milk or top milk is used is shown on the glass at the same height as the percentage of protein (Fig. 45). By using it a few times the physician will quickly grasp the subject of percentage mixtures. __^ mmmma=xm ^____ The modifier is used with a pic- torial prescription blank similar to Fig. 44 which the physician fills out and turns over to the mother or nurse. It is easy to use in practice and does not necessitate any figuring. It will be noticed in the feeding table that less sugar is to be added to the food when gruel is used than when water diluent is employed. This is because the gruel contains consider- able carbohydrates. The quantities added by gruels will be found in the table on page 144. A convenient rule to remember is, when gruels made with one ounce of flour to the quart are used, add 3 per cent, of sugar; and when two ounces of flour to the quart are employed, add 2 per cent, of sugar. These additions would be one thirty- third and one-fiftieth of the total quantity of the food, respectively. These proportions will always make the percentage of carbohydrates in the food between 6 and 8 per cent. A rule often employed for adding sugar to food is, add 5 per cent, or one part to twenty parts of food. This will always make the percentage of carbohydrates fall between 5.5 per cent, and 9.5 per cent, when water diluent is used and much higher when gruel diluent is employed. One part of sugar to twenty-five parts of food makes the percentage of carbohydrates fall between 5 per cent, and 8 per cent, when water diluent is used. When gruels are used to dilute the milk the percentages of protein in the mixtures will be greater than those given in the feeding table which are for milk and water mixtures. By referring to the table on page 144 it will be found that a mixture made with milk and the gruel given above (one ounce flour to quart) will contain 0.82 per cent, protein, WWMIHG PERC£A7*$" \ tlRta CO.TAPPAH? Fig. 45.— Deming's percentage milk modifier. PRACTICAL FEEDING. 151 which when made with milk and water would contain only 0.40 per cent, protein. The mixture containing 0.80 protein would contain 1.16 per cent, if the gruel was employed, the 1.2 per cent, mixture would contain 1.5 per cent., and the one containing 1.6 per cent, would be increased to 1.8 per cent, protein if the gruel was used. The pro- tein thus added by the gruel not only increases the tissue-building value of the mixtures, but acts as a mechanical diluent or softener of the solid formed from the protein of the cow's milk, and hence makes it more digestible. As the value of gruels when used intelligently has become better appreciated, they have come to be employed more and more, and whenever they are tolerated they should be used in preference to water for diluting the milk. Two kinds of gruels are employed: (a) those made by boiling the cereal in water, which contain starch in an unchanged condition; (6) those to which an agent for changing the starch into dextrin and maltose is added. Gruels so made are called, respec- tively, plain gruels and dextrinized gruels. Dextrinized gruels should be used for young infants and when plain gruels are not well borne. Directions for Making Gruels. — Stir from one to four level table- spoonfuls of the cereal flour (p. 142) into one quart of cold water to avoid the formation of lumps. Place the mixed flour and water into a double boiler (Fig. 46) and with constant stirring bring to a boil. This will Fig. 46. — Double boiler cause the flour to swell up, owing to the gelatinization of the starch. Now allow the gruel to boil for fifteen minutes. Stirring will not be necessary. If an open kettle is used the gruel may burn at the bottom and impart a bad taste to the food. If the gruel is to be used plain, strain through a fine wire strainer and add enough boiled water to make one quart of gruel. If it is to be dextrinized set the cooker into cold water for two or three minutes and when the gruel is cool enough to taste add a teaspoonful of some preparation of diastase. A de- coction of diastase may be made at home by covering a tablespoonful of crushed malted barley grains by a little cold water and placing the mixture in the refrigerator over night. In the morning the water that 1.32 DISEASES OF CHILDREN. is strained off will be active in diastase, but will not keep long. A glycerite of diastase known as Cereo is now made for this purpose, and has proven to be reliable. Stir and the gruel will become thinner as the starch goes into solution and forms dextrin and sugar. Strain and add enough boiled water to make one quart of gruel. The floccu- lent matter in the gruel is mostly protein. No matter which kind of gruel is employed it should be cooled and kept on ice until ready to be mixed with the milk. Adaptation of Food to Infant. — So far the directions have had to do only with bringing together the food elements in quantities capable of producing proper growth and development at different ages. But this is a small part of practical infant-feeding, for any one of the fore- going mixtures may not agree with the infant. The problem then becomes how to adapt the food so that it will agree with the particular infant. Adaptation may be accomplished in a number of ways, as follows, beginning with simple changes in the food and ending in methods that are more complex in their effects: Symptoms. — The infant has no digestive disturbances, except slight con- stipation and scanty stools, but does not gain in weight. What to Do. — Increase the strength of the food by using the next higher formula. Symptoms. — The infant vomits, some time after taking its food, rancid- smelling material; its stools are soft and contain small flecks or white particles. What to Do. — Reduce the amount of fat in the food by using weaker top milk or plain milk in making the food. In extreme cases use skimmed milk in making the mixture and add a pinch of bicarbonate of sodium to each feeding. Symptoms. — The infant's stools are inclined to be too soft, but otherwise it seems to be doing well. What to Do. — Use barley or wheat in making gruels, and if necessary use weaker top milk to reduce fat, which may be excessive. Symptoms. — The infant is doing well with the exception of being more or less constipated. What to Do. — Use oat gruel for diluting the milk as it has a laxative effect, and increase the fat in the food to 3.5 per cent to 4 per cent, by using richer top milk. Give boiled water between feedings. Symptoms. — The infant suffers from colic, but has no curds in the stools. What to Do. — Change the form of cereal gruel employed, and dextrinize, if plain gruel has been used. That is, if oat gruel has been used, try barley or wheat gruel which has been dextrinized in its place. Pasteurize the food temporarily. Symptoms. — The infant has colic with more or less curdy stools. What to Do. — If water has been used in making the food mixture, try plain or dextrinized barley or wheat gruel instead and pasteurize temporarily. If this does not overcome the difficulty, add one to two tablespoonfuls of lime-water to each feeding bottle; or add one to three grains of citrate of sodium; or add two to ten grains of bicarbonate of sodium to each feeding bottle. The effect of these additions will be found at page 130. The citrate of sodium or bicarbonate of sodium should not be added for long periods, as they interfere with normal di- gestive development. Symptoms. — The infant has sour, watery stools. PRACTICAL FEEDING. 153 What to Do. — Reduce the quantity of sugar in the food, as it is fermenting, and also change the form in which it is given. If granulated sugar is being used, try milk-sugar. If dextrinized gruels are being employed try plain gruels. Pas- teurize. In any event change the form of the carbohydrates. Food for Infants Previously Badly Fed. Feeding History. — These cases almost invariably have a history of being well nourished at birth, and perhaps of doing well at the breast until for some reason substitute feeding became necessary, when con- taminated milk, improper modifications of milk, or proprietary infant foods were tried at random, and many or few changes in the food were made as method after method failed. These infants may not have gained in weight, or if they have gained in weight the flesh produced has been fatty, caused by high carbohydrates in the food with low protein. They may be suffering from incipient rickets, or show signs of scurvy, and in severe protracted cases may have drifted into marasmus. Many cases not so severe simply show a loss of weight with the infants in a fair condition. Management. — When seen early this is the simplest class of cases the physician is called upon to treat dietetically, and with careful management they promptly respond to treatment, but when the bad feeding has been prolonged the cases are often difficult and tedious. One of the greatest aids is to work out the composition of food pre- viously given, and to consider the methods of adapting the food that may have been used, such as addition of lime-water, bicarbonate of sodium, citrate of sodium, etc. It is of material assistance to know what has failed and whether failure followed a method properly carried out or whether it followed incorrect application of correct principles. In this connection it may be stated again that the physician should understand every detail of the preparation of food by all methods, be able to make gruels, should know the physical properties of food prepared in different ways, and also be acquainted with their taste and flavor., Barley gruel has a slightly bitter taste, oat gruel has a distinctive flavor, as has also legume and wheat gruel. A gruel that has been cooked in a stew pan often has a scorched taste which is sometimes very repulsive. The food may have been kept in a warm place or in a poor refrigerator, or the milk may have been stale or it may have been partially soured. Occasionally it may be found the proper top milk is not being used. These are a few sug- gestions which show no detail of preparing the food should be over- looked or unknown to the physician. For mild cases putting the infant on a formula similar to one given on page 149 for healthy infants of the same age will be all that 154 DISEASES OF CHILDREN. is necessary, although a very good plan to follow is to give the food for a younger infant for a few days and if it agrees a stronger formula may then be ordered. In more troublesome cases the digestive organs must be given a rest, either complete or partial; that is, no food at all must be given for a few hours, or the infant must be given not much more than enough food to keep it from living on its own tissues. The following food mixtures may be tried, using whichever agrees best or can be prepared to best advantage, taking into consideration the probabilities of directions being carried out properly. Dextrinized barley, legume, oat or wheat gruel, made with one to two ounces of flour (four or eight level tablespoonfuls) to the quart of gruel, directions for preparing which will be found on page 151, or whey made as follows may be used : Directions for Making Whey. — From a quart of milk remove all of the cream. Then add to the skimmed milk a tablespoonful of liquid rennet or one junket tablet such as may be had at grocery stores. Place the milk in a double boiler (see page 151), and warm slowly. When the milk has solidified or "set" cut it in all directions into small pieces to allow the whey to escape. Now warm up to about 150° F., and stir while doing so. The curd which was all broken up will cohere into one or more large pieces which may readily be re- moved, and about twenty ounces of clear whey will remain. If the whey is heated above 160° F. the albumin will coagulate. The whey should now be cooled and kept on ice until ready to be fed. Its composition will be about, protein 0.80 per cent., fat 0.30 per cent., carbohydrates 5 per cent. Whey and Cream Mixtures. — In some cases mixtures of whey and cream are tolerated better than other forms of food. They may be conveniently made as follows: From one quart bottle of fresh milk remove with the dipper the top 6 ounces. Place the remaining 26 ounces in a double boiler, add a tea- spoonful of liquid rennet and warm slowly. When the curd has become firm, cut it into small pieces with a knife and slowly bring to 150° F. Strain through a fine wire strainer, or cheese-cloth, and cool the whey. By combining the whey and the top 6 ounces removed from the quart milk bottle a great variety of mixtures may be obtained as follows : Use of the top 6 ozs. Use of the whey. Approximate Composition Protein Fat Carbohydrates 1 oz. 2 ozs. 3 ozs. 15 ozs. 14 ozs. 13 ozs. .80% 1 1 % 1 5% 1.00% 2.5% J 5% 1.20% 3.3% | 5% PRACTICAL FEEDING. 155 The quantities to be given are a little less than the amount of food that would be appropriate for a well infant of the same age. If any of these foods are well borne, milk may be added, a teaspoonful to a feeding, to see if it will be tolerated, and if so a weak milk mixture may be given and the strength of the food increased by degrees until full strength for the age is reached. If rickets or scurvy is present, more care in treatment will be necessary, and this must be according to lines laid down under these titles. Food for Infants of Feeble Constitution. This is one of the most difficult classes of infants the physician has to feed, and they often tax his ingenuity to the utmost. They are generally the offspring of nervous parents and are easily thrown out of equilibrium. They catch cold easily and are subject to attacks of indigestion from trivial causes. During the warmer months they are readily attacked by gastroenteritis, and their management then becomes tedious and their progress is slow, careful watching of the feeding being necessary at all times. Whenever possible a wet-nurse should be obtained for these cases. Artificial feeding is unnatural in all cases, and while it may succeed in a majority of instances, its success is due not so much to the superior character of the food as to the infant's ability to adapt itself to its new food. This power of adapting to environment is feeble in these infants of unstable constitution, and too much depend- ence should not be placed upon it. Valuable time and strength should not be wasted in attempts at finding a food that will agree with the infant when it is possible to secure a wet-nurse. At this point it will be well to refer to page 90 where the natural place of breast- feeding will be impressed upon the mind. A Wet-nurse Unobtainable. — When the services of a suitable wet- nurse cannot be had, substitute feeding must be tried, and methods that at one time would have been looked upon as quite unscientific are the ones most likely to give good results. One should not approach these cases with fixed ideas of what they ought to take and keep on with food that is evidently disagreeing. All of the infants must have protein, mineral matter, fats, carbohydrates, and water, and in this class of cases it is perfectly justifiable to supply them in any form that is acceptable to the infant. Of course, this statement is not to be con- strued as meaning any nostrum that may be suggested should be tried, but a combination of the food elements that is quite unlike either human milk or cow's milk in general composition or physical properties, such as given on page 156 may be offered. The point to 156 DISEASES OF CHILDREN. bear in mind in the management of these cases is to keep the infants alive and as rapidly as possible build up their strength, and when this is done place them on a more natural diet. There is more to feeding than combining food elements in certain more or less definite proportions. A subtle factor in manag- ing these difficult cases is the arousing of the dormant powers of diges- tion and assimilation of the infants. This is often accomplished by a change in the flavor, taste, or physical condition of the food and in the form in which some of the elements are supplied. So simple a change as substituting dextrinized gruel for plain gruel of the same strength, in a modified milk mixture, has changed an infant which had worn out a family with its digestive troubles into a well-satisfied, contented baby in one day. The use of cooked foods, broths, or other forms of food, such as egg mixtures or legume gruels, has also brought about sudden and permanent improvement. Chemical analysis does not show what there is about the food that produces such changes in digestion and assimilation, but that different forms of food do have different effects on different individuals is an undeniable fact, well known to animal feeders, who find that by catering to the idiosyncrasies of indi- vidual animals, much better assimilation is brought about, and more economical use is made of the food. This comes under the head, or in the same class, as the fact that food served to an adult in an attractive, appetizing manner will be digested much better than if it is served in an unattractive, repulsive condition. Food for the Acutely 111. Classification of Cases. — Under the heading of Acutely 111 it is intended to group only those whose illness is reflected in disturbances of the digestive organs or by general malnutrition. Infants may be acutely ill with pneumonia or other infections and still not show special derangement of the nutritional functions. Again, as in gastro- enteritis, there is an infection or intoxication which calls for more than dietetic treatment, so such cases will be treated under their respective titles. Management of Cases. — In all of these cases it is of first impor- tance to find something that will be retained, and before time is wasted in calculating a theoretically indicated mixture which may be re- jected, it will be best to try some of the following mixtures, which if retained, will serve as a starting-point in working up to a suitable food mixture. 1. Dextrinized barley, legume, oat or wheat gruel made with one ounce of flour to the quart, as directed on page 151. If any PRACTICAL FEEDING. 157 one of these gruels agrees, the strength may be increased to two ounces of flour to the quart. Such gruels will contain about 0.80 per cent, protein and 5 per cent, carbohydrates, except the legume gruel, which will contain about 1.5 per cent, proteins with about 5 per cent, carbohydrates. 2. Whey, made as directed on page 154, may be tried, which will contain about the same quantities of protein and carbohydrates as the gruels made with two ounces of flour to the quart. 3. The white of one egg beaten up in eight ounces of water may be retained when nothing else is tolerated. Such a mix- ture contains about 1.5 per cent, of protein, but no carbohydrates or fat. Its nutritive value is not great. 4. White of egg and dextrinized gruel, made by beating up the white of one egg with eight ounces of dextrinized wheat flour gruel (1 ounce to quart) will sometimes agree. If it is acceptable, one to two even teaspoonfuls of granulated sugar may be added to the eight- ounce mixture, which will then have about the following composition, protein 2 per cent, and carbohydrates 6 per cent. 5. Yolk of egg and dextrinized gruel, made by adding the yolk of one fresh egg to eight ounces of dextrinized wheat flour gruel (1 ounce to quart), and if tolerated adding one to two level teaspoonfuls of granulated sugar, is highly nutritious and especially rich in blood making substances. If well borne in malnutrition cases legume flour may be used in place of the wheat flour. This will increase the quan- tity of nucleoproteids in the food materially. 6. Meat broths oftentimes arouse the appetite, and if acceptable may be mixed with dextrinized gruels made with two to three ounces of flour to the quart, in equal parts, or they may be thickened with the gruel flours by stirring in an ounce of flour to the quart of broth and boiling. This will make a thick broth. To make broths, take one pound of lean mutton, veal, or chicken with some cracked bone and cut into small squares; add one pint of cold water, heat gently, and allow to simmer for about three hours. Strain and add enough boiled water to make a pint of broth. When cool remove the fat or skim it off while hot. The broth will be gelat- inous when cold and should be served warm. 7. Beef tea is often useful as a digestive stimulant and is made by taking a pound of lean beef and cutting it into small pieces and allowing it to stand in a pint of cold water for an hour. It is then heated to not above 160° F., and the meat is expressed through cheese cloth. If heated to above this temperature the albumin of the meat will coagulate. If the coagulum is allowed to remain in the tea none of 158 DISEASES OF CHILDREN. the nutritive value will be lost, but if it is removed the tea will have little but flavor. 8. Beef Juice is often a useful addition to other foods in cases of malnutrition and may be made as follows : a. Slightly broil a thick piece of round steak that is perfectly free from taint. Cut into small pieces and press in a clean meat press or lemon squeezer. b. Cut the fresh steak into small pieces and just cover with cold, slightly salted water, and set on ice for several hours. Then press by squeezing in a piece of cheese-cloth. The quantity of beef juice given should not be over one ounce in twenty-four hours, and it is given to best advantage when added a teaspoonful at a time to other feedings, as in larger quantities the in- fant soon tires of it. If any of the mixtures just given agrees, attempts at adding fresh cow's milk, a teaspoonful at a time, may be made. If the milk is tolerated the quantity may be increased cautiously until it forms one- fourth of the mixture, when the fats may be increased and the infant can be put on a formula suitable for its age as indicated on page 149. When All Attempts at Adding Fresh Milk Fail. When infants fail to thrive on any of the foregoing mixtures and all attempts at giving fresh milk in any quantity fail, the following mixtures may be tried and often are highly successful. Whenever the foods that are cooked are used, a teaspoonful or two of beef juice or orange juice should be given daily, as on such foods infants are liable to develop scurvy. Formula A T o. 1. Whole milk 12 ounces. Wheat or oat gruel flour 4 level tablespoonfuls. Granulated sugar 2 level tablespoonfuls. Salt 1 pinch. Cold water 22 ounces. Mix cold and with constant stirring slowly bring to a boil and boil for three minutes. Strain and add enough boiled water to make thirty-two ounces. Feed quantity appropriate for age. For young infants or very delicate ones the food may be diluted with one part of water to two parts of the food. Approximate Composition.— Fat, 1.5 per cent.; carbohydrates (starch, milk- sugar, cane-sugar), 7 per cent.; protein, 1.5 per cent. By using the top 16 ounces from one quart of milk and taking 12 ounces of this instead of whole milk in the above mixture the percentages will be: Fat. 2.5 per cent.; carbohydrates, 7 per cent.; and protein, 1.5 per cent. PRACTICAL FEEDING. 159 Formula No. 2. Whole milk 12 ounces. Wheat or oat gruel flour 4 level tablespoonfuls. Glycerite of diastase (Cereo) 3 teaspoonfuls. Salt 1 pinch. Cold water 22 ounces. Mix cold and with constant stirring bring slowly to a boil, and boil for five minutes. Strain and add enough boiled water to make 32 ounces. Feed quantity appropriate for age, or dilute two parts of the food with one part of water for very young or delicate infants. Approximate Composition. — Fat, 1.5 per cent.; carbohydrates (soluble starch, dextrin, maltose, milk-sugar), 6 per cent.; proteins, 1.8 per cent. If top 16 ounce milk is used instead of whole milk, the percentage of fat will be 2.5 per cent. With both of the formulas above it will be better to begin with whole milk and increase to top sixteen ounce milk if digestion is good. Keller's malt soup is a mixture similar to the above. It is made by boiling milk, water, wheat flour, and Loeflund's malt soup extract together. The carbohydrates in the mixture are starch, maltose, and milk-sugar. A few cases may be met in which no food previously suggested agrees. In these cases condensed milk, peptonized milk, or buttermilk may solve the problem. Condensed Milk Mixtures. — Fresh condensed milk is to be preferred, but if unobtainable the best brands of sweetened condensed milk should be employed. A teaspoonful of condensed milk to four ounces of plain or dextrinized gruel may be used at the start. If this is well borne, the quantity of condensed milk should be rapidly increased until two to four teaspoonfuls to four ounces of diluent are used. Then equal parts of cream from bottled milk and condensed milk should be mixed and used for dilution, which may be reduced until one part of this mixture is used with five parts of diluent, which will give a mixture of about the following composition: Protein, 1 to 1.5 per cent.; fat, 2 to 3 per cent.; carbohydrates, 6 to 8 per cent. Peptonized Milk. Warm Process. — (1) Empty into a clean quart bottle the contents of one of Fairchild's peptonizing tubes; (2) add four ounces (eight tablespoonfuls) of cold water; shake, and (3) add one pint of cool fresh milk and again shake; (4) place the bottle in water not too hot to be uncomfortable to the hand for ten minutes. Then either place on ice or boil to prevent further digestive action. This milk is likely to taste bitter. Cold Process. — Prepare the bottle as before, but set on ice without warming. This milk is only partially peptonized so will not have a bitter taste. 160 DISEASES OF CHILDREN. Buttermilk. — For temporary use buttermilk has a limited field. It is best made at home by using one of the lactic acid ferments on the market. These consist of lactic acid bacteria which, when placed in milk, produce lactic acid from a portion of the milk-sugar, which precipitates the casein. Natural buttermilk , contains little fat, as this has been removed as butter. In making buttermilk the cream may be removed and the ferment added to the skimmed milk, or whole milk may be used. Two types of buttermilk food are employed. First, the raw buttermilk, which contains enormous numbers of lactic bacteria; second, buttermilk to which one ounce of flour (four level tablespoon- fuls) is added to the quart, and boiled. Raw buttermilk introduces harmless bacteria into the digestive tract which may kill off those present that are harmful. Cooked buttermilk supplies a fairly sterile acidified food in which the casein is finely divided and cannot form a solid mass in the stomach. Laboratory Feeding. — In many of the larger cities are to be found the Walker-Gordon laboratories at which food for infants is prepared upon prescription of the physician. They were established as the results of Rotch's teachings. In their early days the food was pre- pared upon the principle that all differences in milks of different species were due merely to differences in percentage composition and in their reaction to litmus-paper, and the prescription blank employed was gotten up on this basis. The Walker-Gordon Laboratory Per cent. Remarks. Fat Milk-sugar Albuminoids Number of feedings? Amount at Total solids Infant's age? 100 00 For whom ordered. Date, Signature. If the physician does not care to mention the especial percentages, he can ask for percentages which will correspond to the analysis of average human milk, and he can then vary any or all of these percentages later, according to the need of the special infant prescribed for. PRACTICAL FEEDING. 161 But with the increase in knowledge of the properties and functions of milks of different species, and of the effect of the various additions to and manipulations of milk, which made it acceptable to infants, a new and broader prescription blank was prepared which is now available. Fats f Lactose (Milk Sugar) ,*«.... Maltose (Malt Sugar) (a) CarbO-hydrateS \ Sucrose (Cane Sugar) Dextrose (Grape Sugar) I Starch (b) Dextrinize (c) Proteids (Whey (. Casein (d) Peptonize (e) SodiUm Citrate . . . / % of milk and cream 1 % of total mixture (f) SodiUm BiCarb / % of milk and cream ( % of total mixture (g) Lime Water { % of milk and cream I % of total mixture lartir Arid f 1 To inhibit the sapro- (\\) „ :„ J PMes ° f fermentation V * BaClllUS "J 2 To facilitate digestion I of the proteids Heat at °F Per Cent. EXPLANATORY (a) It requires .75% starch to make the precipitated casein finer. (b) One hour completely dextrinizes the Starch. (c) In case physicians do not wish to sub-divide the proteids, the words "Whey" and "Casein" may be erased. (d) Twenty minutes renders the mix- ture decidedly bitter. (e) It requires 0.20% of the milk and cream used in modifying to facilitate the digestion of the proteids; i. e., the formation of a soft curd. 0.40% to pre- vent the action of rennet ; i. e., the for- mation of tough curd. (f) It requires 68% of the milk and cream used in modifying to favor the digestion of the proteids. 1.70% of the amount of milk and cream used suspends all action on the proteids in the stomach. .17% of the total mixture gives a mild alkaline food. (g) It requires 20% of the milk and cream used in modifying to favor the di- gestion of the proteids. 50% of the amount of milk and cream used suspends all action on the proteids in the stomach. 5% of the total mixture gives a mild alkaline food. (h) Percentage figures represent the per cent, of Lactic Acid attained when the food is removed from the thermostat. When the Lactic Acid Bacillus is used to facilitate digestion of the proteids, this is the final acidity, as the process is stopped by heat at this point. When the Lactic Acid Bacillus is used to inhibit the growth of saphrophytes, the acidity may subsequently increase to a variable de- gree, as the bacilli are left alive. .25% Lactic Acid just curdles milk. .50% gives thick curdled milk. .75% sepa- rates into curds and whey. WALKER-GORDON LABORATORY CO. 793 Boylston Street, Boston ! And all Large Cities The products of the laboratories, however, are not available for the majority of physicians. 11 Number of Feedings. Amount at each Feeding, ORDERED FOR Addr Date. 190 M. D. NOTE— See back of pad. 162 DISEASES OF CHILDREN. Calorie Feeding. — An attempt has been made to establish a calori- metric standard for use in feeding infants, which at first thought seems simple and interesting, but it is based on incorrect principles. A Calorie is a measure of heat, being the amount of heat required to raise the temperature of one liter of water one degree Centigrade. Heat, as is well known, is produced by chemical action, friction, mechanical movements, and in the utilization of food by the animal organism. It has been determined by experiment just how much heat is produced by the oxidation of practically all food substances and the burning of different kinds of fuel. In mechanical operations it is possible to calculate closely from the amount of heat obtainable from any substance the amount of work it can be made to perform. And, conversely, to calculate the amount of fuel needed to perform any required amount of work. As infants and animals are constantly pro- ducing heat and excreting it, by measuring the quantity of the heat it becomes possible to determine how much food is required to be burned to produce this amount of heat. When animals are used to supply mechanical power this process of determining the amount of food or fuel necessary is useful, within certain limits, but the ease with which the food is assimilated is an important factor, for with some classes of foods not one-half of the amount of heat the food is capable of producing becomes available, the greater portion being wasted in the process of assimilation. In selecting food for infants the primary object is not to convert the energy content of food into heat, but to supply materials from which blood, muscle, and bone can be constructed. An ounce of food containing 1 per cent, fat yields 1.8 Calories 1 per cent, proteins yields 1.23 Calories 1 per cent, carbohydrates yields 1.23 Calories and if the amount of heat the food would supply was all that determined its suitability for infant-feeding it would make no difference if the food was all fat or proteins or carbohydrates. A mixture which is much used in feeding infants contains protein 1 per cent, fat 3 per cent., and carbohydrates 6 per cent. By multiplying the percentages, of each ingredient by the number of Calories each per cent, will yield, it will be found that one ounce of this mixture yields seventeen Calories. The following formulas show a few mixtures of widely differing composition, each of which yields seventeen Calories to the ounce: Protein 0.5% 1.0% 1.5% Fat . . .3.0% 3.0%I3.0%> Carbohydrates . . .6.5% 6.0%|5.5% 2.0% 3.0% 5.0% 2.5%3.0%l3.5%2.0%3.0%3.0% 3.0%3.0%!1.0%1.5%1.5%2.0% 4.5%,4.0%8.0%S.0%7.0%6.0% In practice these formulas would not be interchangeable, although from the calorimetric standpoint they are equally valuable. PRACTICAL FEEDING. 163 As infant-feeding centers around a supply of protein, and the well- being and development of the infant depend absolutely upon a suffi- cient supply of this element of food, the standard is being modified to include the principle that a certain proportion of the food be com- posed of proteins. The amount of heat an infant will excrete will depend upon the character of its food, and the season of the year. Food that is difficult of digestion causes more heat to be excreted than easily digested food, and sometimes gain in weight can be made on a smaller quantity of easily digested food when no gain is made on a much larger quantity of food that requires more digestive effort. In hot weather the infant does not need food to supply heat, as it has no need for it, and is constantly excreting surplus heat produced by its mechanical movements. Under certain conditions the whole suc- cess of managing infants during the heated term depends upon re- ducing the amount of heat it produces, and food that produces little heat is given, or none at all, and the infant is sponged to aid in re- moving the heat unavoidably produced. In practice the calorimetric standard will be found to possess no advantages over the standards generally used except possibly as a check on the total quantity of food. Directions for the Mother or Nurse. Education of Mother Necessary. — One of the greatest aids in the feeding of infants artificially is intelligent cooperation of the mother, and it should be explained to her that as she would naturally feed the infant until its digestive organs are sufficiently developed to digest soft table food, (Fig. 25 page 90), it is her duty to become acquainted with the details of preparing and administering artificial food. Time expended in teaching a mother how to prepare food and why the differ- ent processes are used will be well spent and will eventually repay the physician. The mother or nurse should be shown just what she is expected to do. Directions should be written out. The feeding schedule on page 149 may be followed as a general guide as to what the formulas for different ages should be and the pictorial directions (page 148) when shown to a mother will make things clearer than long explanations. Care of Food. — When a good, clean milk cannot be obtained, or when the conditions are such that the food after being prepared cannot be kept below 50° F., it should be pasteurized. The fact that the food is kept in a refrigerator does not necessarily mean that it is 164 DISEASES OF CHILDREN. kept cool, as the temperature in some refrigerators is above 60° F. The food should be kept surrounded by ice. Nursing bottles of the style shown in Fig. 47 should be used, as they can be readily cleaned. After the food is placed in them they should be stoppered with clean absorbent cotton. Corks should not be used, as the milk gets into the pores and sours, or otherwise spoils and infects the next feeding. If the food is to be pasteurized the Freeman pasteurizer (Fig. 48) or Arnold Sterilizer (Fig 49) may be used, or when these are not avail- Fig. 47. — Nursing bottle, preferable. Fig. 48. — Freeman pasteurizer. able a home-made pasteurizer may be employed (Figs. 50, 51). This is made from a six quart tin pail. A false bottom is made by punch- ing holes in a tin pie plate which is then inverted in the pail. The bot- tles of food or milk are placed on the false bottom, and water is poured around them up to the level of the milk. The pail is then placed on a stove and the water brought to a temperature of 165° F., as determined by a thermometer. The pail is now covered with a cloth and removed from the stove, and allowed to stand for half an hour. A folded news- paper is a good thing to stand the pail on as it will prevent too rapid loss of heat. After standing half an hour the food or milk should be cooled by placing it in cold water, until thoroughly cooled, otherwise the bacterial spores which are not destroyed by pasteurizing will germinate and may cause disturbance of the infant's digestive tract. Old pasteurized milk should never be used. Fresh food should be made every day. PRACTICAL FEEDING. 165 Administration of Food. — Regularity in feeding should be in- sisted upon. The food should be slightly warmed by placing the bottle in warm water for a few minutes. Night feedings should not be Fig. 49. — Arnold sterilizer. warmed before retiring and kept warm. This ' is a pernicious practice. The cotton stopper is then removed and a black rubber nipple should be placed on the bottle which should be inverted to see that the hole in the nipple is large enough to allow the food to f^ k k A Fig. 50 — Home-made pasteurizer. (Russell.) Fig. 51. — Pasteurizer for bottled milk (Russell.) drop slowly, but not so large as to permit the food to run in a stream. The mother or nurse should be cautioned not to put the nipple in her mouth. By allowing the food to drop on the wrist it will be possible to determine whether it is too hot or too cold. 166 DISEASES OF CHILDREN. The infant should not be over twenty minutes in taking its food, and if satisfied will drop off to sleep. Never use the food that may be left in the bottle, but throw it away. If a considerable portion of the food is left in the bottle the nipple should be examined to see if the hole is too small or has become clogged. Care of Utensils. — After preparing food the dipper, double boiler, bottles, spoons, and all articles that have been used should be washed, first with cold water, and then with soap or washing compound and hot water, and then scalded. The bottles should be cleaned with a brush (Fig. 52), and after being scalded should be kept inverted until ready to be filled again. The nipples should be thoroughly washed and kept lying in a cup of water in which a good-sized pinch of borax has been dissolved. Examination of Stools. — The mother should be taught to examine the stools and to report to the physi- cian the appearance of anything abnormal, as change of color, diarrhea, the appearance of curds or of mucus. The mother should not be taught that these are alarming symptoms, but that they indicate something is wrong and needs attention. Fig. 52.— Bottle brush How to Interpret Results. Weighing the Infant Important. — Infants should be weighed at regular intervals in about the same clothing, as steady gain in weight is one of the indications that they are thriving on their food. But judging the value of a food by the mere fact that it causes gain in weight is quite wrong as the gain may be only in fat. The composition of the food, (see page 145), the general develop- ment and gain in weight should be taken into consideration, and no infant should be dismissed until its food contains considerably over one per cent, of protein and it is gaining in weight on it. The gain in weight is greatest in proportion during the first few months, as food is assimilated more completely at this period, as has been explained on page 135. Just how much an infant should gain each week cannot be stated definitely, as infants vary in this respect. Some will gain a pound and others not over two ounces, but the latter gain is too small for a healthy infant. Six ounces is a good gain. If the food is agreeing the quantity or strength may be increased cau- tiously to see if greater gain will result, but this plan must not be pushed PRACTICAL FEEDING. 167 to an extreme, for loss instead of gain may result. A record of the weight should be kept on a weight chart, according to the plan shown in Fig. 54. Weight charts have been prepared on which is shown the "normal weight curve" deduced from the average gains of a large number of infants. It is better not to use this style of weight chart, as few infants pass their first year without some ups and downs, and the slightest variation from the "normal curve" is a cause of worry and anxiety to the mother and through her to the physician. Fig. 53. — Weighing the infant Feeding in Hot Weather. — Upon the advent of hot weather special precautions should be taken to forestall attacks of gastroenteritis. The means for keeping the food cool should be looked after, and tested with a self-registering thermometer, or the food should be kept packed in ice to make sure it is kept cool. Pasteurization may be necessary if ice is not available. If the infant has a tendency to indigestion or to vomiting, the amount of fat in the food should be reduced by using whole milk instead of top milk in making the food. One or two feed- ings of gruel used as the diluent may be put up, and given as night feedings or as substitutes when milk feedings seem to disagree. If the air is humid and the temperature high, the infant should be given a sponge bath twice a day. The excess of body heat is ex- creted by the evaporation of perspiration, and this is retarded by high 168 DISEASES OF CHILDREN. humidity. And unless the skin is kept clean and free from the residue from the evaporation of perspiration, this will also retard evaporation. Feeding when Traveling. — Changes in the food are risky at any time and especially so when traveling. A good plan to follow is to have 1 1 WEIGHT IN GRAMS. Qeoooo>o^eoioiHt-'tai-<-oo ^OOCOt-t.-'° I W £ : ! ■ ; S -*=> "« CM 1 ■ : , 1 ;_ CO . s° * es" i ■ . !■ : 2 li «.- I i * — » >o_ ±i ! ■ ' , S- o 1 1 J~ 2 00" j i : 7 ^J **r- ' — ' " 1 1 ■ •*" ...... ■P ^ee _l a 2 '* , ' ; : o co o'^T_ : * "* g - Jh w 2 ' 1 u « j ; ■ , ! 1 ^ g - £ 5 5 _ i 1 s < "_ = : . c ■>« r-! *»,- : ' 1 1 o ' ! T^ 1 c ._„ _ J_ 1 i : .*« - 1 *-~ "* U N S^ r^ **_ ti - i • fc i t \ ~ i i ' \ - 1 ' 1 ,, \ - - — •"■ - - \ — ^ I ° ■ 00 \ 1 "" . ■ r / => -J \ ■° A "*-"" 1 h- V : Mil: 1 p" L t n -4 \ V \» o N» •"* N? « •* ei •*■ cm •* © st -- 5* * 8 2 - •s &W5 aNn Od h : - * J! 1 H0I3 M at* >X -T i~ a? 1 - 1 the regular food prepared and packed in ice to insure thorough cooling and then to place it in vacuum bottles, such as the Thermos (Fig. 55). The bottles should be filled right up to the stopper, otherwise the agi- tation of the food will churn the milk so that the fat will separate as PRACTICAL FEEDING. 169 butter. Several of these bottles will be required if the journey is to last several days. If there is a question about the food being kept cool, it should be pasteurized, then cooled or iced if possible, before being put into the vacuum bottle. These bottles while expensive will be found useful. to those who can afford them. They will keep food cold for about seventy-two hours or hot for about twenty-four hours. The food for the infant can be poured from the vacuum bottle into a clean nursing bottle and warmed as wanted. But the food should be slightly shaken so as to mix the cream which will have risen to the top with the remaining milk. The food should not be warmed and then kept in one of these bottles to save warming. Milk soon spoils if kept warm. For a single day's journey the food may be put up as usual in the home and boiled and then iced and, when cold, wrapped in newspaper, each bottle being wrapped separately; or the food may be put in a pail with cracked ice around the bottles, which is preferable. When it is not possible to have the foregoing directions carried out, one of the best brands of sweetened condensed milk diluted with boiled water may be used. The boiled water may be carried if it will not be obtainable during the journey. Feeding when Away from Home. — During the heated term large numbers of families leave the cities and live in the country at boarding houses, hotels, or in their own homes. In many of the more remote districts the milk-supply problem has not yet been solved and much disturbance may be caused by milk which has been improperly handled through ignorance. In such instances the mother should make an arrangement with some milkman or farmer to supply milk produced under sanitary con- ditions. The farmer should be instructed to clean the cows as thor- oughly as he cleans his horses, to wipe the belly and udder with a damp cloth before milking, to wash his hands before milking, and to reject the first two or three jets from each teat. The milk pail should be well washed and scalded after being used and kept inverted in the sun. As soon as the milking is finished the milk should be mixed, as it is not uniform in composition as it leaves the cow, and then poured into quart milk bottles. These should be set in ice-water, or if this is not obtainable, into cold well water which rises nearly to the tops Fig. 55.— Thermos vacuum bottle. 170 DISEASES OF CHILDREN. of the bottles. The milk can be delivered in the morning in time to prepare the food for the day. Such milk will cost more than the ordinary milk ; but it is worth all it costs, and will be found cheaper in the end. The mother should see for herself that the milk is produced under cleanly conditions. She would not tolerate a filthy wet-nurse for her infant and should not allow her infant's food to come from a filthy cow. Feeding Among the Poor. — The preparation of food or even obtaining suitable food materials is often a perplexing problem among the poor and in the tenements of large aities. The intelligence of the mother may be limited and even when the mother is capable of carry- ing out directions the facilities for preparing food and keeping it cool are wanting. Some families are too poor to buy clean bottled milk at ten cents a quart and oftentimes such milk is not offered for sale in the poorer sections of a community. Correct dietetic principles must be applied as best they can be. Where good milk can be obtained, but careful modification cannot be expected, the food may be made with whole milk and gruel, using one-fourth, one-third, and one-half milk and adding one part of granulated sugar to thirty-three parts of food, or two level table- spoonfuls to the quart of food. Where good milk is unobtainable, condensed milk may be used with water or barley gruel made with one ounce of flour to the quart. The milk should be diluted 8 to 15 times, that is, one part of condensed milk to 7 to 14 parts of water or gruel. No sugar is to be added. Cod-liver oil or olive oil can be given daily, one teaspoonful three times a day to supply the fats. Infant's Food Dispensaries. — The unsatisfactory results obtained in infant-feeding among the tenement population, owing to improper preparation of food or lack of suitable food, has led to the establish- ment of food dispensaries in the crowded sections of many cities. There are three types of these feeding stations: (1) Those at which a few formulas of modified milk may be obtained in nursing bottles by anyone who applies for them, no supervision of the cases being made. (2) Those at which fixed modifications of milk are given out by trained nurses or physicians who examine the applicants and aim to give a formula which is likely to agree. (3) Those at which the food is prepared for each infant while it waits, upon the prescription of the attending physician. The feeding stations at which food is dealt out without taking into consideration the condition of the infant are not to be encouraged, for while they do much good, they also do harm. PRACTICAL FEEDING. 171 Where the infant-feeding problem among the poor is handled on a large scale and physicians who have not had wide experience in feeding infants and in the actual processes of preparing food see the patients, the second type of feeding station will be most successful. For these stations the food is prepared at a central station on a large scale and delivered iced to the local stations, where the mothers bring their babies, and the physician or nurse in attendance examines them and orders a food mixture. The formulas given on page 149 may be followed closely, and if the infants are not acutely ill, digestively, beginning with a weak mixture and going from this to stronger ones will be found quite satis- factory. During the heated term feedings of plain and dextrinized gruels made with one to two ounces of barley or oat gruel flour to the quart should be kept on hand to be given when milk feedings disagree; for infants that are quite sick they may be diluted once with boiled water. Making Feedings on a Large Scale. — To those who are not familiar with methods of handling milk it sometimes becomes a difficult matter to work out the proper quantities of ingredients to use to get the desired formulas. By referring to the key on page 141, the required percentage of fat in milk and the proportion of diluent to use to obtain any desired percentage combination will be found. Thus, if a mixture containing 0.80 per cent, protein and 1 per cent, fat was desired, it would be found necessary to use milk containing 4 per cent, fat with three parts of diluent. If 1.5 per cent, fat was desired with 0.80 per cent, protein, it would be necessary to use milk containing 6 per cent, fat with three parts of diluent. On a small scale these milks can be readily obtained from quart milk bottles, but when large quantities are to be made the milks must be standardized. The milk should be obtained from a farm where cleanliness is observed, and it should be kept cool until delivered at the central station where the food is to be prepared. A sample which represents the entire lot should be drawn, by dropping a long tube or pipet through the milk from top to bottom so as to remove a sample that represents the entire can. This is then tested by the Babcock milk test, which consists of mixing a definite quantity of the milk with sulphuric acid in a special bottle and then whirling it in a centrifuge. Great heat is produced which melts the fat. The protein dissolves and the percentage of fat is read directly from the neck of the test bottle. The milk should also be tested with lime-water and phenolphthalein (page 131) to see if souring has commenced. 172 DISEASES OF CHILDREN. A certain amount of cream or skimmed milk will always be needed. If a centrifugal separator is available, they can be obtained by centri- f uging the milk. Otherwise the cream must be skimmed by hand from a can of the whole milk. The cream and remaining milk will also have to be tested for fat. Knowing the percentage of fat in the whole milk, cream, and skimmed milk, it becomes necessary to calculate the quantities to mix to make any standardized milk. To Increase the Amount of Fat in Milk. 1. Determine the quantity of standardized milk to be made, it may be pounds, quarts, or gallons. 2. Multiply the quantity of standardized milk by its percentage of fat. Example, 100 pounds of 6 per cent, fat milk, 100 X 6 per cent. = 600 per cent. 3. Multiply the desired quantity of standardized milk by the percentage of fat in the whole milk as determined by the Babcock test, as, for example, 100 pounds X 4.7 per cent. = 470 per cent. 4. Subtract the amount of fat in the quantity of whole milk from the amount of fat in the desired quantity of standardized milk, to find how much fat must be added, as 600 per cent. — 470 per cent. = 130 per cent. 5. Determine the percentage of fat in the cream, as, for instance, 21 per cent. 6. Subtract the percentage of fat in the whole milk from the percentage of fat in the cream to find how much fat one part of cream contains in excess of that in the whole milk. Example, 21 per cent. — 4.7 per cent. = 16.3 per cent. 7. Divide the additional fat required by the amount one part of the cream adds to find how many parts of cream must be used. As, 130 per cent. -=-16.3 per cent. = 8 parts. 8. Thus 8 pounds of cream, 21 per cent, fat, and 92 pounds of milk, 4.7 per cent, fat, make 100 pounds of 6 per cent, fat milk. Proof: 8 X 21% = 168% 92 x 4.7% = 432% 100 600% or one part = 6%. To Decrease the Amount of Fat in Milk. Proceed as in 1, 2, and 3 above. Then divide the percentage of fat in the total quantity of standardized milk desired by the percentage of fat in the whole milk. For example, 100 pounds of milk containing 3 per cent, fat were needed, and the whole milk available contained 4 . 7 per cent. fat. 100 X 3 =300. 300-5-4.7 per cent. = 64 pounds. By adding to this quantity 36 pounds of skimmed milk there will be produced 100 pounds of milk containing 3 per cent, of fat. If the skimmed milk contain not over 0.5 per cent, fat, the result will be accurate enough. After standardized milks are made, great care must be exercised in keeping the feeding bottles clean and in washing them, for all the care employed in preparing the milk may be rendered useless by water used in washing bottles, as this may be infected and produce a high bacterial count in the food. PRACTICAL FEEDING. 173 Feedings Prepared at the Feeding Station. — When a physician who thoroughly understands the preparation of food can have a good nurse to carry out his directions and with only two rooms, one to be used as a kitchen and the other as an examining room, highly sat- isfactory results can be obtained. The physician can examine the infant and order. any kind of food prepared, and the nurse will prepare it while the mother waits. The food is put up in nursing bottles and given to the mother in a box or pail filled with cracked ice. By using bottled milk and the Deming Milk Modifier, percentage mixtures can be quickly made. Gruel mixtures, whey, or whatever is desired can also be made. One nurse can attend to about thirty infants in a morning. CHAPTER XVII. DIET DURING THE SECOND YEAR. By the beginning of the second year the infant's digestive organs should be sufficiently developed to warrant giving some soft food. The greatest amount of trouble will be caused by cereals which are not properly cooked. Fig. 56 shows a cross section of an oat grain. It will be observed that the protein and carbohydrates are in- closed in cells. These are composed of cellu- lose which is indigestible, and they must be raptured by cooking before the digestive secretions can get at their contents. Fig. 57 shows what takes place when cereals and vegetables are cooked properly and too much emphasis cannot be laid upon the importance of thoroughly cooking cereals. Oatmeal par- ticularly should be cooked in a double boiler several hours. Flours do not need such long cooking. The following schedule has been arranged as a suggestive scheme for the feeding of older normal children : Fig. 56. — Section of oat grain, c, protein layer; d, starch and protein. (Goodale.) Fig. 5' ■Rupture of starch grains by cooking. (Langworthy.) Many children are indiscriminately fed, and the physician being unfamiliar with the kind of food suitable and agreeable to the child neglects to supply directions as to the dietary. Changes should be made 174 DIET DURING THE SECOND YEAR. 175 in the list if there is illness, habitual constipation, or difficulty in digest- ing certain forms of food. It should be recollected that the child can be trained to like almost every suitable article, and it is a mistake to cater to their likes and dislikes if they are not developing and gaining weight. Under their respective sections changes in the character of the food have been suggested where they have any bearing on the progress of the disease. Dietary. Twelfth to Eighteenth Month. — Select from the following articles: First meal — on arising. Juice of a sweet orange, one to two ounces. Pulp of six stewed prunes. Pineapple juice, one ounce. Milk, eight ounces, zwieback, toasted biscuits (as Huntley & Palmer's), stale toasted bread. Second meal — during forenoon. Milk alone or with zwieback. Noon meal. Soup made of chicken, beef, or mutton, six ounces; or beef juice three ounces. Stale or toasted bread may be added to the above. Fourth meal — afternoon. Milk, or toasted bread and milk. Evening meal. Gruel made of oatmeal, farina or barley, taken with whole milk, four ounces of each. Apple sauce or prune jelly. Zwieback. Eighteenth to, the Twenty -fourth Month. Breakfast. Juice of one sweet orange. Pulp of six stewed prunes. Pineapple juice, one ounce. A cereal, such as cream of wheat, oatmeal, farina, or hominy preparations with top milk (top 16 oz.). Sweetened or salted. A glass of milk. Forenoon. A glass of milk with two toasted biscuits or zwieback. 176 DISEASES OF CHILDREN. Dinner. Broth or soup made of beef, mutton, or chicken and thickened with peas, farina, sago or rice; or beef juice with stale bread crumbs; clear vegetable soup with yolk of one egg; or egg, soft boiled, with bread crumbs, or the egg poached. A glass of milk. Dessert. — Apple sauce, prune pulp, stale lady-fingers, or graham wafers. Supper. Custard. Cup of milk warm or cold. Stewed fruit. Zwie- back. Two to Three Years. Breakfast. Juice of one sweet orange; pulp of six st ewed prunes. Pineapple juice, one ounce, or apple sauce. A cereal, such as oatmeal, farina, cream of wheat, hominy, or rice, slightly sweetened or salted as preferred, with the addition of top milk (top 16 oz.) ; or a soft-boiled or poached egg with stale bread or toast. (If there is a tendency to constipation give the fruits before breakfast with water; if not, they may be given during the forenoon if preferred.) A glass of milk. Dinner. Broth or soup made of chicken, mutton, or beef thickened with arrowroot, split peas, rice, or with the addition of the yolk of an egg or toast squares. Scraped beef, white meat of chicken, broiled fish (halibut is free from bones). Mashed or baked potato, fresh peas, spinach, asparagus tips. A glass of milk with educator crackers, Huntley & Palmer biscuits or graham wafers. Dessert. — Apple sauce, baked apple, rice, junket, or custard. Supper. Stewed fruit. A cereal or egg (if not taken for breakfast); bread and milk; or custard; cup of warm milk or cocoa; crackers or zwieback. DIET DURING THE SECOND YEAH. 177 Three to Six Years. Breakfast. Fruits. — Oranges, cantaloupe, apples, or stewed prunes. Cereal or eggs (not both). Oatmeal, hominy, rice and wheat preparations, well cooked and salted, as described on page 174, with thin cream and sugar. Eggs. — Soft boiled, poached. Milk. — Milk or cocoa to drink. Dinner. Supper. Soups. — Beef, chicken, or mutton. Meat. — Chicken, beefsteak or roast beef, fish. Vegetables. — Spinach, carrots, string beans, peas, cauliflower tops, mashed or baked potato, asparagus tips. Bread and butter (not fresh bread or rolls). Dessert. — Custard, rice or bread pudding, tapioca, ice cream (once a week), prune souffle, or baked apple. Milk. Milk toast, or a thick soup, as pea, or cream of celery, or a cereal and thin cream. Stewed fruit, custard or a plain pud- ding graham crackers and milk. Suggestive Diet List Suitable for Children's Hospitals. Monday. Breakfast. — Oatmeat, bread and butter, milk. Dinner. — Beef soup, chicken, mashed potatoes, bread and butter, corn starch pudding, "milk. Supper. — Bread and butter, milk, apple sauce. Tuesday. Breakfast. — Eggs, bread and butter, milk. Dinner. — Chicken soup, chicken, mashed potatoes, bread and butter, rice pudding, milk. Supper. — Bread and butter, milk, stewed prunes. Wednesday. Breakfast. — Hominy, bread and butter, milk. Dinner. — Beef soup, roast beef, mashed potatoes, bread and butter, bread pudding, milk. Supper. — Bread and butter, jam, and milk. 12 178 DISEASES OF CHILDREN. Thursday. Breakfast. — Eggs, bread and butter, milk. Dinner. — Beef soup, chicken, mashed potatoes, bread and butter, ice cream, milk. Supper. — Bread and butter, jam, and milk. Friday. Breakfast. — Oatmeal, bread and butter, milk. Dinner. — Mutton broth, roast mutton, mashed potatoes, bread and butter, custard pudding, milk. Supper. — Bread and butter, milk, apple sauce. Saturday. Breakfast. — Hominy, bread and butter, milk. Dinner. — Beef soup, roast beef, mashed potatoes, bread and butter, chocolate pudding, milk. Supper. — Bread and butter, milk, stewed prunes. Sunday. Breakfast. — Oatmeal, bread and butter, milk. Dinner. — Beef soup, roast beef, mashed potatoes, bread and butter, ice cream, milk. Supper. — Bread and butter, milk, jelly. Suggestive Diet Lists for Day Nurseries and Creches. Group 1 (Bottle-weaned babies). Milk (whole milk), warm or cold, 8 ounces. Farina gruel with milk and sugar, zwieback. Beef or mutton soup, thickened with toast crumbs. Orange juice, 1 ounce. Apple sauce. Prune pulp. Amount needed daily — three meals — 24 ounces milk, 10 ounces soup, zwieback, 2 pieces, fruit, one kind. Group 2 (" Runabouts"). Milk. Zwieback or toast, or stale bread. Soft-boiled egg. Farina, cream of wheat, oatmeal. DIET DURING THE SECOND YEAR. 179 Soup, beef or mutton thickened with split peas, rice, or farina. Baked potato, mashed potato, carrots, beets. Custard, cornstarch, farina pudding, apple sauce, prune jelly, or apple butter. Amount required daily, three meals, 36 ounces of milk, one cereal, one vegetable, one soup, bread, one fruit. Group 3 (Kindergartners — two meals). Bowl of crackers and milk, farina, oatmeal. Beef or mutton stew. Eggs, soft-boiled or scrambled. Mashed potato, peas, carrots, beets, cauliflower. Rice pudding, cornstarch pudding, baked apple, apple sauce, prunes. Amount required, three cups milk, soup, vegetable, bread and butter, cereal or pudding. Group 4 (School age). Noon. Soup, beef or mutton. Beef or mutton stew. Potato (mashed), spinach, carrots, or beets. Bread and butter. Pudding, farina, rice, cornstarch. 4 P. M. Milk, cocoa. Bread and butter, jam. Raw apples. Diet During Later Childhood. The period of growth from early childhood to puberty requires careful oversight of the nutrition. The child must be regularly trained in all the hygienic details of feeding, including slow eating and the avoidance of strenuous exercise just before or after eating. The diet requires a large amount of protein owing to the rapid growth, and this must be supplied principally by the ordinary meats (beef, mutton, and chicken) and such vegetables as peas and beans. All the cereals will also supply some protein with a large amount of starch. The heat- and energy-producing foods (starches, sugars, and fats) may be supplied in the form of potatoes, cereals, fruits, and fats from milk 180 DISEASES OF CHILDREN. or meat. It is very desirable to train the child to take a varied and properly balanced diet, which includes all the foods in common use. Thus if very much meat is taken to the exclusion of carbohydrates, the protein will be employed too largely in oxidation to produce body heat instead of in building tissue, and hence growth may be retarded. A certain amount of the carbohydrates acts as protein sparers, and thus allows the protein to be used entirely in its proper function of building tissue. This is an example of the desirability of a properly balanced diet. The green and succulent vegetables and fruits also have an important function in nutrition, as is seen in cases of scorbutus where there has been a long deprivation of these articles of diet. Lesser degrees of malnutrition result if they are not taken in proper amount. The two usual cycles of growth, namely at the second dentition and adolescence, require an especially generous diet. Rapid growth always uses up nutrient material and hence calls for food, rich in protein, otherwise various grades of anemia are liable to result. SECTION V. DISEASES OF THE DIGESTIVE SYSTEM. CHAPTER XVIII. DISEASES OF THE MOUTH. General Considerations. It is very essential that the normal condition of the mouth be preserved in infancy, as the act of sucking may be impaired and thus result in malnutrition of the infant. The mucous membrane of the mouth is particularly delicate, and bacterial invasion follows readily any injury to its surface. Even well-meant but too vigorous cleansing by the attendant may lead to serious mouth disease. Not until the teeth are present should any special effort be made to cleanse the oral cavity. The primary teeth should receive regular attention, and the aim should be to preserve them as long as possible, and thus ensure a vigorous and well-formed permanent set. A soft tooth-brush, used with an up-and-down movement, will effectively cleanse the teeth from adhering particles of food, especially if the child learns to flush or gargle the mouth after its use. The nodules formed near the raphe in infants are normal cystic bodies called epithelial pearls, and must not be considered pathological. We have seen harm done by measures used for their removal. Desquamative Glossitis. (Geographic Tongue. Ringworm of the Tongue.) The above headings apply to a condition of the tongue in which there are areas sharply circumscribed by sinuous borders. The bor- ders are made up of enlarged 'papillae of a dull grayish color which tend to intensify the denuded areas. Numerous microorganisms of a low order are found especially in the borders of the patches. The varia- tions in the outlines have given rise to the term " geographical tongue/' It is found among all classes of children; it can only occasionally be associated with the derangement of the digestive tract. It gives no symptoms, and is productive only of alarm to the mother. It is most commonly seen in children under three years of age. Treatment. — The mother should be reassured as to its unimpor- tance. Nitrate of silver, J dram to the ounce, applied with a cotton swab and neutralized with a salt solution has seemingly arrested the 181 182 DISEASES OF CHILDREN. process in a few cases. In others it has persisted for months, only to finally disappear spontaneously. Simple Stomatitis. (Catarrhal Stomatitis). Simple stomatitis is an inflammation of the mucous membrane of the mouth, with the characteristic symptoms of pain, redness, and swelling, and an increase in the normal amount of secretion. Etiology. — It is mainly observed in the first year of life, and re- sults from some form of irritant, which may be chemical, mechanical, or thermal in its nature. Among those commonly causative are im- properly prepared food, thumb or nipple sucking, and too vigorous mouth washing. Excessive use of carbohydrates, especially cane- sugar, may be a cause, and the disease is occasionally an accompani- ment of prolonged fever due to intercurrent maladies. Symptomatology. — The babe refuses to take its nourishment or has pain while taking it. This should direct attention to the mouth. There is marked drooling, and on inspection, redness, swelling and congestion of the mucous membrane are apparent. The tongue may be more or less coated. The temperature, if elevated at all, is not high. There is no adenitis. The restlessness and irritability point to a constitutional involvement. Treatment. — The affection tends to a spontaneous recovery, es- pecially if the causative factor is removed. After a few days there is restitution to normal conditions. Prophylactic treatment embraces the constant care and cleanliness of everything coming into contact with the child's mouth. On the other hand, we have observed the inflammation following well-meant but too vigorous mouth cleansing. Local applications hasten recovery. A 1 per cent, solution of nitrate of silver may be brushed over the surface by the physician once a day, and a 2 perfcent. solution of boric acid is swabbed on every two hours by the attendant. The following is an excellent and soothing lotion for all forms of sore mouth: Py Sodii sulphis 5 j Glycerini 3ss Aquae rosse q.s. ad. Bij M. Sig. — Paint over the tongue and inside of the cheeks every two or three hours with a camePs-hair brush. Order the food diluted one-half and given cold. If the nipple is refused in an artificially fed baby, feed with the spoon or dropper. It is rarely necessary to resort to gavage. DISEASES OF THE MOUTH. 183 Aphthous Stomatitis. {Herpetic Stomatitis, Aphthce, Follicular Stomatitis, Vesicular Stomatitis, Maculo fibrinous Stomatitis.) Definition. — A disease characterized by isolated yellowish-white spots on the lips, mouth, or palate, surrounded by a reddened mucous membrane. Etiology. — No specific exciting cause has as yet been firmly estab- lished. The weight of evidence seems to point to an infective rather than to a neurotic origin, since clinically we have found its spread possible through communication. Lack of proper cleanliness is the cause in the great majority of cases. Most of the attacks occur dur- ing the second year of life; and we have in addition to uncleanliness of the mouth and utensils, the direct dirt infection produced by the crawling, hand-sucking infant. It is also seen occasionally in connec- tion with such diseases as pneumonia, gastroenteritis, or the infectious diseases proper. Lesion. — The superficial mucous membrane shows a fibroplastic exudate in a localized area, having a reddened areola. The process does not go on to ulceration, the mucous membrane healing without scar formation. Symptomatology. — Before the lesions are observed it may be noted that food is refused or taken with discomfort by the infant. The pain causes irritability and disturbed sleep. There is sometimes a low febrile reaction. The breath is not foul. The saliva flows freely. After a few days the glands beneath the jaw may be somewhat enlarged and painful to the touch. Inspection shows a number of whitish spots, which sometimes coalesce, on the lips, cheeks, or palate, surrounded by a red ring. The pseudomembrane cannot be removed without exciting some slight bleeding. Course and Prognosis. — The affection lasts about a week and tends to recovery. With proper treatment the course is considerably shortened. Treatment. — Prophylactic. This embraces all that was said under simple stomatitis, and may be stated in one word — cleanliness. Local. — The early application of a 2 per cent, solution of silver nitrate, once or twice daily, shortens the disease and makes the infant much more comfortable. A 2 per cent, solution of chlorate of potash may be applied by the attendant three times a day with a brush. General. — A dose of castor oil is usually indicated and helpful. The diet should comprise cool milk or gruels until the discomfort has disappeared. ■ 1S4 DISEASES OF CHILDREN. Bednar's Aphthae. These are superficial ulcerations which occur in the new-born or in early infancy on either side of the palatine ridge at the hamular process. They are usually the result of traumatism caused by too energetic cleansing or the sucking of artificial nipples. This portion of the mucous membrane is normally thin and tightly-stretched, and therefore easily abraded. Not infrequently these ulcerations are seen following thrush. They are usually bilateral, about the size of a small bean, and are covered with a grayish-white necrotic coating which cannot easily be washed away. Nursing is interfered with on account of the pain they cause. Treatment. — Prophylactic. — The proper care of the infant's mouth (see p. 182) and the early treatment as in thrush. Locally. — The application daily of a 2 per cent, solution of silver nitrate, which is neutralized by salt solution, will readily effect a cure. Perleche. This is an ulcerative process superficial in character which appears at the angle of the mouth of children of school age. Radiating fissures first appear at the corners of the mouth which are browmish-yellow in color, and soon become covered with desqua- mating epithelium. A gummy exudate contracts the angles which readily bleed if stretched. Licking the lips, no doubt, infects these areas, and prevents healing. Contamination to others in the family is occasionally observed. Treatment. — Proper advice as to contact infection by kissing, food utensils, etc., is to be given. Locally, the area is thoroughly cleansed and swabbed with silver nitrate 2 per cent, or burnt alum. An antiseptic powder such as bismuth subgallate may then be applied. Mycotic Stomatitis. (Parasitic stomatitis, Thrush, Sprue, Soor, White Mouth.) Definition. — This is a local mouth disease produced by the growth of a specific cryptogamic fungus. The affection occurs most frequently in early infancy. The children of the poor, because of parental ignorance or neglect, are prone to the disease. Badly or improperly fed infants are subject to this affection because of the greater liability to uncleanliness in the feeding apparatus. Marasmic and atrophic infants seen in hospital DISEASES OF THE MOUTH. 185 and dispensary practice, seldom pass through the first few months of life without contracting the disease. Specific Cause. — Under the microscope a small particle of the growth appears as a matted fungus microorganism, made up of shreads, composed of jointed filaments. Spores are found at the junction of the filaments, which reproduced the growth. This par- ticular fungus has not as yet been properly classified. Symptomatology. — Small rounded white masses appear on the mucous membrane of the mouth. The tip of the tongue, and next the cheeks and gums are affected. In exceptional instances remoter areas of the gastrointestinal tracts, as the esophagus and stomach, are involved. As the masses fuse, the characteristic appearance, i.e., a whitish coating resembling milk curd, is seen in the mouth. The masses, if an attempt is made at removal, come away with difficulty, leaving a reddened surface beneath. As the disease pro- gresses, the infant has difficulty in feeding and will be restless and peevish. There is rarely any constitutional disturbance or rise of temperature. Occasionally there will be concomitant irritation of the alimentary tract with the production of vomiting and abnormal stools. If the reaction of the mouth be taken with litmus-paper it will invariably be found acid in reaction. Exfoliation of the pellicles take place after a week or ten days, leaving the mucous membrane reddened and glistening. Course and Prognosis. — The affection lasts from a few days to a week at the most. The exceptions appear in infants with constitutional diseases in which thrush appears as a complication; in these it may persist for a long time or add to the fatality of the case. Treatment. — Prophylactic. — Thrush does not appear in those infants who have been properly cared for. The essential prophy- lactic measures are constant supervision and great cleanliness of the infant's utensils, which should be boiled and kept for the one infant only; washing the mother's nipples, avoidance of harsh mouth wash- ings, removal of soiled clothes and diapers, and absolute restriction of all manner of comforters or soothers. The diet must be carefully regulated, as infants suffering from this disease have nearly always been wrongly fed. (See section on Infant Feeding.) Local. — Swab with a 2 per cent, or a saturated solution of boric acid (avoid the honey and boric preparations), three or four times a day, and follow with copious washing of sterile water. This is curative and soothing. In stubborn cases swab once with a weak for- malin solution (1-100) and then use the boric wash. Sodium sul- 186 DISEASES OF CHILDREN. phite dram one to two ounces of water may be used after each feeding. If the nipple is refused, feed with a dropper for a few days. Ulcerative Stomatitis. (Stomacacoe, Putrid sore mouth.) Etiology. — This form of stomatitis is found after the second year of life, when the teeth have erupted and caries or neglect of the teeth has taken place. It follows the infectious diseases, especially measles, and results from the lowered resistance that the previous disease has imposed. Bernhem and Pospisil have isolated a bacillus and a spiro- chete, which they find quite constantly in ulcerative stomatitis, and they have been able to prove a distinct etiological relation. Minerals, such as mercury and phosphorus, are able to produce an ulcerative stomatitis through their irritative action. Symptomatology. — Attention may be attracted to the child be- cause food is refused and pain is caused by attempts at eating. The breath is foul. The tongue is coated. The children are irritable and sleep poorly. There is a low-grade temperature. They become weak and depressed from lack of food. The examination of the mouth shows the gums at first to be swollen and red. The lower jaw is commonly involved at some point situated on the edge of the gums. A purulent exudate is then formed that goes on to necrosis and the formation of an ulcer. As a rule, the preliminary stages are not observed. An ulceration on the gum margin which spreads even to the buccal por- tion of the gum is the usual picture. In aggravated cases the tooth is exposed and loosened in its socket. The odor is distinctly fetid and quite characteristic of this form of mouth disease. Drooling is pro- nounced. The cheek and lips may also be involved by contact, and even necrosis of the jaw may follow in the pathological process. The neighboring lymph-glands become hypertrophied. Course and Prognosis. — The prognosis depends greatly upon the vitality of the child. In poorly nourished, anemic children, it may run an obstinate course of several w r eeks. As a rule, it begins to clear up after the first week. Differential Diagnosis. — The almost typical picture, with the fetid breath, salivation, and localization on the gums, stamps the disease quite clearly. In gangrenous stomatitis we have marked and early constitutional symptoms and prostration, with a limited dark, pur- plish area of tissue involved. Treatment, Local. — The mouth should at once be carefully flushed with a mild antiseptic, such as boric acid or peroxid of hydrogen well DISEASES OF THE MOUTH. 187 diluted. Remove the offending carious tooth if present, and then use chlorate of potash locally (and also internally, see below), four grains to the ounce, applied carefully with a brush or cotton applicator. Silver nitrate in a 1 per cent, solution locally, is serviceable, if the process is obstinate. If necrosis of bone has taken place, surgical intervention is necessary and should not be delayed. General. — The nutrition should be rigidly kept up and detailed feeding lists supplied. Milk and eggs made palatable (see diet lists) should be forced if necessary. An antiscorbutic diet, such as is described under infantile scorbutus is particularly serviceable in these cases. Medicinal treatment is confined to the use of the chlorate of potash in 2- to 3-grain doses, three or four times a day. It is better not to write for more than a three-ounce mixture, as the potash may affect the kidneys if given for too long a period. Gangrenous Stomatitis. (Noma, Cancrum oris.) Definition. — A rapidly developing and usually fatal gangrene, beginning in the cheek. Etiology. — No specific organism has as yet been satisfactorily proven as the causative agent. The disease occurs in children only, most often between the ages of two and five years and rarely in nurs- lings. Children living in bad hygienic circumstances that have had their resistance much lowered by previous diseases, especially those that have been confined to hospitals and asylums, are more prone to the affection. It may follow measles, diphtheria, typhoid, ulcerative stomatitis, scarlet fever, enteritis, pneumonia, pertussis, tuberculosis, etc. The greater number of cases occurring in this country have followed severe cases of measles, and in the epidemic form in institu- tions, it may there even follow mild cases. Symptomatology. — A putrid odor from the mouth may be the first symptom to attract attention. Inspection may then disclose a stomatitis as a forerunner. In other cases there is first observed a swelling of the cheek, which is hard, shining, and pallid. Pain is not caused by the examining finger. The inner surface of the cheek may show the original site of the infiltration and at this point an ulceration is observed. The submaxillary glands if not as yet affected soon hypertrophy. The infiltrated area in the cheek now becomes dark red, and soon is bluish and later black in color. The fetor increases. A line of demarcation now appears about the dark area and spreads upward to the eye and outward toward the ear. A punched-out 188 DISEASES OF CHILDREN. area soon appears, permitting inspection into the mouth. The gums are correspondingly affected, being covered with greenish-gray slough. The periosteum may be separated. The teeth are loosened or even drop out. There is seldom any bleeding because the process is a gangrenous one. The stench is now almost intolerable. As may be supposed the general condition soon suffers from such a destructive process. The pulse and temperature are elevated — 102° to 104° F. — with a correspondingly weak pulse. While at first nourishment is taken and little pain complained of, soon the patient succumbs and is badly prostrated. Signs of exhaustion are apparent. Patches of bronchopneumonia or a diarrhea complicate the disease. A comatose condition with septic rises of temperature usher in the fatal ending. In certain cases in female infants the necrosis involves the vulval ring which may soon completely slough out. Course and Prognosis. — The course is rapid; the disease may end in a week or last three weeks from its inception. Only 15 per cent, of the cases recover (Moro). Those that do live are left with severe deformities of the face. Treatment. — Strict attention to the nasopharyngeal toilet in the infectious diseases will tend to prevent this affliction. The early and complete extirpation of the diseased area and cauterization of the edges is the modern treatment adopted by the surgeons, and the results achieved warrant its recommendation. Wherever possible, attempts should be made to save the angle of the mouth to prevent a disastrous deformity. Loosened teeth or necrotic alveolar structure should be removed. Meanwhile, the internist will flush the mouth with a 2 per cent, solution of peroxid of hydrogen, or swab with a 5 per cent, solution of nitrate of silver, followed by salt solution. Nourishment should be forced and stimulation in the form of brandy and strychnia given. Turpentine spirits, if kept near the patient, will mitigate the nauseating odor. Elongated Uvula. Although rarely observed, this condition has led to much improper medication for persistent cough. The elongated uvula irritates the pharynx and causes a cough which is especially marked when the prone position is assumed or when the child is overtired. If the chest is negative, this condition should be thought of. Treatment is by astringents, applications of silver nitrate, but usually amputation is indicated and necessary. CHAPTER XIX. DISEASES OF THE DIGESTIVE TRACT. Corrosive Esophagitis. Etiology. — This condition is caused by the swallowing of caustic chemicals, such as potash and sulphuric acid, which produce corrosive burns of the esophagus. Lye is the most common substance ingested by children. The lesions vary. There may be an intense acute inflam- mation, a necrosis of the mucous membrane, or extensive ulcerations which produce cicatricial strictures in healing. Symptomatology. — If much caustic has been swallowed, death may shortly result; otherwise there is prostration and vomiting of shreds of bloody mucus, or even pieces of mucous membrane may be expelled. The child cannot swallow without pain. An erosive hemor- rhage may occur after a day or two, or a deep-seated cellulitis may result with infection. A stricture is very likely to develop in severe cases. Treatment. — Appropriate antidotes are to be given if the patient is seen early; such as the acids or the alkalies, depending on the character of the poison. The prostration must be combated by supportive treatment, hypodermatic injections of camphor or strych- nia. For the intense pain, codein subcutaneously will be indicated. Olive oil thrown into the esophagus is a distinct advantage, and if the child can swallow, this should be regularly administered. The treatment of the stricture is surgical. The string method has given some brilliant results in cases coming under our observation. Gas- trostomy may be necessary to preserve the life of the child if sudden occlusion of the esophagus results. Congenital Occlusion of the Esophagus. This condition is rarely observed. Difficulty in swallowing and the regurgitation of the smallest quantities of food should lead to an investigation with the bougie. The atresia or stricture is usually situated at or near the bifurcation of the larynx. 189 190 DISEASES OF CHILDREN. (Acute Gastric Indigestion. Acute gastritis, acute dyspepsia, acute gastric catarrh.) Etiology. — Errors in diet are the principal cause. In infancy the quality and quantity of the milk, or the irrational use of extraneous articles added to the dietary act as causes. Improper feeding habits will bring on occasional attacks. Sweets, unripe fruits, and pastries in older children or even large quantities of one kind of food may produce an attack. Usually there is more or less involvement of the intestinal tract. Symptomatology. — The symptoms very often begin suddenly with fever, headache, abdominal pain, and vomiting. The temperature may reach 104° F. with a correspondingly high pulse rate. The vomiting is repeated several times, and the evidences of undigested food, or a certain article of food which has caused the attack, as unripe fruit, are seen therein. The patient is chilly at times and apt to be sleepy. Food is abhorent, the tongue is coated with a thick fur, and the breath is disagreeable. Occasionally convulsions occur, especially in neurotic children. After the vomiting has ceased or a (compen- satory) diarrhea has set in, there is relief from the distressing symp- toms, although nausea and vomiting may reappear if the child is pressed to eat. Prognosis. — This is usually very favorable, although the onset of convulsion in a weakly infant would warrant a guarded prognosis. Treatment. — In breast-fed infants, examine the mother's milk, and give plain boiled water until vomiting and fever have subsided; a cleansing enema will complete the cure if the milk is not perma- nently abnormal. Bottle-fed infants suffer often from this malady, and the food formula and its preparation should be inquired into most minutely, for well-intentioned attendants often make griev- ous errors. Calomel gr. i in divided doses every ten minutes will clear the bowels. If there is a convulsion, clean out the bowels at once with an enema and later wash out the stomach if vomiting has not been free. In all cases the patient should be put to bed, without a pillow, and a mustard paste applied to the epigastrium in the strength of one to seven of flour. The fever is controlled by sponging with alcohol and water. Dietetic management is very important. Infants may be kept on albumin water, cereal decoctions, or whey, and then gradually returned to their regular feedings. Older children are not allowed to take any food for twelve to twenty-four hours, except sips of cold water. Then beef tea, toast, and crackers are allowed and later milk, milk toast, etc., slowly returning to the regular diet. DISEASES OF THE DIGESTIVE TRACT. 191 Chronic Gastritis. Definition. — A chronic inflammatory disturbance of the gastric function, associated usually with a similar involvement of the intestinal tract. Etiology. — Improper feeding at irregular intervals is the main cause, especially when coupled with bad hygienic living. Rickets, tuberculosis, and chronic affections of the liver predispose to a chronic gastritis. Among the well-to-do or pampered children it results from the use of sweets, pastries, and rich dressings which the child is allowed to have. Symptomatology. — Frequent vomiting first attracts the attention of the parent. This after a time follows each meal. There are eructa- tions of gas and a feeling of discomfort after eating. The tongue is coated. The appetite is capricious. The outline of the stomach shows a well-marked dilatation. The abdomen remains quite per- sistently distended in spite of medication. The child is fretful and restless in sleep; the weight falling off gradually in aggravated cases. In infancy the picture of marasmus may be seen. Periods of pros- tration and collapse may precede a lingering death. Older children show no inclination to play, slowly grow more feeble and flabby; mucus is seen with greater regularity and in greater quantity in the vomitus. Diagnosis. — From a basilar meningitis the disease may be dis- tinguished by the absence of stupor or coma and lack of reflex changes. In doubtful cases the Von Pirquet reaction or a study of the spinal fluid could be resorted to for verification. Pyloric stenosis should be excluded by careful physical examination and the character of the vomiting. Course and Prognosis. — The disease may last for weeks and the child drag on a miserable existence until it succumbs to a terminal dis- ease, such as bronchopneumonia or marasmus. Infants rarely with- stand the disease, while if they survive they are apt to be weak and puny. In older children the prognosis is better and treatment of greater avail, although convalescence is prolonged sometimes through months. Treatment. — If all children were brought at stated intervals to their physician for examination and counsel, whether well or ill, chronic gastritis would be a much rarer disease. "Proper food prop- erly given" is the prophylactic treatment. The treatment is mainly dietetic. A careful history and study of the previous diet is the first requisite. Find the factor that is causing the disturbance; determine whether it is the butter fat, carbohydrates, or protein elements, for 192 DISEASES OF CHILDREN. example, that is at fault. The periods of feeding, the quantity, the quality, and the digestive ability of the stomach itself must be weighed in the balance and corrective measures instituted as described in the chapter on Infant Feeding. The fact must not be lost sight of that some children cannot digest cow's milk in any form. For the correc- tion of the vomiting and to control the failing nutrition it is necessary to supply such food as will meet the lowest nutritional requirements, and in as readily a digestible form as possible. It is well to wash out the stomach before beginning the treatment. The legume flours, as pointed out by Edsall and Miller, are excellent substitutes for cow's milk if it disagrees, and they furnish sufficient protein to keep up nutri- tion. Beef blood, yolk of egg, and gruels are to be tried, and if they agree, that is, cause no vomiting, may be alternated so that they will not pall on the appetite. If an increase in weight is obtained, weak- ened regular milk feedings may then be cautiously tried. Occasionally the stomach-tube must be used in obstinate cases. Rectal feeding is without much merit in these cases. Children two to three years old are often benefited by a change to the seashore. The appetite is thereby stimulated and the strict dietetic regime more willingly fol- lowed. A special diet list should be prepared by the physician for each case. From this should be excluded all sweets, gravies, and pastries. Milk, gruels, eggs, and the softer vegetables should be the mainstay. Coupled with the dietetic management, the daily routine of the child should be outlined. A fresh-air life, plenty of sleep, plenty of water to drink, and agreeable baths are necessities. Cases seen late or doing badly require stimulation, and this is best given in the form of the tincture of nux vomica one minim well diluted one-half hour before meals. Constipation is relieved by milk of magnesia or cascara in children or with a suppository in infants. Dilatation of the Stomach. Etiology. — This condition results from causes which tend to weaken the muscular walls of the stomach. It is more commonly ob- served in infants suffering from constitutional diseases, such as rickets marasmus, syphilis, and tuberculosis. Among the rarer causes are pyloric hypertrophy or stricture. Symptomatology. — Those which result in the course of the consti- tutional diseases will be here described. Vomiting occurs usually some time after meals; food is not taken with avidity, and later in the disease may be abhorent. Constipation is a noticeable symptom. The abdomen is usually tympanitic, tongue coated, and in older chil- dren headaches may be complained of. DISEASES OF THE DIGESTIVE TRACT. 193 Physical Examination. — In emaciated subjects the greater cur- vature of the stomach may be seen on inspection. The abdomeo Le generally prominent, but percussion over the dilated viscus give- a highly resonant tympanitic note. If fluid is present asuccussion note can be obtained by tapping with the ends of the fingers. If the diagno- sis is still indefinite, water or air may be introduced as an aid in deter- mining its size and capacity. Prognosis. — Unless due to a congenital stenosis, the prognosis is fairly good, but the course is slow and dependent upon the underlying disease. In itself the condition may retard the progress of a case of rachitis, for example, or even become the factor that may lead to a fatal termination. Treatment. — The motor inactivity necessitates in the beginning a course of gastric lavage coupled with dietary regulations as outlined under the article on Chronic Gastritis. Fresh air, massage, electricity, or vibration will be additional aids, no matter what the underlying dis- ease. The tincture of nux vomica in small doses will stimulate the appetite and assist the motor functions. If the disease is depen- dent upon a stricture, radical measures may be necessary to effect a cure. Stenosis of the Pylorus and Pyloric Spasm. {Congenital hypertrophy of the pylorus.) This is a condition in infancy in which there occurs an obstruction to the passage of food from the stomach as a result of hypertrophy or spasm of the pylorus. Etiology. — There are no positive etiological factors known. Pathology. — The muscular, and occasionally the connective tissue at the pylorus, is hypertrophied. The stomach is dilated and thick tenacious mucus is found on the mucous membrane. Symptomatology. — The disease is usually not recognized when the first symptom appears. An apparently healthy infant at the breast may begin to vomit after nursing. This being repeated at frequent intervals, advice is sought. The usual corrective measures do not suffice and the vomiting is more persistent. Closer observation will show that the stools are extremely small, that the urine is scanty, and that the vomitus is projectile in type. The diagnosis now becomes more apparent. Physical examination may show a thickening about the pylorus, especially if anesthesia is used, but this is not always present. The cases of simple pyloric spasm do not give evidences of tumor formation; the vomiting is not quite so persistent, and the 13 194 DISEASES OF CHILDREN. emaciation not so rapid. The stools are small and like dry putty, sometimes alternating with diarrhea. Owing to the obstruction, little or no chyme enters the duodenum, and progressive emaciation results. The stomach is dilated, but the intestines are collapsed, a valuable sign in this disease. A peristaltic wave majr be observed Fig. 58. — (a) From a case of congenital hypertrophic pyloric stenosis: infant six weeks old — seen by one of us (b) section of tumor in same case. passing from left to right upon slight mechanical stimulation. Ex- amination of the stomach contents shows a mixture of food and mucus, but without any bile. Hyperchlorhydria may be present. If measures for relief have not been successful the child dies of starvation. Diagnosis. — The characteristic vomiting without dietetic error, visible peristalsis, and a palpable tumor are of especial diagnostic DISEASES OF THE DIGESTIVE TRACT. 105 importance. If to these are added the sunken abdomen and pro- gressive emaciation, the diagnosis should be more certain. Course and Prognosis. — In cases of true stenosis, due to hyper- trophy, the course is progressively downward and, unless there is successful intervention, ends fatally in six to ten weeks. (Some cases reported lived to twenty weeks and one five } r ears.) Cases have been cured by medical treatment alone, but appear to be those in which there was spasm only present and not a true stenosis. Heubner is inclined to give a hopeful prognosis with palliative treatment. It is certain that the older the infant becomes before symptoms appear, the better its chances for recovery. Treatment. — As soon as the diagnosis is made, stomach washing should be regularly done twice a day. The food, preferably breast milk, should be fed by gavage and always after the stomach washing. Mustard applications, one to six of flour, may be tried before feedings. If the vomiting persists so that no gain is made, surgical intervention should be resorted to as offering a hope of recovery. The surgeon will elect to do a gastroenterostomy or a pylorodiosis (Loreta's operation). As the number of failures reported is far behind the cures recorded, we will offer no statistics on this point. Cyclic Vomiting. {Recurrent Vomiting, Periodic Vomiting.) This symptom-complex occurs in older children and is character- ized by periodical attacks of vomiting and prostration, usually with- out fever and without indiscretions in diet. Etiology. — The condition is usually ascribed to some form of toxemia. Children from five to twelve years of age are more fre- quently affected. It is more apt to occur in the families of the well- to-do than in the poor. Metabolism is disturbed, as shown by the presence of the acetone and diacetic acids in the urine. Edsall believes that in the majority of cases faulty digestion is the underlying factor. Symptomatology. — In cases already under observation, a prodro- mal stage may sometimes be detected, but for the most part the attack comes on suddenly in children who are considered to be in good health. Occasionally constipation, lassitude, loss of appetite and a slight temperature precede the attack. The vomiting is persistent, recurs frequently and sometimes contains blood; nothing is retained. The child soon shows the effects of the strain, lying quite prostrated with 196 DISEASES OF CHILDREN. sunken eyes, anxious expression, coated tongue, sweetish breath, and a high pulse. Thirst is a prominent symptom and cannot be relieved on account of the vomiting. The abdomen becomes scaphoid in shape, and sometimes is sensitive to the touch. Constipation is almost the rule. There may be periods in which vomiting ceases for a short time and some fluid or food can be retained. The attacks recur in varying periods — it may be weeks or months. The urine when examined is found deficient in amount and clouded, and usually gives a marked acetone reaction. Indican, diacetic acid, albumin, and casts are occasionally found. Recovery is rapid when the attack has ceased and food can be retained. Diagnosis. — This must be made after excluding meningitis, nephritis, and appendicitis. The sudden onset, acetone breath, absence of high temperature in a child without a history of dietary indiscretion, would call attention to this symptom-complex. Prognosis. — As to life, the prognosis is distinctly favorable, although fatal cases have been reported. The attacks tend to recur unless the underlying cause be removed. Treatment. — Of the attack. Rest of body and stomach are essential; nothing should be given by mouth. To allay the thirst, colonic irrigations of normal salt solution, allowing four to six ounces to be retained, are effective. If the attacks persist beyond the second or third day, codein hypodermatically may be neces- sary, followed by nutrient enemata. Peptonized milk with whisky serves this purpose. Small doses of carbonated water may be tried when the vomiting begins to abate. Later, hot broths, dextrinized gruels, orange juice and semisolid food is offered until convalescence is established. In the Interval. — This should be influenced by the family history, the dietetic faults, and an examination of the urine. The child should be under constant medical supervision. A suitable diet list should be prepared, and its effect on the urine noticed. The bowels should never be allowed to be constipated. A specific amount of water should be given daily. The daily life of the child must be apportioned, as in this way only may we hope to prevent recurrences. Stools. The stools of the breast-fed infant may be from one to five in number, and numerically we should not judge them as abnormal, pro- vided their color, consistency, and odor are within the normal limits. Their color should be a yellow or orange tint with homogeneous con- DISEASES OF THE DIGESTIVE TRACT. 197 sistency produced by the unchanged bilirubin. Their reaction should be acid and the odor not disagreeable. The amount of residue found in the stools will be in direct proportion to the amount ingested or retained. The latter statement, however, does not hold true for the babies artificially fed. Stools of Artificially Fed Infants. — Cow's milk normally produces a stool lighter in color, bulkier, and numerically fewer. The feces amount to about 5 per cent, of the food ingested. In the hand-fed infant the protein elements are longer exposed in the intestinal canal to putrefaction. Examination of Stools. — If we examine a freshly passed stool from an infant fed on human milk, and with an improvised spatula spread out a central portion, we may find that there are yellow masses or flakes present; these are often mistaken for curds, but in reality are made up of fats; firm, hard curds are not found in mother's milk — only in cow's milk. Such a stool in an infant not steadily gaining would in- dicate a scanty milk supply, and if the stools were frequent, dark green and mucoid, with very little milk residue, the maternal font would surely be found to be at a low ebb. The indication would be wet-nursing or alternate feedings and regulation of the diet and life of the nurse. In the bottle-fed baby we are often confronted with the symptoms of constipation or diarrhea. Either of these conditions may arise from too much protein in the food. The constipated stool will be friable, like dry putty, while the loose stool due to this cause can be smoothed out and the masses will be readily soluble in ether, proving them to be fat and not curds, as they are so often designated. True curds are formed in the stomach by the action of lactic acid or an excess of hydrochloric acid and rennet on the paracasein. They are hard, smooth, yellowish on the outside and white within, with a cheesy odor when opened, and will not dissolve in ether. The remedy for too much protein is evident. Correct the formula, and if true curds are present, examine the character of the milk. The milk may have been sterilized or it needs to be mechanically diluted with gruels, or chemically modified, when the stools will assume the normal type. A loose, greasy, sour-smelling, acid movement, resembling scrambled eggs, will indicate excessive fat in the dietary. Examination of the breast milk or a study of the formula will show that the fats ingested have been persistently too high. Three per cent, of fat should never be exceeded by an infant to the third or fourth month, and more than four per cent, should never be prescribed. It should be recollected 198 DISEASES OF CHILDREN. that a certain amount of fat is always present, but should not be visible in distinct masses. Mothers often erroneously speak of large quantities of mucus as present in the baby's stools. The doctor must remember that some mucus is normal; that it should, however, be found intimately mixed with the feces. Barley water produces a slimy stool often mistaken for mucus, and undigested food elements also cause this error. If mucus is seen in any quantity with the naked eye by a competent ob- server,' it is pathological and means inflammation, usually located in the large intestine, of a subacute or chronic form. If the disease is in the small intestine, the mucus is mixed with the stool and it is usually found to be bile-stained. The hint for correction is embodied in the following fact — that the greater the amount of nonassimilable substances present, the greater the amount of mucus. The color of the stools when immediately passed should be considered. If the absorptive process has been delayed and putrefactive changes have taken place in the protein element, the bilirubin will be changed to biliverdin, but it is not known whether the reaction itself, or chromo- genic bacteria, produce the coloration. Nitric acid will prove whether or not we are dealing with bile salts by the familiar play of colors. The green color in conjunction with mucus, and fecal acid reaction, indicate true intestinal disease and call for radical change in the die- tary. Acid fermentation will require such temporary food as albumin water for its correction, while alkaline putrefaction will respond to the carbohydrate foods, as dextrinized gruels. The brownish movements often seen, if we exclude certain drugs and blood, are due to the inges- tion of undextrinized starches alone, or a preponderance of carbohy- drates in proprietary infant foods. A stool that presents a foamy, bubbling appearance and is acid in reaction will signify the presence of too much sugar in the mixture, as is often the case in canned condensed-milk feedings. We have not hinted at the bacterial examination of the stools, as it has proven of no clinical value as yet. The reaction of the stool is a help and should be ascertained, and always taken from the middle of the fresh stool. If a blue color is obtained, we-have alkaline protein putrefaction going on, and if the color of the litmus is unchanged, we have acid fermentation due to the breaking down of the fats and carbohydrates. Again, the stools may be of considerable aid to us in certain pathological conditions, as illustrations of the intensity of the process in the summer diarrheas, and in such pathological states as intus- susception, in which we have frequent paroxysmal discharges with DISEASES OF THE DIGESTIVE TRACT. L99 blood and mucus, but no feces. Rectal polypi should be strongly suspected where we have a normal stool, except for a fresh-blood coating; these hemorrhages being intermittent in character and not necessarily connected with a hard or scybalous mass. Fissures may be produced by hard fecal masses and have a blood coating, or in their passage produce bleeding from the rectum. Dark grumous blood mixed with the feces is indicative of hemorrhage, higher up in the bowel — probably from intestinal ulcerations. In gastric or acute duodenal ulcer there is vomiting of blood and mucus, but there is no fresh blood in the stools. Colic. (Enter -algia.) The term colic is used to designate the paroxysmal pains which occur in the abdomen. It is a symptom and not a disease, and usually denotes the presence of an abnormal amount of gas in the intestines, which stimulates undue peristaltic movements. Etiology. — It occurs most frequently in artificially fed, babies, as a result of digestive disturbances dependent upon the food ingested. This food may have been unwholesome, too great in amount, or one of its constituents may have been in excess. For example, the per- centage of proteins in a given mixture may be too high, or the sugar may cause fermentation if present in undue amounts (beyond 6 per cent.), or there may be starchy indigestion. Breast-fed infants may suffer from a poorly balanced milk or from overfeeding or too hasty nursing. Colic occurring in the course of other disease is dependent upon the resulting atonic condition of the intestinal walls. Symptomatology. — The attacks come on suddenly, the infant is restless and uneasy, and cries unceasingly. The abdomen is dis- tended and rigid and the thighs are drawn up over the abdomen. The extremities may be cold. If during the examination some flatus is expelled the screaming ceases and the evidences of relief are apparent. Treatment. — In the attack, heat should be applied to the abdomen, an enema of warm saline solution should be given and sips of hot water given by mouth. These measures will usually be effec- tive. If relief is not obtained, massage of the abdomen with warm olive oil, followed by a hot colonic irrigation containing two drams of the milk of asafetida to four ounces of water can be used. 200 DISEASES OF CHILDREN. The following prescription may be of occasional service: 1^. Chlorali hydrati gr. viii Sodii bicarbonatis gr. x Sodii bromidi 3ss Aquae menthae pipertae oss Aquae q. s. ad S i j Misce et signa. — Give a teaspoonful in a little hot water every two or three hours. The further treatment resolves itself into efforts to discover the cause of the colic. The details of the preparation and administration of the infant's food may disclose a fault worthy of correction. The care of the mother or wet-nurse must not be forgotten when colic is present in the breast fed. Acute Gastroenteritis. (Summer Diarrhea. Summer Complaint. Infectious Diarrhea.) Etiology. — Artificially fed babies in the hot, humid summer months are especially prone to this infection, superinduced by the ingestion of unwholesome milk. Infants and children under two years are mainly attacked. The children in the tenement-house districts of our large cities show the greatest morbidity to infectious diarrhea. The bacillus dysenterise (Shiga-Flexner bacillus) can be isolated from many of the stools. The infection is usually from with- out, but autoinfection is possible. The lack of refrigeration, the feeding of food unfitted to the age, plus the devitalization by the summer heat, makes infection easy and common. Babies in crowded hospital wards may become infected by careless handling of the soiled diapers. Pathology. — No special characteristics are observed at necropsy. A congested mucous membrane in the stomach and small intestine, with enlarged lymph glands, are commonly observed. Cloudy swelling of the kidneys is quite constant. Symptomatology. — Mild Form. — The stools first attract attention. The} 7 are curdy, loose and foul. The fever is moderate and the child fretful. The character of the stools soon changes to a greenish-yellow, and they become more numerous, five to six a day, and the fever rises to 102° or 103° F. If prompt measures, as indicated below, are taken, recovery is rapid and quite certain. Severe Form. — Vomiting with loose, frequent spinach-green stools and high fever may be seen at the outset or result from neglect of the milder types. Vomiting follows the ingestion of nearly all the food offered. The fever and inability to take food produce weakness and extremely rapid emaciation, and later a comatose condition with DISEASES OF THE DIGESTIVE TRACT. 201 marked prostration. The fontanel is sunken and the pulse is weak. The stools may be streaked with blood and contain mucus in consider- able quantity. The fever frequently rises to 104° or 105°, F. and death may be preceded by coma or convulsions. Toxic Form. — From the onset the symptoms are usually severe. High fever and intense prostration are added to the vomiting and frequent stools. The color of the stools is constantly green, the odor extremely foul, and blood-streaked mucus appears early. Cerebral symptoms soon supervene, delirium and coma usher in the end, which may come on in a day or two, or even within twenty-four hours. In this form the Shiga bacillus can usually be demonstrated. Course and Prognosis. — This has been indicated under the separate divisions, depending upon the severity of the infection. If seen early, the mild and severer forms are amenable to treatment, while the toxic type usually baffles even the most heroic measures. The ability to command good nursing and change of locality naturally influence the prognosis. Treatment. Prophylactic. — Breast-feeding whenever possible, especially in the summer months, is desirable. Cleanliness and care in every detail of the child's diet and clothing are necessary. The use of pasteurized or constantly refrigerated clean milk is indicated. Proper disinfection of stools and the nurse's hands must be insisted on. Regulation of the diet, according to the heat and the condition of the infant, will help in prevention. General Management. — Place the patient in the coolest, cleanest and largest room possible. A cotton slip and diapers only are to be worn. Secure a competent nurse if possible to intelligently follow orders. Re- duce the fever by frequent cool sponging or tepid baths. If the tempera- ture is above 104° F. and the pulse permits, use an ice-bag to the head. An initial purge with castor oil or calomel is indicated (see p. 203). Dietetic. — Stop milk in all forms for at least twenty-four hours, placing the child on a starvation diet of boiled water alone or on barley water, made with one ounce of flour to the quart. If at the end of a day the frequent stools persist, continue the substitute feeding until a change for the better is noticed. If barley gruel is not palatable or tolerated, one may try rice water or albumin water. (See section on Dietetics.) In the case of nurslings resume the feeding at longer intervals preceded by a dram or two of boiled water. In artificially fed babies, resumption to cow's milk feedings must be made only when the stools resume the normal type. Whey or buttermilk feedings are serviceable substitutes. Begin with a modification lower than the original prescriptions. 202 DISEASES OF CHILDREN. The diarrheal diseases of infancy and childhood do not permit as yet of any definite classification, for the etiological factors may be the same in a number of the allied affections, and the various patho- logical changes found are often those of degree or situation only. It is to be hoped that in the near future these grouped diseases may be more accurately separated and defined. Acute Enterocolitis. Definition. — This is an inflammation of the mucous membrane of the small and large intestine associated with ulcerations and charac- terized by tenesmus and blood-stained stools. Etiology. — Children in the summer months, especially those who have had previous attacks of gastroenteritis, or who suffer from chronic indigestion, are especially liable to attack. The children of the poor in the large cities because of improper food and uncleanliness are most frequently the victims of the disease. Such constitutional dis- eases as rickets, tuberculosis, and syphilis are predisposing elements. The Shiga bacillus is found in a great many of the cases. Pathology. — In the colon and about the ileocecal valve the charac- teristic lesions are commonly observed. In some of the lighter forms of the disease we find only evidences of congestion and inflammation with a roughened or somewhat denuded epithelium. The lymphatic structures are hypertrophied or show loss of tissue. If the affection has been of a severer grade, the follicles are degenerated, producing a slight ulceration and consequent uneven feel to the gut. These changes are commonly seen in the colon and rarely in the ileum or rectum. In the usual type seen after a severe illness quite deep ulceration may exist, so as to produce a shaven beard appearance. The ulcers may later extend down to the muscular layer, and a large area of ulceration may be found by the coalition of a number of smaller ulcers. Another type occasionally seen presents a fibrinous deposit over isolated areas of the colon. Quite generally there is a swelling of the retroperitoneal and mesenteric glands. Bronchopneumonic patches are often found at necropsy. Symptomatology. — In a child whose vitality has already been im- paired by previous disease the attention may be directed to the con- dition of the stools, which are passed with much straining. These stools may contain blood-streaked mucus with undigested food masses. Fever is quite constant and varied in degree, in the beginning 102° to 105° F. and a correspondingly rapid pulse rate. In the severer cases there is rapid prostration and vomiting. The stools are passed with DISEASES OF THE DIGESTIVE TRACT. 203 abdominal pain, and tenesmus may be marked. There is restlessness and often delirium. Thirst is intense. The eyes are sunken and expressionless. The lips and tongue are dry and coated. The stools are now frequent — from ten to twenty a day — small, and contain almost no feces. Death will occur from exhaustion or a pneumonic complication if the symptoms do not show signs of abatement. Im- provement is shown by a decrease in the number of stools, a lowered temperature with absence of vomiting and tenesmus. The lost vitality is regained very slowly. For days or weeks there is a low-grade tem- perature, and temporarily the tenesmus or green stools may appear. The appetite is capricious for a long time. The abdominal tone which is lost during the height of the disease will now slowly return to the normal, and the child will gain in weight. Diagnosis. — The diagnosis is made from the presence of mucus and blood in diarrheal stools passed with straining over a period of several days or weeks in a child of deficient vitality. Intussusception is differentiated by the absence of fever, the acute onset, the pain, the presence only of mucus and blood, but no feces, and a tumor palpable through the abdomen or rectum. Course and Prognosis. — Severe types end fatally after a few days, or a week at most, of high fever and prostration. The mortality rate is from 30 to 40 per cent. The subacute types remain ill for a month or six weeks with periods of remission and relapses and a slow painful convalescence. The prognosis is more favorable in this class, especi- ally if they are removed to suitable surroundings, and have proper nurs- ing and attendance. Infants withstand the disease badly. Treatment. — This does not differ from that given on page 201, under Diarrheal Diseases. It should be recalled that these infections may be communicated to others in a family or ward. An initial cleansing of the bowel with castor oil or calomel is imperative, followed by starvation for twelve to twenty-four hours. Egg albumin, bar- ley water, or beef broth may be given (see p. 156). Equal parts of beef broth or barley gruel (1 oz. to the pint) are sometimes more acceptable. The tenesmus is relieved by the control of the diet and by the use of codein gr. i to J, according to the age, or Dover's powder, gr. A to 2 grains every two or three hours, until the painful symptoms abate. Suppositories containing cocain gr. I and aristol gr. \ are soothing in older children. Bismuth subnitrate gr. 5-10 or bismuth subgallate gr. 2, with powdered ipecac gr. 1, may be given advantageously every two or three hours for the control of the mucus and blood in the stools. Whey is permitted when the stools show improvement, and after 204 DISEASES OF CHILDREN. the acute symptoms have subsided sterilized milk is allowed in small amounts well diluted with barley or wheat-flour gruel. Later pasteur- ized milk is permitted with jellied gruels and broths. The prostration may require hypodermatic medication in the form of atropin gr. 4^- with strychnin sulph. gr. -^q. As a daily routine, one saline irrigation at 100° F. serves a double purpose, as a cleansing solution and for absorption of part of the water. Strychnin sulphate gr. -3^-3- may be given as a tonic three times a day, and astringent enemas for the control of blood and mucus. Silver nitrate (j-^jrd) or a starch paste in less severe cases may serve the latter purpose. They should not be given more than once daily, and discontinued if the effect is not satisfactory. Too frequent irrigations often cause irritation and ag- gravation of the symptoms. Removal to the seaside or cool mountain air is a great help in the management, particularly in the convalescent Chronic Gastrointestinal Indigestion. This is a condition congenital or acquired, resulting from deficient motor and secretory powers in the alimentary tract, or as a result of improper food. Etiology. — Improper feeding, especially in poor children in the cities where the surroundings are unhygienic, is the principal cause of this affection. When the food is radically wrong, or unwholesome, an acute condition develops which makes the parent seek medical treat- ment; on the other hand, the chronic condition due to incapacity to digest certain ingredients of the food is often overlooked or ascribed to anemia, parasites, etc. An excess of the fats, carbohydrates, and sugars or of the proteins may overtax the intestinal digestion, thereby using up energy which should have produced development and growth. In older children badly prepared foods or indulgence in rich foods, pastries, and condiments lead to this condition. Pathology. — There are no definite organic changes found in this disease. If of long standing, the lymph follicles in the region of the ileocecal valve may be hypertrophied or a chronic colitis may be found. Symptomatology. — As indicated above, the symptoms are not appreciable at first, unless the disease directly follows an acute gas- tritis or enterocolitis. After some time failure to gain weight is noticed; the child sleeps badly, has frequent attacks of colic, and cannot easily be comforted; the stools become diarrheal for several days then resume a more normal appearance, only to relapse into a condition of DISEASES OF THE DIGESTIVE TRACT. 205 diarrhea or even constipation. Closer examination of the stools shows that they consist of masses of undigested food, intermingled with a small quantity of mucus, while streaks or splashes of green color are not infrequent. The musculature becomes soft and flabby. If the child has pre- viously sat up or walked, it may now be unable to'do so. The abdom- inal wall offers little or no resistance on palpation and the normal peristalsis is sluggish. The temperature is rarely elevated except late in the disease; on the other hand, a subnormal temperature is not uncommon. Intertrigo in the napkin region is exceedingly common. If corrective measures have not been instituted by this time a marantic condition supervenes which may lead to a fatal issue. In older children the symptoms are not as marked, but the sta- tionary weight or loss of weight, anemia, and listlessness should recall the possibility of this condition. The appetite is capricious, and as a consequence the children are indulged to a vicious degree by their parents. Attacks of constipation alternate with diarrhea, the urine is somewhat decreased in amount, it may be cloudy, and contains an excess of indican (see Plate I). The children become irritable and moody, having seemingly lost their former characteristics. They become cold easily, develop headaches, and are easily nauseated. The abdomen becomes prominent from gas distention, the stomach itself, if mapped out, shows enlargement, but there is no pain or tenderness on abdominal palpation. Treatment. — Good hygiene and proper dietetic treatment are absolutely necessary to effect a cure. In the case of the poor, removal to a properly conducted hospital, preferably one near the seashore, will often work wonders. The diet must be so adapted that it will correct the former faults, but still take into consideration the deficiency of digestive secretion and maldevelopment of the alimentary tract. An analysis of the breast milk or of the last formula given to an infant, studied in con- nection with its stools, will usually show which ingredient is at fault. A wet nurse will sometimes quickly produce an amelioration of the symptoms. Detailed instructions as to the room, air, bathing, and exercise must be given if the patient is to remain at home. The roof or piazza can be effectively utilized, and the greater part of the day should be spent out of doors. Before any dietary changes are made it is well to wash out the stomach, and thoroughly irrigate the bowels with saline solution. In some instances the bowel irrigations may have to be repeated once or twice. An initial dose of castor oil, one to two drams and a minim or two of the tincture of mix vomica. 206 DISEASES OF CHILDREN. three times a clay, will usually constitute all the drug treatment that is necessary. If the infant is artificially fed, the milk can for a time be so modified as to prevent the curdling action of rennet in the stomach by the use of peptonization or the alkalies or the addition of sodium citrate. A formula weaker than the requirements of a normal child of a corresponding age must be temporarily given. Rapid gain in weight must not be expected. Convalescence is slow and protracted. The management in the case of older children is mainly dietetic. From time to time a diet list of certain permissible articles of food should be given beginning with such as are easily digested and assimi- lated and gradually increasing the number and variety as the improve- ment warrants (see diet list, p. 176). Aerotherapy, stimulating baths, and massage are necessary adjuncts to the dietetic treatment. Without constant supervision and attention to the daily routine, meager improvement will be experienced. Congenital Dilatation of the Colon. (Hirschsprung's Disease.) This is a rare condition which consists of an increase in the length and circumference of the descending colon and the sigmoid flexure. In some cases there is an added hypertrophy of the muscle fibers. As a result of this condition the abdomen is greatly distended from meteorism, feces are more or less retained, the constipation is ex- tremely obstinate, and when the fecal masses are passed, either natur- ally or by artificial means, they are extremely foul, putrescent, and may be covered with mucus and some blood. Treatment. — Daily high irrigations must be used to produce bowel evacuation. Massage and douching of the abdomen with cold water should be persisted in for a long time. Internally the daily administration of a laxative and drop doses of the tincture of nux vomica before meals are advisable. Cholera Infantum. Cholera infantum is a very acute disease characterized by rapid prostration, vomiting, and a profuse serous diarrhea. Etiology. — It occurs almost entirely in the hot months of the year, among the poorer classes who live on inferior milk, and very rarely attacks breast-fed infants. It is the result of a toxic poisoning from an organism or group of organisms still undetermined. disk asks of the Digestive tract. 207 Symptomatology. — The symptoms arc out of all proportion to the anatomical lesions which are found at necropsy. A child apparently quite well or only ill from a digestive disturbance suddenly begins to vomit and has a rise of temperature. A profuse diarrhea follows. possessing the characteristics of decomposition with very foul-smelling stools. The stomach and intestinal contents are at first expelled in this manner. The vomiting then consists of a watery fluid with flakes of mucus. The stools also now lose their fecal character, and are watery, greenish-gray in color, with a peculiar old musty odor which is quite characteristic. These discharges at first copious and explosive become smaller in amount but very frequent; they consist of serum and mucus, and may be as many as twenty or thirty a day. In some cases there is an almost constant oozing from the anal ring. The vomiting and diarrhea with the high temperature causes a quick collapse and an emaciation which is extremely rapid, due to the character of the dis- charge which is largely blood serum. The extremities are cold, the pulse feeble, the respirations shallow and sighing, and the infant lies in a semicoma. Thirst is extreme, and water is eagerly taken. Men- ingitic symptoms supervene, with delirium, twitching, purposeless movements or convulsions. Unless the progress of the disease is arrested, the temperature rises to 105° or 107° F., with coma and death resulting from cardiac exhaustion at the end of the second or third clay. If the treatment has been successful, the convalescence is extremely slow and demands incessant care. Course and Prognosis. — This should always be given as extremely bad. If prostration comes on rapidly, with high temperature and nervous symptoms, the course is often not longer than twenty-four hours. Treatment. — This must be energetic and heroic if any good is to be accomplished. Gastric lavage with warm saline solution should be made if the patient is seen early. If prostration is apparent, stimu- lation is the first indication, and is here best obtained by the use of hypo- dermoclysis which supplies the tissues with fluid and likewise stimu- lates. Inject eight to ten ounces into the subcutaneous tissue of the abdomen — using for this purpose sterile normal saline solution (6 grs. to the liter) and repeat this every four to six hours. Enemas of nor- mal salt solution may also be employed. For a very rapid effect a hypodermatic injection of atropin gr. -g--^ is efficacious, acting also as a check to the serous waste. This may be repeated every three hours if necessary. Camphor in sterile olive oil (one grain of camphor to every ten minims of oil) may be injected in the intervals, if the cardiac action is feeble. Immersion in warm baths at blood heat, or at 1 10° F. 208 DISEASES OF CHILDREN. if the temperature should suddenly drop, is efficacious. They should be continued for a half-hour, and repeated at three-hour intervals; gentle friction and the addition of mustard, one tablespoonful to the bath, will assist in keeping the extremities warm. No food is permitted and no medicines should be administered by mouth until the danger of death from collapse is past. Should the child rally, cautious feed- ings and medication as outlined under the article on Summer Diarrhea, is to be followed under the supervision of a competent nurse. As soon as possible thereafter a change to the seaside should be made. Constipation. This should be regarded as a symptom and not a disease, and accordingly the underlying cause should be sought for and corrected. Etiology. Rare Causes. — The condition may be caused by con- genital anatomical abnormalities, by new growths, or by the dispro- portionate length of the sigmoid flexure. Adhesive peritonitis (espe- cially the tuberculous variety) also causes constipation. The commoner causes are mainly dietetic. Artificially fed infants are the most frequent sufferers because of badly balanced food mix- tures (see Artificial Feeding, p. 153), either too large or too small an amount of one ingredient of the milk, or the boiling of the milk itself acting as causes. Breast-fed infants are constipated from deficiency in the fat or total quantity of solids present in the mother's milk. In older children a badly arranged dietary, especially a deficiency in the carbohydrates and fruit juices, will cause this symptom. Next to the diet, the lack of training of the child is an important cause in pro- ducing constipation. Children who suffer from constitutional diseases, such as rickets and infantile atrophy, may be constipated because of the lack of expulsive power and deficient peristaltic action. Other causes are deficiency of the intestinal and biliary secretions, nervous inhibition of the normal peristalsis in such diseases as menin- gitis, and intestinal parasites. The fear of causing pain when at stool, as from fissures of the anus, may lead to constipation. Symptomatology. In Infancy. — Colicky pains and flatulence precede the passage of the fecal mass, which is hard and dry or putty- like. Absorption of the toxins may cause rise of temperature or possibly convulsions. These infants are inclined to be fretful with ca- pricious appetites and are poor sleepers. They are likewise inclined to eczema. Rectal examination will reveal the fecal masses. In Older Children. — The tongue is coated, the breath is foul, and there is lassitude and depression with headache, There may be a DISEASES OF THE DIGESTIVE TRACT, 209 slight rise of temperature, and the complexion becomes sallow or pasty. The appetite is lost. Sleep is disturbed. The stools are passed with an effort, may be mucus-coated and exceptionally large and ball-like. The child may go for several days without a movement. Digital examination will clear up any doubtful case. Treatment. — With persistent and patient effort all cases can be cured. The food taken by the child must be studied and the error which is usually dietetic set right. Medicines should have a minor place; the main reliance should be on diet, correct habits, and massage. Deficiency in the total amount or irregularity of any of the food components must be properly balanced. If the fats are deficient in the mother attempt should be made to improve the milk by dietetic and hygienic measures, and by regulating the amount of sleep and exercise. If this fails, alternate feedings or supplementary feedings of modified milk may be given. Nursing mothers should be placed on a diet list which would include plenty of clean raw 7 milk, corn- meal gruel, and water between meals. Feeble infants in whom the efforts to expel the mass are unsuccessful, as is evi- denced by the finger in the rectum, are helped by gentle massage of the abdomen, the introduction of a gluten suppository or the nipple of a rectal syringe. Artificially fed babies are most often constipated be- cause they are usually on a modified food incorrectly ordered. See to it that there is a sufficiency of fat and protein in the mixture and that the curd is mechanically broken up by the addition of a gruel. Oatmeal gruel may be tried in infants suffering from constipation. Water between the feedings must be offered freely. A tablespoonful or two of orange or pineapple juice is decidedly beneficial in infants after the first six months of life. Beef juice or chicken ^j^p^ broth are laxative and maybe judiciously employed. Fig. 59. — Rec- If the mixture has been made up with a proprietary infants'^ 1 infant food, this should be changed. If the constipa- tion has been neglected for some time it may be necessary to use soap enemata, four to eight ounces at a time. Glycerin suppositories at first may be tried in conjunction with a proper diet and hygienic measures, and then gradually use milder procedures as improvement takes place. By simpler procedures is meant the injection of a few drams of olive oil or an ounce of warm water with a baby rectal syringe. The elixir of cascara sagrada (N F.) ten to thirty drops may be H 210 DISEASES OF CHILDREN. prescribed, or malt and cascara given in the miminum dosage possible to produce a satisfactory movement (one-half to one teaspoonful). As soon as the supplementary measures can be depended upon, the medicines should be abandoned altogether. A regular stooling habit can be cultivated almost from infancy by placing the baby on a small commode at regular intervals and is a prophylactic measure of importance in child life. The constipation of older children may be corrected by the addition of cream and butter to the food, or in other instances, a greater amount of vegetables and fruit must be ordered. Taking a glass of water on arising, followed by a cold sponging and abdominal massage will cure many cases if regularly carried out, besides im- proving the general body tone and blood-supply. Calomel, castor oil or the salts should not be given for this condition. They are cathartic in action and tend to produce constipation. PLATE III. Tenia Ova of the cestodes of early life. Tenia solium (Pork tape-worm), p-p aagioata (Beef tape-worm), q-q'; Bothriocephalus l ; ,n> s (1msIh,|.«->,,) U . Urinaria americana (Hook-worm). x-x'-x"-x'" : Ascans lumbricoid,* (Round- worm), y-y"; Oxyuris vermioularia (Thread worm), d-d -<1 -a . CHAPTER XX. THE ANIMAL PARASITES. These may be conveniently divided into several groups and sub- groups (see table below). Only those that are found with some frequency in childhood will be described and pictured. Parasitic Protozoa. Animal Parasites Found in Childhood: Nematodes. — Oxyuris vermicularis (thread worm). Ascaris lum- bricoides (round worm). Trichina spiralis. Ankylostoma americana (hook worm). Cestodes. — Tenia saginata. Tenia solium (pork tape-worm). Bothriocephalus latus. Although infection is more frequent with intestinal parasites among children than in adults, the cases are mainly found in the off- spring of foreigners in this country. These parasites are taken to be the cause of many of the ailments of children by parents frequenting the dispensaries and many of them have been given the therapeutic test without any clinical evidence of the parasites being present. When they are present in any quantities they may do harm, especially in sickly children, by impoverishing the albumin content, by acting as foreign bodies in unusual sites, and by poisoning their host through their metabolic products. The evil effect of intestinal parasites is often exaggerated in the mother's mind. Oxyuris Vermicularis. (Thread Worms.) These are small white filament-like worms usually found in the rectum. The female is larger than the male, and usually is found in the cecum, until impregnated, when it descends to the rectum. The eggs are oval, asymmetrical, about 0.05 mm. in size Their interior is filled with a granular yolk, containing a clear nucleus. The oxyuris differs from some of the other parasites in that it does not require an intermediary host. The worms and the eggs pass out of the rectum alone or with the feces, ami may 211 12 DISEASES OF CHILDREN. directly inoculate a human body. The child may reinfect itself by handling toys, or food, and may infect its playmates. Symptomatology. — The worms by their presence may produce irritation of the anus, or if present in sufficient numbers, even a colitis or proctitis may result. The children sleep poorly and scratch about the anus. They lose their appetites, be- come irritable, and even anemic. In girls, particularly, the parasites may invade the genitals, and result in masturbation or incontinence of urine. Sometimes no symptoms are to be noted. Diagnosis. — An enema of cold water will disclose any parasites present if they are not found in the stools or at the anus. The eggs are found with difficulty in the stools; more often they are found under the finger-nails of the infected child. Treatment. Prophylactic. — By atten- tion to the person of the patient, self-in- oculation can and must be prevented. Baths, clean finger-nails, restrictive ap- paratus for the hands or heavy canvas drawers to prevent scratching are some- times necessary. Examine other suscep- tible members of the family to prevent reinfection. Internal. — A grain of calomel or a tea- spoonful of Rochelle salts in water is given to bring down the females from the cecum. Locally. — Daily enemata of saline solution may be given followed three times a week by injections of the infusion of quassia, this to be retained for a time if possible. Further, a 2 per cent, yellow oxid of mercury ointment is applied about and into the rectum at night. This treatment should be persisted in until the bowel is thoroughly rid of the worms, and renewed if any are seen at a later date. Fig. 60. — Oxyuris vermicu- laris. a, Sexually mature female; b, female with eggs; c, male. (After Heller.) Ascaris Lumbricoides. (Round Worm.) This parasite is round with a smooth body from four to six inches long and pointed at each end. The mouth has three suckers and teeth. THE ANIMAL PARASITES. 213 The female is very prolific, producing millions of eggs. These are rounded or oval in shape (see Fig. 61). It has been proven by experimentation that no intermediary host is necessary. Although they normally inhabit the small intestine, they move from place to place. They have been frequently vomited from the stomach and have been found in the gall-bladder and appendix in children. Through its ova it gains entrance to the human intestinal canal. Symptomatology. — The parents themselves often make the diagnosis of round worms when they have seen them passed. When questioned the majority of the patients do not give any symptoms directly referable to the worms, and many have had no symptoms whatever. The symptoms usually present are loss of appetite, nausea, or diarrhea, occasionally there are pains referable to the abdomen, which are soon forgotten, only to reappear again. Pruritus ani, pavor nocturnus, choreiform movements, and convulsions have been observed. A rather constant eosinophilia is pres- ent in patients with round worms, and this should be a stimulus to examine the feces for ova. By their local action or migration they may produce obstruction of the intestine or even a fatal issue, as in laryngeal obstruction. Diagnosis. — The microscopic ex- amination for the ova is readily made and should not be omitted in ques- tionable cases having an eosinophilia. Treatment. Prophylactic. — Cleanliness of body, a pure water- supply, and avoidance of unboiled Fig 81. — Ascaris lumbri- coides. .1 . A female; />'. a male, oatural siae; />, cephalic end. en- larged, showing lips v i Paris.) 214 DISEASES OF CHILDREN. vegetables for children decrease the possibility of infection. Care in the handling of the stools of children will also prevent infection of others. Internal. — Calomel and santonin is a dependable combination for this parasite. A half-grain of each drug with sugar of milk is usu- ally sufficient. Never give more than a grain of santonin, as poisoning may be produced. It is best given with some food and in divided doses. The stools should be examined for ova each week for three weeks, as until then there is no positive certainty of their absence. Cestodes, or Tape -worms. General Characteristics. — The tape-worms commonly met with in this country in children are the Tenia mediocanellata (or saginata) or beef tape-worm, and the Tenia solium or the pork tape-worm. They are flat, ribbon-like, jointed parasites, yellowish in color, and vary in Fig. 62. — Head of Tenia sagi- nata, much magnified. Fig. 63.— Head of Tenia solium, showing scolex, suckers, hooks, and neck. length from ten to twenty feet, the segments growing smaller until the head is reached. It is only in the intestinal tract of man that the fully developed parasite is found. The ova are taken into the alimentary tract of an animal and their covering is dissolved and they then pass through into the muscles of the animal and become encysted there. Such meat is commonly spoken of as being "measly." This infected meat when eaten by man allows the larvae to develop into the tape- worm. Although occurring rarely, man may himself act as the inter- mediary host and cysticerci develop in his organs. THE ANIMAL PARASITES. 215 Tenia Mediocanellata or Saginata (The Beef Tape-worm). These worms may be distinguished by the appearance of their heads under the magnifying glass. The head of the beef worm is cuboid, slightly darker than the rest of the body and it has no hooka as the pork worm has; instead four suckers are seen on the head. Its eggs are smaller than that of the Tenia solium, and contain hooklets. Tenia Solium (The Pork Tape-worm or the Armed Tape-worm). The head of this parasite which is about the size of a pin-head, has besides the four suckers found on the beef worm, a set of hooklets. They often reach nine feet in length. The eggs are round and contain the embryo with its hooklets. Symptomatology. — In the great major- ity of cases there are no pathognomonic symptoms referable to the teniae. Often it is only when the segments are passed that their presence is indicated. Older children may complain of grumbling, griping pains, and have symptoms of indigestion. They become anemic, have headaches, and com- plain of dizziness. Sometimes a capricious or voracious appetite may excite suspicion, if coupled with a history of eating raw beef or pork. Treatment. Prophylactic. — Proper meat inspection at the abattoir. A dis- semination of the harm that may be caused by eating of raw or badly cooked meats and destruction by fire of all segments passed would materially reduce the number of these cases. The children of foreigners are especially to be warned. Internal. — The parasites can be removed if a systematic cure is outlined and rigidly followed, as the head is firmly attached and must be dislodged to effect a cure. First day: a dose of castor oil. at least a half ounce, is given, followed by fasting for the remainder of the day. FlG. 64. — Portions of a Tenia saginata. (After Leuckart, natural size.) 216 DISEASES OF CHILDREN. Second day: following a cup of clear consomme or weak tea, give the following prescription for a five year old child, while the child is kept in bed. Oleoresinse aspidii 5 j Mucilaginis acacia? oij Spiriti chloroformi tt^x Aquae cinnamomi q.s. ad. o j Misce et Sig. — One-half the quantity at a dose. The remainder is given after a few hours, if the child should vomit the first dose; they rarely reject the second, if kept prone in bed. Several hours after the vermifuge has been given, a glass of the effervescent citrate of magnesia is taken. The worm should be passed into a clean vessel, containing warm water, and careful examina- tion made for the head, for unless this is identified, the cure will be unsuccessful. This treatment has been so successful in our hands, that there has been no necessity to resort to less reliable vermifuges, as the pelleterine t annate, kousso, kamala, etc. Uncinaria Duodenalis. (Ankylostomum Duodenal e or Hook Worm). This parasite has assumed a greater interest for us in the past few years because of our new possessions in the West Indies, and since the pub- lication of the investigations of Stiles who has shown how prevalent .they are in the children of the Southern States. The hook worms are small thread-like parasites with four teeth which enable it to attach itself to the intestine. The jejunum being its favorite site. The eggs develop rapidly and the embryos are very tenacious of life. The eggs are oval in shape, with a distinct capsule and a brownish con- tent. Unclean water, the eating of raw vegetables, and unclean hands and bare feet are the means through which infection takes place. Symptomatology. — The children having hook worms are pasty, white and thin. The appetite is abnormal; mainly a craving for the unusual. The anemia is marked, so that the patient is listless, without Fig. 65. — Unci- naria d u o d e n a 1 is. (Afte? Loss, x 105.) THE ANIMAL PARASITES. 217 ambition, and mentally dull. Later the abdomen becomes prominent and there is edema of the extremities. The stools if examined show the ova. Treatment. — Thymol is almost a specific for the hook worm. The bowels should be emptied with calomel or castor oil, the diet restricted, and thymol given in five-grain doses every two to three hours until twenty grains of the solid drug are taken. Another purge should now be administered or a high enema given. Weekly exami- nations of the stools should be made, and if any are found, repeat the cure each week. Following the elimination of the ova, an iron pep- tonate should be prescribed until the hemoglobin content is normal. Fig. 66. — Oral capsule of Uncinaria duodenalis. Trichina Spiralis. Children are liable to infection from this parasite by eating diseased pork. Those living in country districts where the curing of the pork is done at the farmer's home are especially liable. The encapsulated trichinae are freed in the stomach, propagate and deposit living embryos. Those which are not passed out of the intestinal canal, reach the muscles where they develop and finally become encapsulated. Symptomatology. — During the first week of their ingestion the symptoms are slight and those of a gastrointestinal nature. Then general muscular pains with high fever develop and are often mistaken for rheumatism or typhoid. Transitory swellings appear. The muscles are painful to the touch; nausea and vomiting or diarrhea may be present. Dysphagia prohibits the taking of nourishment. Stupor and coma may ensue in fatal cases. Eosinophilia is marked and is a distinct aid to the diagnosis. Treatment. Prophylactic. — Reliable meat inspection and thorough cooking of all hog meat (200° F. are necessary to kill encapsulated 218 DISEASES OF CHILDREN. trichinae) are measures of prophylaxis which are self evident. Better still, pork in any form should be prohibited in the dietary of the child. Internal. — Calomel is given until free purgation is obtained. Benzol is then administered in grain doses, alternating with glycerin half a dram every four hours. Good nursing is necessary to keep up the strength of the patient through long convalescence. Fig.. 67. — Encapsulated muscle trichinae. {After Leuckart, x 10.) CHAPTER XXI. DISEASES OF THE LIVER. The Liver. The liver is of relatively large size and functional importance in early life. In fetal life it is a very important factor in the circulatory system, while the lungs are largely inactive. Thus in the mature fetus the liver holds a quarter or more of the entire volume of blood, and it is greater in size than both lungs. As the lungs of the fetus are solid, and almost impervious, the placenta of the mother performs the double function of a respiratory and of a nutritive organ. After the venous blood is received from the fetus it must be returned reoxy- genated, and nearly the whole of this purified stream is carried to the liver by the umbilical vein and circulates through this organ before reaching the vena cava and the general circulation. The large size and importance of the liver in fetal life are thus understood by con- sidering it a sort of intermediary organ between the placenta and the general circulation, as far as the reoxygenated blood is concerned. At birth the lungs should at once inflate and assume the respiratory function. The umbilical vein is completely obliterated in a few days and finally becomes the round ligament of the liver and the ductus venosus is likewise obliterated. Although the liver now loses its preponderating importance in the economy, it still remains relatively larger and heavier than in later life. The diminution of the organ is due to its altered blood supply, and is especially marked in the left lobe. The loss of weight that begins at birth continues, so that there is a direct ratio from infancy to old age in this relative diminution. In infancy the liver weight is in proportion to the whole body as one to twenty; at puberty, one to thirty; in adult life, one to thirty-five; in middle life, one to forty; in old age, one to forty-five. Examination of the Liver. The child is placed in the recumbent position with the thighs flexed in order to relax the abdominal muscles as much as possible. The organ may then be mapped out by palpation ami percussion. The liver projects from h inch to 1 inch below the free borders of the 219 220 DISEASES OF CHILDKEN. ribs. In the median line the lower border of the left lobe extends to within about an inch of the umbilicus. It must be borne in mind that the liver ascends and descends with full inspiration and expira- tion. If the organ is enlarged it can be detected by deep palpation, and effort should be made to map out the seat and character of the swelling. On percussion, liver dullness along the upper border will begin at the right sternal margin and in the mammary line in the fifth inter- costal space, in the axillary line at the seventh rib, and in the scapular region at the ninth rib. Upon very light percussion, the dullness will be noted a little below these lines. Apparent enlargement of the liver may be caused by a slight displacement induced by the bony deformity of the thorax in rickets, by effusion in the right pleural cavity, by tumor of the right kidney, by fluid in the abdominal cavity, or by subphrenic abscess. The commonest causes of true enlargement of the liver in early life are abscess, fatty degeneration, cirrhosis, and leukemia. Jaundice. Icterus neonatorum has been considered in the section on Diseases of the Newly-born. In attacking infants some time after birth j aundice is due to causes similar to those found in children and adults. Owing to some obstruction in the biliary canals, the bile, instead of passing into the intestine, is absorbed into the blood. An inflammation of the duodenum, accompanied by swelling of the mucous membrane at the opening of the ductus communis choledochus, may be responsible for this obstruction. The inflamma- tion may also extend by direct continuity from the duodenum to the ductus communis and hepatic ducts, and thus cause retention of bile in the liver. A plug of inspissated bile in the common duct, and, more rarely, gall-stones may also cause obstruction. Complete stoppage has been reported by a round worm penetrating the common duct from the duodenum. Inflammatory changes in the liver, as in cirrhosis, may induce jaundice by obstruction from pressure in the intrahepatic ducts. Finally, certain toxic conditions, as in paludism and various infectious diseases, and rarely phosphorous poisoning may act as causes. Symptomatology. — The most objective sign is the general yellow- ness of the skin and the conjunctivae. Other abnormal tints of the DISEASES OF THE LIVER. 221 skin simulating jaundice may be differentiated by the yellow conjunc- tivae and by the presence of biliary pigment in the urine. Itching of the skin may be present. Urticaria, which is so com- mon in children, sometimes ensues when the papules and wheals will present a deep-yellow tint. The yellowness of the skin is usually only to be noted in a natural light. The most marked internal symptoms may be those that can be referred to a duodenitis or a gastroduodenitis. In the latter case there is more or less nausea and vomiting, with pain in the epigastrium, especially upon the ingestion of food and tenderness upon pressure in this region. There may be a subacute duodenitis without gastritis being- present, when pain will be noted some hours after taking food as it passes from the stomach into the duodenum. The stools may be clay colored from an excess of undigested fat when no bile reaches the in- testine. When the obstruction to the passage of bile is only partial the stools may retain a natural brownish-yellow color. The complete absence of bile will be shown by a quick decomposition of the intestinal contents as exhibited in the free formation of gases and a foul odor of the feces. The pulse may be slow as the biliary salts have a sedative effect on the circulation. Most cases of jaundice in young children disap- pear in a few weeks without leaving any serious consequences, but rarely there may suddenly ensue evidences of blood-poisoning, followed by death. Occasionally the jaundice will last for months without giving rise to much apparent disturbance except a slight stupidity. Treatment. — Where there is no evidence of gastroduodenal in- flammation, active peristaltic action in the duodenum to be trans- mitted to the bile ducts may be induced by calomel, rhubarb, aloes, or colocynth. This may be followed by a mixture containing tincture nucis vomicae with bicarbonate of potassium or sodium, as alkalies are supposed to have a liquefying effect upon the bile, thus freeing the ducts when they are occluded by a thickening of this secretion. Only bland and easily-digested food must be allowed. All fatty foods must be restricted and the patient kept on lean meat and plain vegetable food. When the jaundice depends on a subacute inflammation of the stomach and duodenum, the saline laxatives and mineral waters do well. Carlsbad, Vichy, and Congress waters usually are beneficial. Persistent constipation is one of the commonest symptoms, and must always be relieved. 222 DISEASES OF CHILDREN. Inflammation of the Biliary Ducts. An ordinary acute inflammation of the biliary ducts usually under- goes resolution in a few weeks without any bad results being left behind. As a result of the inflammation a collection of mucus, often taking the form of a firm plug, is located at the opening of the common duct into the duodenum, thus causing more or less complete obstruction. In chronic cases there may result a thickening of the ducts, with dilation in places caused by the obstructed secretions. Rarely, ulcera- tion may take place in the walls of the ducts. The mucous membrane of the gall-bladder may likewise be the seat of inflammatory changes. Symptomatology. — Various digestive disturbances shown by coated tongue, nausea or vomiting, and other symptoms pointing to a mild inflammation of the stomach are present at the start. There may be slight fever. In a few days the conjunctivae become yellow, the urine is colored by biliary pigment, and the feces assume a clay-like appearance. There may be a slight enlargement of the liver and the gall-bladder may be palpated. There may be some tenderness on pressure over the right hypochondrium. When the inflammation of the ducts is secondary to congestion of the liver, there is less digestive disturbance and milder jaundice of shorter duration. The treatment is the same as that of jaundice. Where the inflam- mation is induced by changes in the parenchyma of the liver or by certain infectious diseases, treatment must be aimed at the underlying cause. Inflammation of the Portal Vein. Suppurative pylephlebitis may occur as a secondary lesion result- ing from suppuration in some of the organs drained by the portal vein or its radicles. Ulcerations of the gastrointestinal mucous mem- brane, inflammation or ulceration of the biliary duct and umbilical phlebitis in new-born infants whose mothers are septic may spread to the portal system and set up inflammation there. Symptomatology. — Local pain in that part of the portal vein involved will follow the symptoms of the primary morbid condition. Enlargement and tenderness of the liver may be due to a general hepa- titis or to abscesses. The spleen may likewise become enlarged and tender from occlusion of the splenic vein. As pus forms in the portal vein, there will be chills, fever, sweating, and general emaciation. Intestinal indigestion with bilious stools and jaundice usually are present. Although there may be remissions, the disease usually ends fatally in a few weeks. DISEASES OF THE LIVER. 223 Treatment. — All that can be done is to treat symptoms as they arise and sustain the strength as much as possible. Organic diseases of the liver are rare in early life and do not differ essentially from adult life. Congestion of the Liver. This condition may be active or secondary. The active form occurs during certain infectious diseases, especially paludism, and in the early stages of abscess of the liver. The secondary form is seen in affections of the heart and any other physical condition which causes stagnation in the liver by checking the access of blood to the ascending vena cava. The organ is enlarged in both forms, but more so in the cases of passive hyperemia. There is usually tenderness on pressure over the region of the liver. The treatment must be addressed to the disease or local condition that causes the congestion. Phosphate of sodium, citrate of magne- sium, and other saline purgatives may be given to try and deplete the portal circulation. Fatty Liver. This condition may be present in various constitutional diseases, especially rickets and tuberculosis. It is more often secondary to the latter disease than to any other. Chronic intestinal disorders and blood dyscrasias may also act as causes. The organ is generally uniformly enlarged. In some cases the increase in size is very great, but tenderness is absent. There are usu- ally no symptoms, and treatment of the original disease is all that can be accomplished. If there is little enlargement, the condition cannot be recognized during life, but it is seen to some extent in a large num- ber of the autopsies made on' young children. Amyloid Liver. Waxy liver is secondary to prolonged suppuration in any organ, to chronic joint or bone disease, to tuberculosis or syphilis. The liver is generally enlarged, with a hard, rounded border and free from pain on pressure. On section, it gives a reddish-brown reaction with iodin. Similar changes also usually develop in the spleen and kidneys, and the spleen is thus enlarged. There are no distinctive liver symptoms or jaundice. Albuminuria may be present from the kidney affection. 224 DISEASES OF CHILDREN. and ascites or edema from pressure. Gastrointestinal irritation, shown by vomiting and the passage of foul-smelling stools is often noted. When waxy liver is recognized, it means some form of chronic disease and a grave prognosis. The treatment consists in trying to check the original focus of suppuration, in supporting the patient, and in handling various symp- toms as they arise. Cirrhosis of the Liver. This disease is rare in early life and is oftener accompanied by enlargement than contraction of the liver. The commonest primary causes are syphilis, alcohol, and chronic paludism. Syphilitic cirrhosis is seen in early infancy, and is perhaps the commonest form of organic disease of the liver at this time. When alcohol acts as a cause, it is in older children of from ten to fifteen years of age. In chronic malarial poisoning, there is great enlargement of the liver when this organ is the seat of cirrhosis. There may be secondary cirrhosis, as in adults, from hepatic hyperemia due to chronic cardiac disease, from prolonged obstruction of the bile ducts, and possibly from infectious diseases^ such as measles and scarlatina. The pathology and symptoms do not differ from cirrhosis seen in later life. It is often difficult to recognize the disease apart from the general condition, such as syphilis, that produces it. There may be no symptoms directly referable to the liver. Icterus may or may not be present, but enlarged spleen and ascites are common. The treatment must be directed to the primary disease and various symptoms as they arise. Abscess of the Liver. Abscess may follow suppuration within the abdomen, very rarely from the migration of round worms through the common duct, from infectious diseases, and in the newly-born from sepsis. It is very rare, however, and the symptoms are similar to those seen in the adult. The treatment is surgical. Acute yellow atrophy and gall-stones occur with very great rarity in early life, and do not differ in course and symptoms from the same affections in the adult. SECTION VI. THE INFECTIOUS DISEASES. CHAPTER XXII. THE EXANTHEMATA. The exanthemata consist of five diseases: scarlet fever, measles, German measles, small-pox and chicken-pox. All except small-pox are distinctively diseases of childhood; although any of them may occur in adults. Each runs a definite self-limited course, subject to varia- tions and complications. As a rule, each renders an individual im- mune to future attacks of the same disease, but one does not confer immunity from another. Two of them may occur in the same individ- ual at the same time. Each is divided into four stages: the stage of incubation, prodromal stage, efflorescence, and desquamation. The stage of incubation comprises the interval from the time when the contagium is taken into the system until the first symptoms appear. The prodromal stage is the period included between the appearance of the first symptoms and the appearance of the eruption. The stage of efflorescence extends from the time of the first appearance of the eruption until it fades and the stage of desquamation begins. As the great majority of cases run a typical course, such a form of the disease will first be described, always bearing in mind that the many varia- tions and complications which are later described may alter the general picture. Measles. (Rubeola, Morbilli.) Definition. — Measles is an> acute contagious disease characterized by a period of incubation, a prodromal stage with fever, coryza. lam- ination, cough, and Koplik's spots, followed by a red, papular erup- tion and a fine desquamation. Etiology. — No specific microorganism has as yet been discovered. The contagium is contained in the nasal, lacrimal, and bronchial secre- tions and, unlike scarlet fever, to a less extent in the desquamated epi- thelium. It has been transmitted through direct inoculation of the nasal secretions and blood. It is, therefore, more contagious in the early stage. The contagion extends through the eruptive and desquam- ative stages. It has not the property of clinging tenaciously to such 15 225 226 DISEASES OF CHILDREN. object- as clothing, and it is doubtful if it is often carried by a third person; surely not as easily as scarlet fever. Epidemics spread rapidly, owing to its transmission on short exposure and to its highly contagious character before the diagnostic eruption appears. Most people have the disease at some time during life; therefore, adults are not immune unless they have already had it. It is most frequent between the first and sixth years; rare before the fifth month, and only 5 per cent, of the cases occur under one year. It has occurred at birth. One attack usually protects the individual from further attacks, but recurrences are more common than in any of the other exanthemata. It occurs in all countries and at all seasons. Pathology. — The skin shows an infiltration of round cells which surrounds the sweat and sebacious glands as well as the capillary blood-vessels which are found distended with blood. The mucous membranes show inflammatory changes. Other pathological con- ditions, such as bronchopneumonia, are not typical of measles. Incubation. — Eight to twelve days; usually ten days. Prodromal Stage. — Three to five days; generally four days. The onset is not usually as abrupt as in scarlet fever. The child appears to have a cold in the head, has some cough, and a temperature of 100° F. to 104° F., according to the severity of the disease. There is not apt to be vomiting, nor are convulsions common, although either may occur. The coryza gradually increases, lacrimation and the nasal discharge become more profuse, the child grows sicker, and finally the face assumes the puffy appearance with redness about the nose and eyes commonly seen in a severe coryza. Very often a decep- tive fall in temperature with seeming improvement of the child's gen- eral condition takes place on the second day, only to be followed the next day by a further rise of temperature and increased symptoms, which continue to increase until the eruption is at its height. There may be in some cases a regular remittent fever during the three or four days of the invasion. Koplik's spots w T hich are pathognomonic of measles, and almost invariably present, are found on the mucous membrane of the cheeks and lips all through the prodromal stage if inspected in strong sunlight. The first day there are usually less than six of these rose-red spots scattered over the pink mucous mem- brane, in the centre of which are bluish-white specks. Some are minute, about one-eight h of an inch in diameter. Soon they may increase in num- ber until they coalesce and lose their characteristic appearance as the exanthem comes to its height. Koplik's spots are to be differentiated from the rose colored papules w T ith superimposed wmitish vesicles seen on. the soft and hard palate in German measles, scarlet fever, and PLATE VI Measles, showing typical eruption. THE EXANTHEMATA. 227 simple angina, as well as in measles. A redness of the fauces and phar- ynx said to resemble the characteristic eruption on the skin is generally seen. Eruption. — On the third or fourth day the exanthem appears on the face in the form of discrete, raised, red, pin-head-sized papules. They are sometimes arranged in crescents. The eruption spreads to the neck, chest, back, and arms, and within thirty-six hours the whole body, including the palms and 'soles, is involved. While spreading thus, the papules on the face are enlarging peripherically until they become confluent and large areas are covered, with only here and there small areas of intervening normal skin. This process takes place also on the rest of the body in the order in which the eruption originally appeared. The whole face is swollen and has a character- istic mottled appearance when the eruption is at its height. The lids are red and edematous, and the conjunctiva inflamed, tending to keep the eyes half-closed. Photophobia is pronounced. This condition is usually reached within thirty-six hours after the first appearance of the eruption, and continues together with the maximum temperature, coryza and cough, for one or two days. During the next two days the eruption fades and the temperature falls, so that w r ithin seven or eight days from the onset of the first symptoms, the temperature is normal and desquamation is taking place. Desquamation begins in the order in wmich the eruption appeared, often beginning on the face as the exanthem has reached its height on the limbs. It consists of fine flakes unlike the large lamellae of scarlet fever. It is completed in one or two weeks. Variations, Complications and Sequellae. — The incubation may last as long as twenty-one days. There may be no symptoms of rhini- tis or bronchitis whatever, throughout its course. Relapses, i.e., recurrences of temperature and eruption are very rare, but may occur a few days after the temperature has become normal. Fever. — There are afebrile cases and cases with hyperpyrexia, but neither are common in uncomplicated measles. The remission of tem- perature on the second day of the prodromal stage may not occur, but the majority of cases show it. A continued temperature after the eruption subsides, or a persistent rise of temperature during the first or second week of convalescence always leads us to suspect com- plications, particularly bronchopneumonia or middle-ear infection. Exanthem. — Occasionally the eruption itself is so atypical that a diagnosis can only be made by a general consideration of the other features of the case. Rarely it may be erythematous or even vesicu- lar in character, or the papules may be very large or macular from 228 DISEASES OF CHILDREN. the first. They may vary from the typical red color to purple or, on the other hand, they may be very faint pink. There may be minute hemorrhagic spots about the papules even in benign cases; or in the severe toxic and often quickly fatal cases the hemorrhagic areas are extensive and simultaneous hematuria and epistaxis occur. In weakly children the eruption is often very limited even in severe cases. It may vary in the order of its appearance coming simultane- ously upon the face and thorax, or even on the thorax or abdomen first. It may subside entirely in twenty-four hours. Entire absence of the eruption is very rare, if it occurs at all. Lungs. — Here we find the most common and the most dreaded complications of measles. A mild bronchitis with coarse mucous rales throughout the chest is very common during the early stage, and may pass off with the eruption. But often this outcome is not so fortunate, for it may continue into a chronic bronchitis; or while the disease is at its height the respirations may become more rapid, localized areas of fine crepitant rales appear, and bronchopneumonia may develop. Its course differs in no way from the ordinary bronchopneumonia, being the cause of death in the great majority of fatal cases. It may occur at any time between the beginning of the prodromal stage and the completion of desquamation. Lobar pneumonia is seen less frequently. The above-mentioned conditions of the respiratory tract make good soil for the growth of the tubercle bacillus, so that measles is one of the most frequent sources of pulmonary tuberculosis in childhood. L'n- resolved pneumonic areas and continued cough and bronchitis should receive prompt attention, and the physician should have this com- plication constantly in mind. Pertussus from previous exposure is considered a very serious complication. Pleurisy and empyema are less common complications. Nose, Pharynx, and Larynx. — The inflammatory conditions here may cause enough obstruction to lead to much difficulty in feeding or in breathing. Spasmodic croup, a pseudomembrane of streptococcic origin or a double infection with the diphtheria bacillus may complicate the case. Diphtheritic croup complicating measles is very fatal owing to the rapid descent of the pseudomembrane into the bronchial tubes. Ulceration of the larynx may cause great edema with extreme dys- pnea or subsequently the scar may cause a serious stenosis of the larynx. Ear. — The external auditory canal may be painfully swollen through extension from the skin. Otitis media is often of a mild grade when due to infection through the blood, but severe cases are THE EXANTHEMATA. 229 due bo extension through the Eustachian tube. Mastoid disease has its usual relation to the otitis media. \]\ k. Conjunctivitis is of the usual type in a more or Less severe form. Keratitis and iritis may result and do permanent damage to the eye. Any previous condition may be rendered more active. Other Organs. — The intestines are occasionally involved, and the resulting diarrhea is often severe. Stomatitis may occur from the same source. Cerebrospinal meningitis is occasionally seen, particu- larly in the pneumonic cases. The heart and kidneys are rarely affected in uncomplicated measles, although the kidneys may show transient abnormalities through the urine. Osteomyelitis and suppu- ration of the joints have been seen, but are rare. Prognosis. — The mortality from measles itself is not high, but the pulmonary complications render it one of the most serious of chil- dren's diseases. Fatal cases almost invariably show bronchopneu- monia or less frequently lobar pneumonia. The mortality averages 8 to 10 per cent., and is greatest during the first year. Epidemics in institutions often give a high mortality. Prophylaxis. — Measles is by no means a mild disease. Through its complications it is productive of many deaths. All possible pre- cautions should be taken against the exposure of infants, especially those under three years of age. Isolation should be carried out just as soon as the disease is suspected and should last at least three weeks. Children who have been exposed should be kept segregated from other children for that period. Treatment. — Hygienic and hydrotherapeutic measures are of greater importance than the medicinal treatment. Select a well- ventilated room that is as far as possible from direct communication with the rest of the house. The light should be thoroughly subdued with dark shades until all photophobia is past. If the fever is high and causing ill effects, such as delirium, it can be controlled by spong- ing with hike warm water and by frequent drinks of cool water. If a sedative seems necessary, small doses of phenacetin will have the desired effect (one grain for a two-year-old child every two hours for four doses). The cough in the early days of the eruption is often troublesome and prevents sleep. Small doses of the bromid of sodium with chloral may be given for its conrol. (Four grs. bromid with one gr. chloral every four hours for a child of five years or codein phosphate A - °f a grain for one or two doses.) Ammonium chlorid and sweetened cough mixtures only tend to produce an irritable stomach and consequent anorexia. The eyes should be bathed with 4 per cent, boric acid solution. In some cases there is considerable itching o( the 230 DISEASES OF CHILDREN. skin, and this may be relieved by inunctions of 5 per cent, ichthyol and lanolin. The bowels are kept open preferably with small doses of calomel or enemata. The ears should receive careful daily inspection for any redness or bulging, and if present an aurist may then elect to do incision and drainage of the ear drum. By careful attention to the eyes, ears, and nasopharyngeal toilet, many of the disastrous com- plications of measles may be avoided. Bronchopneumonia, as a rule, supervenes more often in those cases that have been treated by sweat- ing and administration of hot drinks, thus further lowering the resist- ance of the child. German Measles. (Roiheln, Rubeola.) Definition. — German measles is a mild acute contagious disease, having a period of incubation, a prodromal stage followed by a red macular eruption and desquamation. It is attended by little if any systemic disturbance. Etiology. — There is no known specific microorganism. The disease spreads with great rapidity, the contagium taking place on slight contact. It is conveyed by direct contact, and is probably not carried by a third person. One attack usually protects, but it has occurred in the same individual a number of times. Neither scarlet fever nor measles render immunity, as it seems to bear no relation to these diseases. Pathology. — There is no specific pathology. Symptomatology. — After an incubation of between two and three weeks, during which there are no symptoms, a slight coryza or sore throat develops with a temperature rarely over 101° F. In a great many cases these prodromal symptoms are wholly lacking, and in about 50 per cent, there is no temperature at any time. There is rarely more than a slight indisposition and loss of appetite. On the first or second day the eruption appears. Often a premonitory gen- eral blushing of the skin fading in a few hours with small discrete macules, deep pink in color, are seen on the face. These rapidly spread to the thorax, and thence within twenty-four hours to the rest of the body, but they are much more numerous on the face than elsewhere. The eruption never reaches its height in all parts of the body at the same time, as it begins to fade on the face before the extremities are reached. The throat is reddened. If there has been any fever it disappears soon after the eruption comes out. In two to four days the eruption has faded, and a slight brownish staining of PLATE VII. H n Rubella (German measles). THE EXANTHEMATA. 231 the skin, with slighl desquamation, is at times Been. The posterior and occipital Lymph nodes are very constantly enlarged, even before the appearance of the eruption, and confirms the diagnosis. Prognosis. — Recovery after a short mild course is to be expected. Treatment. — This is, as a rule, mainly symptomatic. Beyond a liquid diet and sponging with alcohol very little is required. In severer cases the treatment given under Measles may be appropriately followed. The children are isolated for a period of two or three weeks, and their surroundings should be such as described under Measles. Scarlet Fever. (Scarlatina.) Definition. — Scarlet fever is an acute infectious, and contagious disease, characterized by a sudden onset, vomiting, and a generalized scarlet rash" accompanied by high fever. Incubation. — Varying .periods of incubation are recorded. In our experience two to seven days after exposure the symptoms appear The German authors give an incubation period from eight to eleven days. Etiology. — The specific causative factor is still unknown. It occurs more often betw r een the ages of one to five. The incubation period is the least contagious, while the eruptive stage is the most contagious. The stage of desquamation was formerly considered the period of greatest danger. One attack, as a rule, protects the individual from subsequent attacks. The immediate neighborhood of the pa- tient is probably a contagious zone. The secretions, as the urine and feces, clothing, and desquamated epithelium are the agents that seem to distribute the infection. They may retain this power of infection for months and even years. Pathology. — The lesions found vary greatly with the intensity of the infection, and are due to the action of the scarlatinal toxin (strep- tococcic) or to a mixed infection. The heart muscle, and the kid- neys show degenerative changes. The cervical glands are found hypertrophied. Symptomatology (Simple Form). — Vomiting is usually the first symptom. Convulsions may usher in the disease in younger children. The child has fever and within twenty-four hours the rash appears, first upon the neck and chest. It is bright in color, diffuse, pin-point, with no areas of healthy skin in between; it rapidly spreads downward to the arms, trunk, and legs. The face is not as much affected as the rest of the body. Sometimes hardly any rash appears there. The rash 2i>2 DISEASES OF CHILDREN. is accompanied by a variable amount of pruritus. The tongue is coated quite heavily and often has the so-called raspberry appearance, due to the injection of the papillae. Later the tongue takes on a red beefy appearance when the coating disappears. The fauces and tonsils are congested. The fever ranges from 102° to 104° F., with a rapid pulse. The glands in the cervical region are tender and often become swollen, especially in the later stages of the disease. The urine will show traces of albumin, which is often temporary only. It is apt to be scanty and high colored. The blood shows a leukocytosis, while a differential count may assist in the diagnosis by showing an increase in eosinophiles quite early in the disease. Desquamation. — This begins with the fading of the rash about the second or third day. The skin appears in fine scales usually seen first on the face and about the joints, then over the body. On the hands often large sections of skin are shed. The process lasts many days, sometimes weeks, but can generally be assisted by the treatment given below. Anginal Form. — The tonsils and retropharynx are congested. The tonsils may show exudation in their lacunar spaces, and the cervical lymph-glands are much enlarged. In another form, a membrane may be present on both tonsils spreading to the adjacent fauces, and gave rise to the false term of diphtheritic scarlet fever. It is due to a streptococcic infection, and should be regarded as the septic form of this disease, as in these cases there is always more or less general systemic infection. The fever in this form is usually of a remittent character and will be influenced by any complications that may arise. The severe forms cause prostration, stupor, or profound coma. The temperature remaining about 105° F. with rapid pulse. The urine is scanty. Deglutition is extremely difficult. There is marked restlessness. The membrane may invade the nose or larynx, the lips are fissured and the breath is extremely fetid. Routine examination of the ears will often show some degree of involvement in more than a fifth of the cases; if the patient goes on to recovery the lymph-glands degenerate with the formation of ab- scesses. Meningeal symptoms may precede the fatal issue. The mastoid cells may become diseased after convalescence has set in. Septic thrombosis and cerebral abscess are fortunately rarer complications. The otitis media of scarlet fever may persist, and be the cause of partial or absolute deafness. Kidneys. — Modern methods of urine examination will show THE EXANTHEMATA. 233 traces -of albumin and a few hyalin casts even in mild attacks. This should not be regarded as a true nephritis. The septic form of the disease through the agency of its toxins is more likely to be com- plicated by a true nephritis. Puffiness of the eyelids and face, edema about the ankles spread- ing to the rest of the body will be the first objective signs. The urine then persistently contains albumin and mixed casts, with a high speci- fic gravity. The nephritis usually lasts through a protracted convales- cence or may become chronic. Uremic symptoms begin with vomit- ing or convulsions, sometimes only convulsive movements are observed. Coma with feeble heart action are symptoms of grave peril. The Rash. — The development of the rash, usually after twenty- four to forty-eight hours, offers considerable information of value in differentiating scarlet fever from the confusing erythematous eruptions. The examiner should place his patient in a good white light. A magni- fying glass and a glass slide, such as is used for blood and sputum, will be found to be exceedingly helpful in studying the exanthem. The rash first makes its appearance on the sides of the neck, upper part of the chest and face; thence spreads to the arms, upper part of the back, and finally involves the trunk and lower extremities. Its color is not scarlet, but a dull red, almost a brownish-red (Fig. 3, Plate IX). This color varies proportionately to the fever, being more marked usually in the evening. The general characteristics of this rash about to be described, will always be found present in a true case of scarlet fever, even though certain modifications or variations are observed. Close inspection of the rash resolves it into two factors, which are con- stantly present: 1. An erythematous background; 2. small, deep red, injected puncta (Fig. 5, Plate IX). Sometimes variations in the rash just described are present which give a diffuse, a mottled, or a speckled appearance. These changes are caused either by the closer merging or by the non-extension of these puncta with their erythe- matous areola. A normal or pale flesh tint is seen on pressure with a glass slide early in the disease, while later there is a dirty, yellowish- reel pigmentation. Itching is quite a constant symptom, but is more marked when many groups of miliary vesicles are present. At the height of the eruption, it is often possible to find small pin-point, conical, whitish vesicles, with a serous content over the chest and lower abdomen (Fig. 1, Plate IX). When they occur in groups about the axillae or in the groins, they are quite confirmatory from a diagnos- tic standpoint. The harsh, uneven feel which the rash occasionally gives to the hand passed over the skin, is due to papular or even vesicu- lar elevations occurring at the sites of the hair follicles This papula- 234 DISEASES OF. CHILDREN. tion affords another valuable aid, as it does not disappear with the erythematous rash, but the roughness of the skin persists after it has faded. Certain regional characteristics are present in this exanthem, which, if appreciated, tend to help the puzzled physician. The face, for example, shows the true rash only on the temples; the cheeks are profusely red, but the nose, chin, and upper lip appear unduly pale, causing a circum-oral pallid ring which should be sought for in sus- pected cases, as it is not present in the counterfeiting rashes. The flexor surfaces of the joints deserve careful scrutiny and special mention. These regions rarely exhibit the characteristic rash; they are apt to be the site of petechial hemorrhages or else they have a blotchy appearance. If the palms and soles are examined with the magnifying glass, no puncta are seen, only a simple erythematous blush. Desquamation. — In the exfoliation of scarlet fever we expect to find it occurring in the order of the appearance of the exanthem. At first there are observed fine discrete scales in the infraclavicular and episternal regions (Fig. 6, Plate IX). These scales are made up of the epidermal covering of the above-described puncta and vesicles. When desquamation first occurs flakes having a perforated center are cast off. This is known as "pin-holing." Later, and continuing for five to seven weeks, the skin becomes rougher, throwing off irregu- lar rings of desquamation of varying extent. The large strips of epithelium and casts of the hands and feet which are sometimes shed or torn away are more often seen in those subjects who have a skin of coarse texture. Another diagnostic feature of this stage of desquamation is seen in the finger-nails. If the pulp is pushed back from the nail, there will be seen just beneath its free border, a scaling or cracking line which extends up to the fingers. Four to five weeks after the begin- ning of the disease, we may find a transverse linear groove sometimes with a corresponding ridge, which shows itself on the roof of the nail. The thumb-nail exhibits this condition better than the fingers. These nail changes serve as corroborative evidence in the subsequent diagno- sis, and this desquamation may be seen on the nails when other evi- dences are not found elsewhere. On the other hand, it must not be forgotten that the desquamation may be so slight as almost to escape notice. Unfortunately, desquamation alone is often regarded as sufficient evidence of the disease, and a diagnosis is based thereon. In view of the fact that so many of the erythematous eruptions produce skin exfoliation, we are not justified in this conclusion, unless we have PLATE VIII. Rash of scarlet fever. THE EXANTHEMATA . 235 1. the regional involvement; 2. the pin-holing, and 3. the nail changes, plus other pertaining clinical symptoms. The Tongue. — The tongue in the first days is usually thickly coated, and the papillae are obscured, but as the tongue clears up at the edges and tip, we can observe the enlarged papillae (Fig. 4, Plate IX) which become more and more prominent, and show at their best about the fourth day. The lingual mucous membrane now be- gins to exfoliate; the tongue becomes red, dry, and glistening. It is in the posteruptive stage that this feature is particularly of diagnostic importance. The Blood. — The blood in scarlet fever has been carefully studied, and may be of service in obscure cases, as an additional confirmatory link. The red blood-cells are gradually diminished throughout the course. A leukocytosis is present a day or two before the appearance of the rash, and the normal is regained only in convalescence. We have found this leukocytosis to be proportionate to the severity of the angina. The polynuclears are increased and the mononuclears de- creased, both relatively and absolutely. To the eosinophiles we may look for some rather characteristic variations. In the initial stages they may disappear almost entirely, while in defervescence, and later to the sixth or seventh week, 8 to 12 per cent, may be counted. Differential Diagnosis. — The Erythemata. — Erythematous erup- tions which may simulate the rash of scarlet fever are quite common; and if a careful examination and study of the rash is not made, weigh- ing with it all the clinical evidence, mistakes are easily made. The simple form of erythema results from external irritants, while the exanthem of angioneurotic origin results either from systemic disturb- ance, ingestion of certain drugs, or from specific poisons. These for- tunately have certain characteristics which should be borne in mind, for while we are not always able to distinguish them one from the other, the differentiation from scarlet may be thus made possible. One of the striking features is the tendency to recurrence, and undoubtedly many of the so-called second and third attacks of scar- latina have been in this class. In a general way these dermatoses are distinguished by the following peculiarities: They may appear in any region of the body — at one time there may be present in the erythema elements of the various exanthemata. Their type may rapidly change so that they may be scarlatiniform one day and mor- billiform the next. The puncta seen in the scarlet fever exanthem are absent. Desquamation is coarse and flaky, and recurrences are frequent. Erythema Scarlatiniforme. — This is a non-contagious derma- 236 DISEASES OF CHILDREN. titis, simulating scarlet fever in its cutaneous manifestations. It is liable to occur secondarily to other infectious diseases and to medici- nal and food intoxication. As it is important to differentiate the disease from scarlatina, its distinguishing features will therefore be given. This erythema spreads very rapidly, sometimes reaching its height in a few hours. Patches of erythema may alone be present. Under the glass there is no uniform redness. The face is rarely in- volved and the tongue shows no " raspberry" appearance. The fau- ces may be red but are not swollen. Desquamation takes place at an early date after the erythema, sometimes on the second day; it is a quick process and the scales are large, abundant, and furfuraceous. The course is brief, and there are no complications or sequela?. Such a clinical picture, especially in a child who has given a history of previous similar attacks, should exclude scarlatina. A scarlatinoid erythema may follow the use of such drugs as belladonna, quinin, chloral, chlore- ton, salicylic acid, antipyrin, digitalis, opium or veronal, especially in those patients having a drug idiosyncrasy. These eruptions almost invariably follow very quickly after the ingestion of the drug. We have seen it occur within an hour after a dose of antipyrin. The close relationship to the drug taking, is a diagnostic feature of consider- able value. Belladonna rashes are perhaps most often seen. This eruption is usually confined to the face, neck, and chest, and is only rarely generalized. It fades quickly and is rarely followed by any des- quamation. The absence of fever, the dilated pupils, the evanescent rash and the history should cause no confusion. It is well to recollect that drug rashes in general, and in contrast to scarlet fever, appear for the most part on the extensor surfaces of the extremities, and if they be present on the face, then the circum- oral ring is not observed. Moreover, they are not associated with fever, angina, or adenitis. If any doubt still exists, the repetition of the dose of medication under suspicion should be given to reproduce the erythema. Acute Exfoliative Dermatitis. — Another disease which may raise a veritable doubt in the stage of efflorescence or in the desquama- tive period is acute exfoliative dermatitis. It differs in that the consti- tutional symptoms are more pronounced than in scarlatinoid ery- thema, while the eruption appears as a general hyperemia very soon covering the entire body. The exfoliation follows in a day or two, and is general in character and intensely profuse; large papery strips being cast off (Fig. 8, Plate IX). The nails and hair may drop out before the process is complete. i PLATE IX. The differential diagnosis of scarlet fever and the Scarlatiniform eruptions. 1. Scarlet fever rash showing sudaminal vesicles. 2. The fading scarlatina eruption. 3. Scarlatina eruption, early stage. 4. Typical scarlet fever tongue. 5. The scarlet fever rash, magnified. 6. Scarlet fever desquamation. 7. The scarlatinal form of rubella. 8. Acute exfoliative dermatitis. 9. Erythema in- fectiosa. (Pisek's original plate; courtesy Archives of Diagnosis.) THE EXANTHEMATA. 237 Another disease which necessitates correct interpretation is the scarlatiniform variety of rubella; fortunately, this is not a common type (Fig. 7, Plate IX). Close inspection of the rash will disclose morbilli- form characteristics. The mild constitutional symptoms and the enlarged postcervical glands of rubella will define it. Serum Rashes. — The use of antitoxic serum may be productive of a scarlatinoid rash that is very puzzling. This is especially true when antidiphtheritic serum has been injected. The angina of the diphtheria is already present and cannot assist us, while fever and malaise supervene. We must then depend upon the following facts: That the rash frequently spreads from the site of the injection; that these rashes are often polymorphous in character and fleeting in duration. They appear on the third or fourth day, the eruption occurs usually in patches and only rarely appears on the face. A well-marked enlargement of the superficial lymph-glands in the inguinal, axillary, and epitrochlear regions will also help to distinguish this rash from scarlatina. Open wounds and especially burns are liable to direct inoculation. Many of the so-called cases of "surgical scarlet" of the older writers were probably scarlatinoid erythemas or what we now recognize as septic rashes. For our guidance in differentiation the wound is of considerable help; an erstwhile healthy wound may begin to look un- healthy, and an exudate may form upon it. The rash is very likely to first appear at or near the wound. The nearest lymphatic nodes will be found tender and enlarged. Vomiting may occur, but sore throat is rarely complained of. There are no characteristic changes in the desquamation. The septic rashes which were referred to above, occur more often in early life, and either precede or accompany a definite septicopyemia. Occasionally they may indeed be the first to call attention to the true condition of the patient. When the rash is small and macular, it may resemble scarlet fever. Its spotted character and the large macules which are seen on the extensor surfaces of the extremities with ab- sence of puncta fix the diagnosis (Fig. 9, Plate IX). A high leuko- cytosis would be confirmatory. From erysipelas scarlatina can be distinguished by the shining, glazed appearance and characteristic spreading. The Fourth or Duke's disease is of interest in this connection because of its confusion with scarlet fever, provided we accept the dictum that attacks of the Fourth disease do not protect the individual against scarlet fever and measles. The disease is described as differ- ing from scarlet fever in its longer incubation period, absence of 238 DISEASES OF CHILDREN. prodromal symptoms, such as vomiting, high pulse rate, and severe angina. The rash itself shows but little difference except that it usu- ally begins on the face and is not extensive. The desquamation, how- ever, is profuse and out of all proportion to the exanthem. Renal com- plications do not occur. As the practitioner is often called upon to offer a diagnosis at different stages of the disease, the distinctly helpful phenomena to be observed at various stages in scarlatina will be given. Preeruptive Stage. — Here the diagnosis is only rarely possible and then it can be made only in the presence of an epidemic and a history of contagion. The sudden invasion with an angina, bright red puncta seen in the roof of the mouth, and initial vomiting without satisfactory cause, may be symptoms anteceding the eruption. Eruptive Stage. — The diagnosis is at this period rarely obscure. The vomiting, high pulse rate, characteristic punctate rash, congested fauces and evidences of the " raspberry " tongue are usually conclusive, Predesquamative Stage. — The rash has faded or disappeared, and desquamation has not yet begun. Here the distinctively glazed, papillated tongue and the injected fauces are seen. The enlarged lymph nodes beneath the maxilla are tender to the touch. The skin looks dirty yellow under a glass slide, and has a distinctly dry and uneven feel. Sudamina or miliary vesicles may be present in groups. Desquamative Stage. — When the disease is seen late, exfoliation beginning on the face may be found on the fourth to the sixth day of the disease, and on the neck and chest about the twelfth to the fourteenth day. On the palms of the hand and soles of the feet it per- sists sometimes for weeks; this possibly serving to differentiate it from the scarlatiniform erythemas. " Pin-hole" scaling on the body and the lines on and beneath the finger-nails strengthen the diagnosis. It is not uncommon to find still further corroborative evidence at this stage in complications of the kidneys, joints, in the ear or in suppur- ating cervical glands. Prognosis. — In the mild cases this is extremely good. The septic cases in the epidemics raise the mortality. In this country the mortality in several epidemics averaged 3 per cent. Nephritis is the most common complication and often a fatal one through uremia. The chronic form reacts badly to treatment and often ends in death. Otitis and its complications may result in deaf-mutism or have a fatal issue through the involvement of the brain or sinuses. The in- volvement of the serous membranes of the heart or joints tends to a grave prognosis. The older the patient the better the prognosis. THE EXANTHEMATA. 239 Treatment. Prophylactic. — The routine examination of school children which is now practised in a number of the largest cities, will notably tend to diminish the number of scarlet fever cases and pre- vent epidemics. Isolation should be insisted upon, and be carefully carried out even in mild or suspected cases. Children or even adults who have been subject to pharyngitis or tonsillitis are more likely to take or spread the infection. Air and sunlight should be regarded as the best disinfectants. Children from whom enlarged tonsils and adenoids have been previously removed are less liable to such complications as otitis and sinusitis. Sick-room and Quarantine. — A quiet sunny room that can best be used for purposes of isolation should be selected. An open fire-place is preferable to any other form of heating. All unnecessary furniture should be removed, a gown or sheet and a bowl of bichlorid of mercury (1-1000) should be placed in readi- ness in an empty closet outside of the room for the use of the doctor. During convalescence toys of little value, that can be burned, should be provided so that the period of quarantine which is usually six weeks may not be too irksome for the child. Disinfection can be carried out as described on page 312 when the patient is ready to* be discharged. Routine Measures. — All cases of scarlet fever, whether mild or severe, should be regarded as dangerous, as the complications and se- quelae may permanently injure the patient. Skilled nursing will do more to promote the comfort, progress, and the prevention of complications than remedial measures. If circumstances will not permit of a trained nurse, some one member of the household should be put in charge and given careful instructions as to the quarantine regulations and written orders for the patient. The diet should consist wholly of milk in the first few days of the illness, later for the sake of variety fruit juices, whey, buttermilk, or matzoon may be added or substituted. When convalescence is established, gruels, crackers, well-toasted bread, and apple sauce may be added to the dietary. Vegetables and eggs are allowed in the fourth or fifth week if there is no fever or other contraindication. Water should be offered often and freely throughout the illness. The skin should be annointed with a 5 per cent, boric acid oint- ment or with liquid albolin daily as soon as desquamation is estab- lished. If the pruritis is troublesome a 1 or 2 per cent, carbolic acid ointment will be effective in its control. 240 DISEASES OF CHILDREN. The nasopharyngeal toilet should be made daily with a mild alka- line antiseptic or a normal saline solution. The method employed will depend upon the age of the child. Those who are old enough and willing may gargle. A spray or irrigation is necessary for the ob- streperous or septic cases. The solution may be instilled with a medi- cine dropper into the nares of infants. The Urine. — A specimen should be obtained for examination (see Methods, page 445) three times a week. If this is done the com- plicating nephritis will be detected ear y and proper measures can be taken at once. Symptomatic Treatment. — The fever, if high, above 104° F., can be controlled by sponging with water 85° to 90° F. every two or three hours. Cool packs are rarely necessary except in those cases in which there is considerable restlessness and delirium. The child may then be wrapped in a sheet as described on page 68 and left in this for a few hours if sleep is produced. Heart. — Persistent high fever, especially in the septic cases, may weaken the action of the heart so that the pulse becomes soft and somewhat irregular. The first sound is not distinct and the pulse rate becomes high. Stimulation with strychnia alternating with the tinc- ture of strophanthus is now indicated. Alcohol in the form of sherry wine (vini xerici) may be substituted profitably in the septic cases. One to two ounces may be given diluted in water or milk during the twenty-four hours to a five-year-old child. Normal salt solution, two to three ounces, given by hypodermoclysis may tide over a criti- cal period. The bowels are kept open preferably with the effervescent citrate of magnesia. Constipation which is so often present on a strictly milk diet will not be so troublesome if the dietary is varied as out- lined above. The milk of magnesia may be added to the bottle in infants. Complications and Sequelae. — The cervical adenitis which so often occurs requires the use of ice-bags in the early stages. Ichthyol ointment 20 to 30 per cent, in lanolin is applied daily when the acute symptoms have subsided. The abscess must be incised and drained if fluctuation denoting suppuration is detected. Nephritis will necessitate the continuance of a liquid diet, alkaline diuretics, and in the graver cases high colonic irrigations of saline solution twice a day until the normal amount of urine is reached. Otitis. — The ear drums should be examined every other day as a routine measure, and any redness and bulging should receive prompt treatment by incision and drainage as outlined on page 567. If THE EXANTHEMATA. 241 this is done, chronic otitis and mastoid infections with their sequelae may be avoided. Arthritis occasionally occurs as a complication which prolongs the convalescence, and if neglected may cause joint deformities (Fig. 68). Aluminum acetate solution, N.F., applied as a wet dressing, with small doses of phenacetin, may arrest the inflammatian and control the pain. If suppuration takes place surgical intervention is necessary. At the Willard Parker Hospital good results have sometimes been obtained by immobilizing the inflamed joints with plaster of Paris. Fig. 68. — Arthritis, following scarlet-fever, in left hip-joint. The Serum Treatment. — Except in those cases which by culture give evidences of an added Klebs-Loeffler infection, serum therapy as thus far elaborated is without value. Diphtheria antitoxin then should be administered in those cases only in which a true diphtheria is present. Small -pox. (Variola). Definition. — Small-pox is an acute contagious disease characterized by a period of incubation, a prodromal stage with intense constitu- tional symptoms, followed by a progressive eruption of macules, pap- ules, vesicles, pustules, and cicatrices. J6 242 DISEASES OF CHILDREN. Etiology. — Specific. — Councilman in 1903 discovered a protozoan in the skin of small-pox patients The relation of these parasites to the skin lesions is of such a definite and intimate character as to lead to the conclusion that they are the cause of the disease. They have a double life cycle, intracellular and intranuclear, which they undergo in the epithelial cells. In the first cycle they are small homogeneous bodies found in vacuoles in the cells of the lower layer of epithelium, and develop there into large ameboid multi-chambered organisms, destroying the epithelial cell and by segmentation breaking up to form the protozoa of the second cycle. These invade the nuclei of other, epithelial cells and continue their growth until the cell is de stroyed. The parasite has not been found free in the vesicle contents, nor anywhere, as yet, except in prepared sections of the skin. Non-specific. — The contagium exists in the secretions and excre- tions, in the skin lesions, and in the dried scales and crusts that come from them. It clings to everything with which it comes in contact, and may therefore be transmitted by a third person; all public places are thus dangerous for an unvaccinated individual during an epidemic. It is probably contagious during the prodromal stage as well as through- out the course of the eruption an desiccation. A very virulent case of variola may be contracted from the mildest varioloid. Vaccination protects for a variable time (six years to a lifetime) in different individ- uals, and always lessens the danger and severity of an attack. One attack protects for life. Pathology. — The papule is seen to be a focus of coagulation ne- crosis in the rete mucosa, surrounded by an area of active inflamma- tion. The vesicle is made up of numerous recticulae and spaces which contain serum, leukocytes, and fibrin. When the pustule involves the true skin a permanent scar results. Incubation. — Twelve to fifteen days. Prodromal Stage. — Three or four days. Symptomatology. Description of Prodromal Stage. — This is ushered in with convulsions, vomiting or a chill, and in older children severe frontal headache and backache are complained of. The tem- perature quickly rises from 103° F. often to 106° F. The pulse becomes rapid and full, and within twenty-four hours there may be delirium and marked restlessness. This condition continues with no di- agnostic signs on the skin usually for four days, when the eruption appears. Simultaneously there is a fall of temperature even to normal in the less severe cases, and marked improvement in the general symptoms. The Exanthem. — At first the exanthem is in the form of small PLATE X. Differential diagnosis of variola and varicella, (a) variola; (6) varicella. THE EXANTHEMATA. 243 raised red papules, most commonly developing on the forehead, particularly at the junction with the hair, and on the wrists. They rapidly extend to the rest of the face and to the extremities, in- cluding the palms and soles, and in less numbers to ihe trunk. They all come out in one crop within twenty-four hours. They feel hard and have the so-called "shotty" touch, because they extend deeper into the skin than other papules, as, for instance, those of chicken-pox. These same red papules are to be seen on the hard and soft palate and pharynx causing an accompanying sore throat. In two days, sometimes less, the papules on the skin become vesicular with a slight depression in the center of each vesicle, and if pricked with a needle they do not collapse because they are divided into many parts by a reticular construction. They still have an indurated red- dened base. On the eighth day of the disease, four days after their first appearance, the vesicles become full and rounded and the serum in them changes to pus. The skin becomes tense and swollen, and the individual lesions enlarge, so that in the severe cases (confluent form) they coalesce and the face appears much swollen and changed beyond recognition. This is accompanied by a second rise of tem- perature (secondary fever), and a return of the constitutional symp- toms with redoubled vigor. The delirium returns, the pulse grows weaker, and the patient shows every sign of a severe intoxication. In the fatal cases this may go on for two or three days with increased severity until death results. But in the milder cases, within twenty- four to thirty-six hours after maturation takes place, the pustules break and the pus exudes, and on the tenth or eleventh day the tem- perature begins to fall by lysis. The pustules rapidly dry with the formation of crusts, and usually during the third week the temperature becomes normal and the desiccated pustules alone remain. These may adhere for a week or longer until at last they fall off and leave the scar or pit which may, especially in the confluent form, be carried throughout life. A leukocytosis occurs in the pustular stage, but at no other time unless there is some complication to cause it. Variat ons, Complications, and Sequelae. — There are really four forms of small-pox, differing chiefly as to their severity; varioloid, discrete, confluent, and hemorrhagic small-pox. ■ Varioloid is a pox modified by a previous vaccination, and does not often occur in chil- dren, since a child that has been successfully vaccinated is generally immune until after puberty. The mild discrete form is also unusual, because in unvaccinated children small-pox is apt to run a very severe course. These two forms are mild and differ only in degree. The symptoms are all milder than in the other two forms, although the 244 DISEASES OF CHILDREN. initial temperature may be high. The papules are fewer in number, particularly on the face, and do not coalesce. The disfiguration is less. There is less secondary fever from suppuration (in varioloid often more) and convalescence is there ore much more rapid. In the confluent form the eruption is apt to appear earlier, about the third day, with a lesser fall of temperature upon the advent of the eruption. There is more swelling and distortion of the eatures during the suppu- rating and coalesc ng stage and more pain. Delirium, ceaseless, rest- less movements, and other nervous manifestations are prominent in children. Diarrhea is also peculiar in children. The larynx and pharynx may be greatly swollen. Edema at times being the cause of death through suffocation. The cervical glands are much swollen and may suppurate. Hemorrhagic small-pox may show itself either before the real eruption appears or at the time of suppuration and secondary fever the earlier the hemorrhage, the greater the danger. At first there are small punctiform hemorrhages. They rapidly in- crease in size, and soon hemorrhages appear from the mucous mem- branes, hematemesis, hemoptysis, epistaxis, and hematuria develop. Large conjunctival hemorrhages with deeply sunken cornea complete the picture. The pulse is rapid and the respirations frequent. On the other hand, hemorrhage into the vesicles themselves with abortion of the rash and speedy recovery even in cases that were previously con- sidered severe, have been noted. Other complications are fatal; edema or necrosis of the larynx. Bronchopneumonia is common. Heart and kidney complications are rare. Arthritis going on to suppuration, and acute necrosis of the bones have occurred. The eye may be permanently injured by inflammatory changes. Otitis media may complicate. Boils, acne, and ecthyma are apt to be troublesome sequela?. Prognosis. — The matter of previous successful vaccination is the most important item in the course and termination of small-pox. In one large epidemic the mortality of the unvaccinated was 54 per cent., while that of the vaccinated Avas ^ of 1 per cent. In chil- dren it is particularly fatal. Of 3,164 deaths in the great Montreal epidemic, 85 per cent, of these were in children under ten years. The younger the child the more serious the course, and the more fatal the outcome. The hemorrhagic form is almost invariably fatal. The more numerous the lesions on the face the more grave is the prognosis, as is seen in the high mortality of the confluent form. High fever, delirium, continued, convulsions and other nervous symptoms are particularly dangerous. Laryngeal and pulmonary complications are very fatal in children. THE EXANTHEMATA. 245 Prophylaxis. — Vaccination is the measure which, if thoroughly carried out, would eradicate this disease. The strictest quarantine regulations must be enforced even in suspected cases; all individuals exposed are to be immediately vacci- nated. The demands of school boards that all children be frequently vaccinated has been followed by the most satisfactory results. Treatment. — If the patient has not been vaccinated, and is in the incubat on stage, the ravages of the disease may be prevented and only a mild course observed, if he be immediately vaccinated. The high fever is controlled by cold sponging and the use of the ice-bag under skilled supervision. The racking pains are best controlled in children by Dover's powders. Water is freely demanded and should be freely given. Convulsions and other nervous phenomena may be prevented and relieved by insisting upon a cool temperature in the room; preferably at 65° to 70° F. The diet should be liquid during •the febrile period. A 4 per cent, solution of boracic acid should be used for the eyes, mouth, and nose. A 2 to 5 per cent, ichthyol ointment, or a wet dressing of the liq. alumini acetatis (N.F.) will very effectively control the itching in the eruptive stage. A great deal may be done for the patient during the stage of suppuration. Welch, who has had a large experience, recommends the application of a mixture of olive oil and lime-water J oz. each with carbolic acid ten to fifteen drops. Elbow sleeves will effectively prevent the child from scratching and thus causing pitting and disfigurement. Martin states that he can prevent pitting by treating each pustule by incision and drainage. The patient's strength is to be carefully watched and strych- nin prescribed at the first signs of a weakening heart. In the con- valescent stage, forced feeding will serve as the best tonic treatment. Vaccination. Definition. — Vaccination is the innoculation of an individual with the virus taken from the vesicle of a cow that has vaccinia or cow-pox. Etiology. — It is now known that vaccinia is caused by a proto- zoan which resembles that of small-pox, but which differs from the latter in that it has only one life cycle, the intracellular form described under the etiology of Small-pox. Value of Vaccination.— In the immense majority of cases vaccina- tion renders the individual immune from small-pox for many years. Before it was generally practised terribly fatal epidemics swept over different parts of the world, carrying away enormous numbers of victims. Rotch states that in the last fifteen years no deaths from 246 DISEASES OF CHILDREN. small-pox have occured in Boston in children who had been vaccinated under five years of age, and at the same time the mortality in the un- vaccinated was 75 per cent. Where small-pox is acquired after suc- cessful vaccination, even years after, it is the mild form, called varioloid. When to Vaccinate. — Every infant should be vaccinated prefer- ably between the fourth and sixth months of life, before teething has begun and before the child can disturb the dressing. An acute or a severe chronic disease is a contraindication except in an emergency. Revaccination is advisable at puberty, and at any other time when the child has been exposed to small-pox or during a general epidemic. If an unprotected child is vaccinated within two days after exposure to small-pox, it will probably not contract that disease, and if vacci- nated within five days thereafter the small-pox will be modified, and it will convert a possibly severe case into a mild one. Method of Vaccination. — Only sealed tubes or quills should be used. Boys are vaccinated on the left arm at the insertion of the deltoid, girls on the thigh or calf. The skin is carefully cleaned with soap and water and a piece of sterile gauze. It is then washed with alcohol and allowed to dry. A large sewing-needle is sterilized by heating to a red heat over a lamp or a lighted match. The skin is pulled taut without touching the place to be vaccinated and lightly scarified criss-cross without bleeding, in two places ^ inch apart, each being | inch square; the vaccine is then unsealed, applied and gently rubbed in. It is next allowed to dry for twenty minutes, care being taken that it is not contaminated at this time. When dry a piece of sterile cotton or gauze is laid over it and firmly fastened with strips of adhesive plaster. Vaccination shields should not be used, as much contaminating dust and dirt may collect under them. The dressing should not be disturbed except by the physician for the purpose of seeing if the vaccination is successful and uncomplicated at the end of the week. It should be very secure in children who are old enough to tear it off. Vaccination should be attempted at least three times with a different lot of virus each time before one should say that the child cannot be successfully vaccinated. Description of Normal Course. — The scarified area appears to be healing with no general symptoms until the third to fifth day. when a small papule develops at the sight of inoculation. This increases in size, and after one or two days develops into a large vesicle with a raised margin and depressed center, the whole surrounded by a red areola. By the eighth day it has attained its maximum, and on the tenth day the contents are purulent. The surrounding areola is extensive, swol- len, indurated, and painful. The axillan^ or inguinal glands, according THE EXANTHEMATA. 247 to the site of vaccination, are large and tender. On the eleventh or twelfth day the hyperemia diminishes and the pustule begins to dry up, and by the end of the second week only a brown crust remains; this comes off in another week, leaving a round, pitted scar. Usually on the fourth or fifth day some fever and more or less marked consti- tutional symptoms develop and last three or four days. The vaccina- tion has not been successful unless, 1. some reddened areola surrounds a typical vesicle; 2. there is some swelling of the lymph-glands; 3. some, even slight, fever and constitutional symptoms; 4. there should be a permanent scar in which even years after, numerous small pin-point-sized depressions are seen. This last characteristic is very valuable in determining the success of a vaccination for a number of years after. Variations and Complications. — The vesicle may abort and dry up in seven or eight days, in which case revaccination should be practised. Generalized vaccina at times shows itself at the end of the first week by a vesicular eruption in any part of the body. It may continue to make its appearance for five or six weeks. It is not serious, as a rule, but has been known to be fatal. Recurrences of the vesicle at the site of the original vaccination are rare. Reinoculation occurs in children who have scratched the original vesicle and then vaccinated themselves in different parts of the body. Infection with other organisms results from 1. contaminated virus; 2. lack of asepsis in vaccination; 3. traumatism and contami- nation during the vesicular stage. If the vesicle is not ruptured it is not liable to be contaminated, but with a sterile dressing over it there is double protection. The results of contamination may be ulceration more or less severe, or even an extensive necrosis; suppura- tion of the lymph nodes; septicemia or suppuration in the joints. Tetanus, syphilis, and tuberculosis are almost never seen now that animal lymph is used. Other complications are eczema, general urti- carial or scarlatiniform erythematous eruptions. These may occur from the first to the fifth weeks. Varicella. {Chicken-pox.) Definition. — Varicella is a short, mild, contagious disease, with a long period of incubation, a short prodromal stage, followed by an eruption of superficial papules going on to vesiculation. Etiology. — No specific microorganism has yet been discovered. It is an independent disease not closely allied to small-pox. It does 24S DISEASES OF CHILDREN. not protect from small-pox, nor does small-pox protect from it. The disease is most common between the ages of two and six years, and is rare after puberty. It is communicable on slight, short contact, the mode of entrance not being known. Pathology. — The papule and vesicle is near the surface, being formed by the upper layer of the epidermis. The vesicle is seldom multilocular, and unless deeper ulceration takes place, which occasion- ally occurs, it does not leave a scar. Incubation. — Ten to eighteen days, usually fourteen days. The prodromal stage lasts about twenty-four hours. Description. — After a day of slight malaise, with perhaps a tem- perature of 101° F. to 102° F., a few red papules, varying from pin-head to pea-size, are seen anywhere on the body. Usually they are few in number and scattered over the face, trunk, and extremities. The temperature may be lowered a degree or more after the eruption comes out, but the patient still has some constitutional symptoms. A slight sore throat is the rule, as a few of the same isolated red papules appear on the fauces and pharynx. Within a few hours vesicles take the place of the papules which first make their appearance, and at the same time another crop of papules appears scattered here and there, between them. This process continues three or four days, so that at any one time the lesions in their various stages may be seen as small and large papules, beginning vesicles, large full rounded vesicles, and those that are drying up. They may be an inch or two apart, or they may be much closer together. They usually have no umbilica- tion, feel soft to the touch, and collapse when pricked with a needle. As a rule, they do not go on to pus formation, but contain a clear, or at most, a slightly turbid fluid. After two or four days they dry up, the temperature is normal, and convalescence is established. Variations, Complications, and Sequelae. — Many children show little or no constitutional symptoms. Rarely there may be a high fever, even to 105° F., and corresponding symptoms, but this is the ex- ception. In some cases the eruption is profuse on the vulva and nates, with consequent vesical and rectal tenesmus. Occasionally one or two of the vesicles become infected and more or less deep destruction of tissue results. Cases of high fever and pustulation of all the vesicles, lasting a week or longer, have been reported. A depression in the center of each vesicle, that is, umbilication, is not typical, but it occurs often enough to be misleading in differentiating an atypical case from small-pox. Albumin in the urine is not uncommon, but true nephritis is rarely seen, except in an unusually severe case. Acute simple inflammatory o a i c 02 M o CO O o e = Red papules on palate and fauces. Slight malaise. Papules rarely hard, becoming vesicular in a few hours. Seldom umbilicated always collapsable. Individual lesion completes cycle in 2 days. Irregular and general distribution comes in successive crops so that all stages may be seen at the same timeinany one locality. As thick on trunk as on face. Crusts, no pitting. German Measles. Small-pox. > - — — c — e r. > z ■*- — » CO > - — » Red papules on pal- ate and fauces. Sudden onset. In- tense symptoms. Backache. Hard shotty pap- ules in 2 days be- coming umbili- cated noncollaps- able vesicles and in 4 days pus- tules. Total cycle, (> days. Appears first on forehead and wrists. Spreads on face, then on arms. Scattered on trunk. All in same stage of evo- lution. ; co c a CO o " r. u - z — — p Not hing typical. . . . Slight or none at all Slightly raised red macules not co- alescing. Appears first on face. Spreads to whole body. 6 c c c o .bJO 53 CO X H 00 o h BO - r. . >> DO Bj >.— ~ Q ~ 2 a >> X r > _r s- C ■» 1 b£ +i z -/. w G c . od -— S! — z go a At first isolated red papules coalesc- ing with intervals of normal skin, giving a blotchy appearance. Appears first on face. Spreads to whole body. CO p O 02 ej 03 02 c o > 02 -^ u TI C3 TJcN - C — c — Intense hyperemia and typical punc- tate rash on fau- ces and posterior pharyngeal wall. Raspberry tongue Sudden onset with intense-symptoms Sore throat . Yom iting. Convulsions Uniform erythema wi th m inut e puncta. Appears first on chest, spreading to rest of the body. Least in- tense on face. Large flakes and sheets pin-holed. c i 3 2 3 ) o b a +. V a E c *. c s. - ) E i > i > co O c £ 5 * « h |l i o o £ fe ° ° c •S * CO £ 5 c t-t c o Fh o 03 i~ 03 Q "o >> A a t . g,3 H r s E 7 1 P r 1 250 DISEASES OF CHILDREN. involvement of the joints, lasting only a few days, has been noted. Otitis and pneumonia are rare complications. Prognosis. — Recovery to is be expected after a short mild illness. Treatment. — To prevent the transmission of the disease, isolation from other children should be insisted upon, for although the disease is mild it occasionally produces some serious consequences. The child should be kept from scratching the vesicles to prevent infection by the finger-nails. An initial dose of 1 gr. of calomel, and a liquid diet are the only measures, as a rule, required during the illness. Diphtheria. Diphtheria is an acute infectious disease due to the growth and ac- tion of the Klebs-Loefner bacillus on a vulnerable surface producing a local membrane and general toxic symptoms. Etiology. — The disease is endemic in large cities. Local epidemics frequently occur in small towns and villages. Statistics show the disease to be more prevalent in the winter and fall than in the summer months. In fact, vacation periods show a falling off in all infectious and contagious diseases. The disease is contracted directly or indirectly from another case of diphtheria. The indirect means are usually the handling of infected objects and attendants who do not take proper precautions. Even contaminated food, such as berries and milk, have been known to infect the consumer. There is no discrimination as to sex; age, however, plays an important part. Nurslings possess con- siderable immunity. The third to fifth year is the period of greatest liability. From the tenth year to puberty, the susceptibility markedly decreases. Children of the so-called "lymphatic diathesis" are par- ticularly vulnerable, as are those who have been weakened by pre- vious diseases. Pathology. — The pathology is in the main that of the pseudomem- brane. . This is a true coagulation necrosis, wich may be situated upon the pharynx, nasopharynx, larynx, or trachea. More rarely it is found upon the mucous membrane of the nose, conjunctiva, or vaginal membrane. The bacillus or its toxins circulating in the blood may produce myocardial changes of a fatty or degenerative nature. The cervical lymph nodes show a simple cell hyperplasia. The involve- ments of the lungs and kidneys must be regarded as complications. Symptomatology. — The symptoms differ as they are the results of a pure or a mixed infection, and as to the anatomical distribution of the pseudomembrane. The mixed type is usually an association of the Klebs-Loefner bacillus with the streptococcus as in scarlatina. PLATE XI. Differential diagnosis of (a) follicular tonsillitis; (b) scarlatinal angina: (c) diphtheria; (d) lacunar tonsillitis. THE INFECTIOUS DISEASES. 251 The general symptoms of any of the forms of diphtheria are dependent upon the degree of toxemia. The attack is usually ushered in with vomiting or a chill. There is no characteristic temperature curve. The fever is of a low grade, 101° to 102° F., in uncomplicated cases. The pulse rate is increased in direct proportion to the youth- fulness of the patient. Lassitude or somnolence in various degrees may be observed before local lesions are suspected. The quantity of urine is diminished, and traces of albumin are found in a large proportion of the cases. The blood shows a hyperleukocytosis, especially in the polynuclear elements. The red blood-cells and the hemoglobin are correspondingly diminished. Diphtheria (Tonsillar and Pharyngeal. — In this type the clinical manifestations vary from those of an extremely mild variety to severe toxic cases. The child may not complain of any sore throat and the membrane may be found only on routine examination. On the other hand, there may be low fever, vomiting, and some difficulty in swallowing. Examination of the throat, which should always be done with the best possible light and with a curved tongue depressor, may show membrane in the form of a grayish-white patch on one or both tonsils. The tonsils may be enlarged and congested. The uvula or adjacent pharynx soon become involved (see Plate XI). A grayer or dirtier colored membrane is seen after the third or fourth day. In severer cases the uvula, posterior pharynx, and fauces show the characteristic membrane. The general symptoms are now more aggravated, due to the toxemia; prostration is marked. The glands of the neck enlarge and become painful. There is dysphagia and difficulty in enunication. There may be delirium. The breath is offensive and quite characteristic. The pulse is rapid and feeble. The temperature is irregular and at times high. If in this form we have the added complication of a mixed infection the toxemic symp- toms are still further aggravated, becoming those of a true sepsis. Complications are then apt to supervene early, and the kidneys almost invariably suffer. Differential Diagnosis — Tonsillar diphtheria must often be dis- tinguished from a follicular tonsillitis, especially if the exudation from the crypts has merged, and seemingly forms a membrane. This is especially necessary in the absence of a bacteriological diagnosis. (Plate XI.) In follicular tonsillitis, both tonsils are usually involved simul- taneously. There is an initial high temperature of 104° to 105° F. Usually there is no vomiting. Careful inspection will reveal isolated crypts distended with their cheesy detritus. The pseudomembrane 252 DISEASES OF CHILDREN. can be readily removed. The diphtheritic membrane, on the other hand, adheres closely and leaves an excoriated and bleeding surface if forcible attempts are made to remove it. The bacteriological diagnosis should be made whenever feasible, but the returns should not be waited for except in extremely mild suspicious cases. The bacteriological examination may be made with a smear prepara- tion stained with Loeffler's solution and directly examined, or by inoculating the tube of blood serum and examining the growth after twenty-four hours of incubation. The precaution should be observed to take the culture before any antiseptics have been applied, or at least within some hours thereafter. Laryngeal Diphtheria. — In this form the membrane may extend from the nose or throat, or it may primarily involve the larynx. In the latter case there are symptoms clue to congestion of the mucous membrane of the larynx and the vocal cords; that is, a hoarse inspiratory cough, some restlessness and a low grade of temperature. Cultures, if taken at this stage, are usually found to be negative, especially if a laryngeal swab is not correctly used. As the disease progresses symptoms of obstruction are apparent, due to the forma- tion of the laryngeal membrane which is sometimes visible about the epiglottis. The cough is more aggravated and paroxysmal in character; the patient acts as if attempting to dislodge an irritating foreign body. There is partial or complete aphonia with a muffled or supjDressed cough and whispering voice. The accessory muscles of respiration are brought into requisition. The periods of remission from coughing become shorter and shorter in duration, and are easily brought on by disturbing the patient. If the child falls' into a restless sleep, the symptoms are less noticeable, but do not in any sense resemble the normal. The pause between inspiration and expiration is noticeably prolonged. The supraclavicular, epigastric, and diaphragmatic spaces show marked recession at the height of inspiration. The mucous membranes and nails are cyanosed. Unless relief is now obtained, extreme restlessness sets in, and the child attempts in every way to get air; it is markedly cyanosed, a cold perspiration appears on the forehead, stupor supervenes with spasmodic breathing, apnea, and death. In certain cases the membrane may extend to the trachea, even beyond the bifurcation of the bronchial tube (see Fig. 69). Differential Diagnosis. — We have abandoned the term croup as applied to diphtheria as it only tends to misleading conceptions, and perhaps to serious mistakes in management. Clinically, the diagnosis THE INFECTIOUS DISEASES. 253 should be based upon the character of the cough, the aphonia, the muffled cry, the progressive signs of laryngeal obstruction, and the recession of the thoracic spaces. In non-diphtheritic laryngitis the child is taken suddenly ill at night with an attack of suffocation and a brassy, barking cough. Ordinary remedial measures, such as steam inhalations and -emetics, give speedy relief, with the resumption of Fig. 69. -Cast of the trachea and bronchi expelled from a case of laryngeal diphtheria. normal breathing and apparent health during the next twelve to twenty-four hours, when a second milder attack may supervene. Edema of the lungs, especially when it early complicates a broncbo- pneumonia, may simulate an attack of laryngeal diphtheria. The physical signs must be depended upon to clear up the diagnosis. Nasal Diphtheria. — This form is usually seen in children of the school age, and unfortunately the cases are not recognized and isolated as early as they should be. Children with nasal diphtheria are undoubtedly great carriers and disseminators of the infection. The 254 DISEASES OF CHILDREN. disease should be suspected in cases of intractable or aggravated rhinitis m which there is a mucopurulent, blood-tinged discharge, accompanied by evidences of nasal obstruction. The nostrils and upper lip are often excoriated. The children are not sick enough to want to go to bed and may have little or no fever. The use of the nasal speculum will often show the membrane in the nares. It is usually in shreddy patches rather than in firm membranous masses. The glands at the angle of the jaw are moderately enlarged. A culture should be made in all suspicious cases. If the posterior nares is involved by extension from the pharynx, the prognosis is graver, as it tends to lessen the respiratory ability and the willingness of the child to take food. The toxemia is likewise greater, and the cardiac muscle soon weakens. Conjunctival Diphtheria. — As in the other forms, this may be primary or secondary to the disease of the nose or throat. The course is extremely rapid. There may be a profuse purulent discharge with marked edema of the eye-lid; the conjunctiva is clouded with a thin membrane of a gray color which adheres closely and bleeds easily if attempts at removal are made. These local symptoms are accompanied by an increase in the tem- perature and pulse rate and by somnolence due to the toxemia. Complications. — The respiratory tract, the nervous system and the heart are the greatest sufferers from the toxemia of diphtheria. Pneumonia is a frequent complication, especially in badly nourished children or in those that have been intubated. The mixed infections predispose to this complication, especially in those under two years of age. Postdiphtheritic paralysis occurs in about one-fifth to one- seventh of all cases. The common form is the local paralysis of the palatal group of muscles; it may come on early or late in convalescence. The symptoms are regurgitation of liquids through the nose, dysphagia, and dysarthria. The uvula is found relaxed and not supported by its muscles. In the severer forms the physiological action of the pharynx and larynx is disturbed. The muscles of the lower extremities and the eye may be involved in the paralysis. The patellar reflexes are lost, and there may be anesthesia of the lower extremities. Only rarely is there paralysis of the upper extremity as a part of the general paralysis. If the branches of the vagus are involved cardiac irregularity is noticed, and vomiting and pains in the abdomen are complained of by older children. There is a tendency to sudden death in these cases. Neph- ritis occurs as a result of the toxemia and as it often appears insidi- ously without puffiness or anasarca, the urine should be carefully watched. THE INFECTIOUS DISEASES. 255 Prognosis. — This must be formed by a consideration of the patient's age, his resistance, the location of the membrane, whether of the pure or of the mixed type, and the time of the serum administra- tion. The following are the mortality statistics from the Boston City Hospital. (Cases treated with antitoxin.) Under five years, 20 per cent, of all cases. Five to ten years, 8 per cent, of all cases. Ten to fifteen years, 3 per cent of all cases. Exclusively nasal cases offer the best prognosis. Uncomplicated tonsillar or pharyngeal cases rank next in a good prognosis. Laryn- geal cases are the least favorable, especially when the necessity arises for intubation or tracheotomy. In private practice, where the cir- cumstances are the most favorable, the mortality has been reduced to less than one-third of all cases. Antitoxin has been the means of reducing all the mortality statistics; and if given before the fourth day of the disease the prognosis is very favorably influenced. Treatment. — The management may be divided into the prophy- lactic, general, serum, local, and operative treatment. Prophylactic. — Immunization with antitoxin assumes the first place in prophylactic treatment. The immunity lasts from three to four weeks and, as conclusively proven by the statistics from the New York Board of Health and elsewhere, has saved many lives. Thir- teen thousand persons received immunizing injections through the New York Department of Health; of these only three-tenths of 1 per cent, had a subsequent mild grade of diphtheria, and there was only one death. Immunizing doses of 500 to 1,000 units should be given to all the susceptible individuals in a family who have been exposed. In hospitals or institutions patients may be immunized, especially if measles are epidemic. All true cases and suspected cases should be carefully isolated, and disinfection practised as is indicated in the special article on this subject (page 312). General Treatment. — The child should be placed in bed in a well ventilated, sunlit room, capable of separation from the rest of the house. Cool liquid or semisolid foods, such as milk, ice cream, junket, etc., should be offered at short intervals. Cold compresses are useful to mitigate the dysphagia, while light ice-bladders are often agree- able and efficacious when applied to the neck, particularly in glandular cases. The bowels should be kept open with calomel or salines. The urine should be examined at least bi-weekly. Strychnin sul- phate in doses of from ^ to T fo of a grain, according to the age of the child and the necessity for stimulation, may be given every two 256 DISEASES OF CHILDREN. to three hours. Whisky may be alternated with the strychnia in toxemic cases with irregular heart action or bradycardia. Small doses of morphine ^ to y 1 ^ of a grain are often efficacious in control- ling the restlessness, and at the same time acting as a tonic to the heart. Infusions of normal saline solution have been of material assistance in saving desperate cases. Bromid of sodium if not contraindicated by the heart's action is of value as an antispasmodic before extuba- tion in laryngeal cases. Paregoric or Dover's powder in small doses may be given for the same purpose. Serum Treatment. — Antitoxin should be given in all cases of diph- theria or those suspected of being diphtheritic. In its improved form there are no contraindications to its use. Two thousand units should be given in mild cases of faucial or nasal diphtheria, and re- peated with a double dose in twenty-four hours if the false membrane has not shown signs of disappearing; three to five thousand units may be the initial dose in severer cases. In laryngeal diphtheria 5,000 units in infants and 10,000 units in older children should be given at once. The dose should be repeated in twelve hours in cases of stenosis if the respiratory difficulty is not ameliorated. Larger doses must be given if the disease is seen in its later stages. Immunization is satis- factorily accomplished with injections of 500 to 1,000 units, according to the age of the child. The loose tissues under the pectoral region or over the right or left iliac region may be selected for the site of the injection. The skin is made surgically clean, and the antitoxin injected with a large sterile syringe and needle. The wound should be sealed with collod- ion. The pseudomembrane after the injection of antitoxin slowly tends to detach itself. In laryngeal cases, in which the membrane is not seen, the decreasing symptoms of obstruction give evidences of its good effects. The hypertrophied lymph nodes decrease in size, and the general symptoms are all improved. An eruption in the form of an erythema or urticaria sometimes follows the injection of antitoxin. This is attributable to the horse serum itself. A scarla- tiniform or macular rash is occasionally observed. The improved concentrated preparations rarely produce skin manifestations. We have successfully used the serums prepared by Mulford & Co., Parke Davis & Co., and the New York Board of Health. Local Treatment. — The curative effect of antitoxin has superseded the use of the strong antiseptics which were formerly locally applied to the membrane. In older children (those who can gargle) the use of a mild antiseptic solution, such as diluted Dobell's solution, listerine, or a common salt solution, will assist in removing the loosened mem- THE INFECTIOUS DISEASES. 257 brane. Younger children are markedly benefited by irrigations of salt solution especially in nasal diphtheria (half a dram to the pint) used at a temperature between 100° F. and 115° F. An ordinary fountain bag is used, placed about two feet above the patient's head, who lies on his side, prepared as for intubation (see Fig. 70). A small nozzle is then placed in one of the patient's nostrils and the water allowed to flow for a minute or two, with intermissions to allow for expulsion and breathing. If done in this way, the child soon becomes accustomed to the process and is not badly frightened, and much relief is obtained. In certain cases the nozzle may be inserted behind the back teeth, and the mouth thus irrigated. If the bag is not placed too high the pressure will not be sufficient to carry infection through the Eustachian tube. Fig 70. — Position of the patient in intubation. An ice-bag applied to the neck in cases of tonsillar diphtheria affords relief and tends to inhibit the growth of the membrane, and to reduce the swollen lymph nodes. Laryngeal cases are often relieved by swabbing away the col- lected material at the head of the tube, an ordinary laryngeal appli- cator being used for this purpose. Diphtheria affecting the con- junctiva must receive as close attention as a case of gonorrheal conjunctivitis besides the injection of large doses of antitoxin. Intubation. — Intubation or the relief of laryngeal stenosis by the insertion of a tube was perfected by Dr. Joseph O'Dwyer, of New 17 258 DISEASES OF CHILDREN. York, in 1SS3. The brilliant results obtained have brought this moans of relief into universal favor almost to the exclusion of trache- otomy which is now rarely practised. The indications for performing intubation are as follows: Intu- bation should be performed in laryngeal diphtheria when there is marked dyspnea, restlessness, retraction of the epigastric and supraclavicular spaces with evidences of cyanosis. The child is prepared by being closely wrapped and pinned in a sheet (Fig. 70). The operation may be performed in a horizontal Fig. 71 — O'Dwyer's intubation instruments with detachable parts, in an aseptic case. position on a table or in an upright position with the child's head resting against an assistant's shoulder. A second assistant is required to hold the head in the median line and to keep the mouth gag in place, as rapidity and a certain amount of dexterity are necessary. Practice upon the cadaver, and if possible upon the living subject, should be had under the instruction of an experienced operator. The instruments used are generally those of the O'Dwyer pattern, as they conform most accurately to the anatomy of the region. They are now made of hard rubber, metal lined, in sizes according to the age of the child. The neck of the tube is held within the vocal cords, while its lower end extends almost to the bifurcation of the trachea THE INFECTIOUS DISEASES. 259 An introducer, an extubator, the tubes, a mouth gag and scale complete the set. The proper tube having been selected, a loop is made by threading a piece of strong silk through the eyelet placed in one side of its head. The child is firmly held by its head and its extremities kept from moving by a second assistant when on a table, or by the knees of the Introducer, with obturator and tube in place. assistant who holds the patient in his lap. The left index-finger is inserted and the epiglottis found and firmly held forward. The palmar surface of the finger should be presented to the tube. At first the handle of the introducer is held parallel to the child's body; it is then raised until the tube passes between the vocal cords, when it will be beyond a right angle to the body of the child. The trigger of the introducer is now used which allows the body of the tube to pass well beyond the vocal cords, the finger at the head of the tube Fig. 73. — Extractor gently forcing it into place while the obturator is being removed. The cord is still kept in place, but the mouth gag should be quickly removed. A metallic cough and the relief of the symptoms of stenosis will be the proof of success. A series of expulsive efforts followed by free inspiratory effort, disappearance of cyanosis, and a period of calm and rest for the child will follow. 260 DISEASES OF CHILDREN. Fig. 74. — Intubation tubes. I, Granulation or built-up tabes; II, ordinary tube (lateral view); III, ordinary tube (front view). Fig. 75. — The forefinger holding the head of the tube in position as the obturator is removed. (Northrup and Nicoll.) THE INFECTIOUS DISEASES. 261 Failure may result because the operator has not kept closely to the dorsum of the tongue in passing his tube, or because he has failed to keep the handle of .his instrument parallel to the child's body in the first movement toward the epiglottis. In rare instances a certain amount of membrane is pushed down before the tube, and as a result there is no relief, or there may be an increase in the stenotic symptoms. The child should then be held in an inverted position, when the Fig. 76.— Extubation. membrane usually is expelled, and the tube may then be reinserted. If any force is used damage may be done. The cord may be removed after some minutes by placing the finger on the head of the tube and withdrawing it, or it may be fastened on the side of the face with adhesive plaster. Extubation. — This should be performed as soon as there are evidences of marked improvement in the general condition of the patient as shown by decreased toxic symptoms, and a marked decrease in the laryngeal obstruction. This may occur on the third, fifth, or 262 DISEASES OF CHILDREN. seventh day, depending upon the severity of the case, upon the early use of the antitoxin, and upon the age of the child. Children under two years of age cannot, as a rule, be extubated as soon as older children. If cyanosis follows the removal of the tube, it must be quickly replaced, all the preparations having been made for this possibility. Special tubes with built-up heads and retention swells are used in cases demanding prolonged intubation (Fig. 74). They act by preventing and causing destruction of the granulation tissue. The Feeding of Intubated Cases. — Older children soon manage to take fluids and semifluids without much difficulty. Infants and younger children may be fed in a prone position, or with the head lower than the body, being fed, if necessary, by a bottle or medicine dropper for a few days. Feeding by gavage may occasionally be necessary. Tracheotomy. Indications for Tracheotomy. — Tracheotomy should be performed in those cases in which intubation has failed and the membranes are forced further down into the larynx. In cases in which the membrane forms below the tube and no relief is obtained, and in cases of edema of the glottis in which there is extensive infiltration. It may here be mentioned that intubation is far preferable to tracheotomy, and the latter operation should be performed only as a last resort or in those rare cases in which a proper tube is not retained. The operation should be performed under a light general anes- thetic. The patient should be prepared as for any aseptic operation if the circumstances allow, the neck being extended over a sand-bag and kept in the median line. An incision one to one and a half inches long is made through the subcutaneous tissue,, and then the facia and sterno- hyoid muscles are separated. The engorged venus plexus is pushed to one side and the trachea exposed. By means of a bistoury an opening is made sufficiently large to admit the cannula. (An instru- ment which will at once incise and dilate the tracheal wound is now on the market.) When free respiration is established, the cannula is fastened in place by tapes about the neck, and the wound dressed with moist gauze. A steam atomizer to moisten the respired air is helpful. The attend- ant should diligently remove the tracheal secretions deposited upon the pledgets of moistened gauze. The inner tube of the cannula should be removed and thoroughly cleansed three or four times a da} r , or whenever it is obstructed. After the third or fourth day an attempt THE INFECTIOUS DISEASES. 263 may be made to permanently remove the cannula. If the patient can get along without it, the wound is cleansed, dressed, and allowed to heal. Pertussis. (Whooping-cough.) Pertussis is an acute infectious disease characterized by a par- oxysmal cough that consists of repeated expirations ending in an in- spiratory whoop which is often followed by vomiting. Owing to its complications it must be classed as one of the dangerous diseases of early life. Etiology. — No specific organism has as yet been found which can be said to be the true etiological factor. The secretion is apparently the means of transmission from one individual to another and is very communicable. Clothing and the rooms of the patient do not seem to carry or retain the infective agent. Sporadic cases are constantly seen in large centers, and epidemics frequently occur both in urban and in rural districts. Whooping-cough is no respecter of age. It has oc- curred in the newly-born and in well-advanced adult life. Children under two years of age show the greatest susceptibility, while sucklings are in some cases immune. The period of incubation is from seven to fourteen days. The primary stage is probably the time of greatest danger to others. Pathology. — The larynx and trachea show a marked congestion and exudative inflammation of their mucous membrane. In fatal cases, areas of emphysematous lung are commonly found. Subcon- junctival and cerebral hemorrhages have been found. Symptomatology. — For purposes of convenience in description, the disease may be divided into three stages. Namely, the primary (in which the mucous membranes of the nose, larynx and trachea are inflamed), the spasmodic stage, and the period of recession. These, however, merge into each other and are not sharply defined. Primary Stage. — The exposed child after a varying period from two days to two weeks may have suffused eyes, there may be a rhinitis, and a congestion of the pharynx is often seen on examination. The child does not feel sick, but coughs severely, especially at night. It is described as having a croupy character. After a few days it becomes more pronounced at night and more frequent in the day time. Physi- cal examination at this time may give no evidences of bronchitis if this is suspected. These negative signs are valuable in leading to the true diagnosis. An increase in the mononuclear leukocytes is quite 264 DISEASES OF CHILDREN. frequently found at this time. A tongue depressor irritating the pharynx will sometimes produce the characteristic whoop, and thus confirm the diagnosis. A rise of one or two degrees of temperature is sometimes observed, especially when there is an accompanying bronchitis. Spasmodic Stage. — This is so named because of the paroxysmal cough or whoop which follows the several expiratory efforts. The child realizing the approach of a paroxysm, seeks support from its attendant or clings to some article of furniture. There are three or four violent expiratory efforts, followed by a period of apnea, and then the tremendous inspiratory effort is made which, entering through a partially closed glottis, causes the so-called whoop. During this effort the eyes have become congested, the face almost cyanosed, mucus streams from the nostrils, and a mass of mucopurulent secretion follows the whoop. Vomiting occurs if there is any food in the stomach. Relief now comes to the exhausted patient, and after a brief period of rest, during which there is sweating of the forehead and face, the child goes back to its play. These attacks may occur ten or even a hun- dred times a day. Naturally, the nutrition soon suffers; the face may later become edematous or puffy, masking the malnutrition of the body. Severe cases may have subconjunctival hemorrhages or bleed- ing from the nose or lungs. The urine may show traces of albumin and hyalin casts. Convulsions sometimes follow an exceptionally severe paroxysm, especially in infancy. In young infants the spas- modic stage begins very soon after the beginning of the attack and the "whoop" may be absent. Recession of symptoms is shown by a decrease in the number and severit}^ of the paroxysms, ending in a cough which persists for several weeks. Complications. — Bronchopneumonia frequently complicates per- tussis, especially in infancy. This is the result of an infective process made possible by the abnormal condition of the bronchial tubes and the lowered vital resistance. It generally occurs at the end of the par- oxysmal stage. Bronchitis and emphysema are complications more frequently seen in older children. Tuberculosis not infrequently fol- lows in the wake of pertussis. It may be localized (from latent bron- chial lymph nodes) or even a general miliary tuberculosis may result. -Severe attacks of vomiting reduce the general nutrition and predis- pose to more important complications. Convulsions result from con- gestion of the brain, or from minute capillary hemorrhages which may occur during the paroxysm. We have seen hemiplegia due to men- ingal apoplexy follow a severe paroxysm. Hemorrhages into the THE INFECTIOUS DISEASES. 265 conjunctiva and hernias in various parts of the body also result from the severe strain imposed by the paroxysms. Course and Prognosis. — In some cases the disease lasts only a week or two, but on the other hand, we have seen it persist beyond three months. If complications occur it is more apt to be prolonged. The mortality of this disease and its complications is higher than is generally appreciated. Infants, especially, are prone to fatal attacks of pneumonia, convulsions, and tuberculosis. Among the poor where undernourished children are most likely to be found the mortality is high. The prognosis is based upon the general condition of the child, the number, and character of the daily paroxysms, and its ability to retain food. Treatment. — Although whooping-cough, like the other infectious diseases, is self-limited, its severity can be considerably modified and its complications often prevented by appropriate treatment. Aero therapy. — The child should spend the greater part of the day out of doors in pleasant weather. If the circumstances permit removal to the seashore it is of undoubted benefit. The fine saline particles thrown up by the surf give quick relief by being inhaled. The sleeping-quarters should be well ventilated, the child being pro- tected by screens from direct draughts. Drugs. — For the control of the cough in the beginning of the spasmodic stage we have had very satisfactory results with the three following drugs, fluoroform. the bromids, and antipyrin. The treat- ment may be begun by giving two drops of a 2.8 per cent, solution of fluoroform every two hours during the day, and after each paroxysm during the night, to a year-old child. The dose may be increased by one drop for each succeeding year of age. Occasionally this is not effectual enough, or apparently the child becomes accustomed to its sedative action. The bromid of soda in two-grain doses every three hours for a two-year-old child may be substituted. Antipyrin is well tolerated, and can safely be prescribed if complications do not contraindicate. It may also be combined with the bromids as in the prescription given below. A child of six months can be given ^ grain of antipyrin at three-hour intervals, 2 grains to a two-year-old child. If it is used with the bromids the dosage must be regulated accordingly. In exceptional instances in which the paroxysms are particularly severe and are preventing rest, small doses of heroin, as indicated in the prescription below, will give relief for the night. 266 DISEASES OF CHILDREN. Fig. 77. — The Kilmer belt for pertussis. THE INFECTIOUS DISEASES. 267 For a two-year-old child: 1^ Antipyrini gr.xxxij Glycerini 3jij Aquae q. s. ad. 5ij Misce et signa. — One teaspoonful every three hours for six doses. P£ So.dii bromidi gr. xlv Antipyrini gr. xxiv Glycerini oiij Aquae q. s. ad. oij Misce et signa. — One teaspoonful every three hours for a three-year-old child — well diluted. 1$ Heroini hydrochloridi gr. g Antipyrini gr. xvj Elixiris adjuvantis oij Misce et signa. — A teaspoonful every three hours to a child of two years for three doses. Diet. — Food should be taken in smaller quantities and at lessened intervals than in health. This measure in itself prevents the vomiting which readily occurs when a full meal is taken. After vomiting, a cup of milk or meat broth may be immediately given. Only simple, light and nutritious articles should be permitted in the dietary. The inhalation of antiseptics has given us no satisfactory results. In fact, it tends to encourage poor ventilation in the sleeping apart- ment. A belt as suggested by Kilmer can be worn if vomiting is frequent. In a certain number of cases this appliance (see Fig. 77) has given relief from this distressing symptom. Mumps. {Epidemic Parotitis.) Mumps is an acute communicable disease of the salivary glands, characterized by a swelling of the parotid gland and the neighboring- salivary glands, and at times involving the testis or ovary. Etiology. — Children from two to fifteen years of age are most often affected. Epidemics are common in schools and institutions. The specific contagium has not been isolated. Close contact is necessary for its dissemination, but the disease is transmissible before the swelling appears. The portal of entry seems to be the buccal cavity. The period of incubation is an indeterminate one; it ranges from one to four weeks. Immunity is generally conferred by the one attack. Recurrences, however, do occur. Pathology. — According to Virchow, there is an inflammatory serous and cellular infiltration of the intraacinous and periacinous connective tissue, which tends to resolution without induration. 26S DISEASES OF CHILDREN. Symptomatology. — In children the onset is usually mild, with a period of malaise, drowsiness, fever of one or two degrees (only rarely 104° F.), chilliness, and sometimes vomiting. A swelling now appears below the lobe of the ear on one side of the face and in a few days the opposite gland is generally involved. The child complains of a feeling of fullness, with pain localized in the angle of the jaw. The swellings are elastic on palpation. Mastication is difficult and food may be refused for this cause. The fever ranges from 101° to 103° F. Occasionally there is earache or deafness. The swelling may extend over the parotid in front, or involve the submaxillary gland and the neighboring lymph nodes, giving the characteristic rounded appearance. The displacement of the auricular lobule with the lobe of the ear in the center of the swelling assists in fixing the diagnosis. In some instances there is little or no discomfort, and the child is not willing to go to bed. After seven or ten days the swelling subsides and entirely disappears. Relapses, however, may occur. Occasionally the swelling is very large and painful. In exceptional instances only, the submaxillary glands may alone be involved. Lvmphocvtosis is quite a constant symptom, especially at puberty (Wile). Complications. — In boys orchitis is occasionally seen, and the same may be said of ovarian pain in girls. The breasts especially in girls may be tender. When these complications do occur, the child is generally at or near the age of puberty. The lymph nodes ma}' become secondarily involved, and suppuration of the affected glands take place, but only if there has been a mixed infection. Deafness, inflammatory eye diseases and rarely nephritis are com- plications which may occur and should be guarded against. Differential Diagnosis. — Mumps should not be confounded with hypertrophied lymph nodes which present an irregular nodular swell- ing and are not found on the face. An examination of the throat or a concomitant infectious disease may account for such a swelling. In- volvement of the submaxillary glands alone, so-called submaxillary mumps, must, however, be considered. If with a history of exposure there is a large soft swelling filling up the space between the angle of the jaw and the mastoid process, and it lifts forward the lobe of the ear. The diagnosis is quite certain. Prognosis. — In this benign disease, which is rarely complicated, fatalities do not occur, and the prognosis is most favorable. Deafness sometimes results and rarely following an orchitis the testicle ceases to develop. Treatment. — As it is a communicable disease, the children should THE INFECTIOUS DISEASES. 269 be isolated. If there is fever and discomfort, a laxative is given, and the child is put to bed. Local anodyne applications of 3 per cent, ichthyol-lanolin ointment, or warm oil of hyoscyamus are applied. Often a hot-water bag is found to be very agreeable. Mouth-washes of listerin or boric acid solution should be used frequently. The bowels should be kept freely opened, and a liquid or soft diet ordered. Guaiacol ointment (5 to 10 per cent.) is soothing if orchitis is present as a complication. The patient may mingle with other children after the third week. Typhoid Fever. Typhoid fever is a specific infectious disease due to the typhoid bacillus. Etiology. — Infected drinking-water, infected milk, and contact with attendants who may be typhoid bacilli carriers are in greater part responsible for the infection in children. Irresponsible children are liable to drink contaminated water in any place, and especially when going about at summer resorts. Infants and young children are more liable to infection when they are placed close to the ground or are handled and fondled by many adults. Dishes, thermometers, or even flies may carry the infective agent. The fall of the year when the children return from the country always shows the greatest number of cases. The disease is by no means as rare in infants and children as was formly supposed. The Widal reaction has revised the figures. About 6 per cent, of the cases occur under two years, and 8 per cent, under five years, and 46 per cent, between five and fifteen years. Typhoid fever may be transmitted from the mother to the fetus. Pathology. — As differentiated from the pathology of the disease in adults, we have a milder ulceration of the solitary follicles and Peyer's patches; and when examined postmortem, it is often difficult to dis- tinguish the ulceration from a case of ileocolitis. In infants there may be no ulceration whatever. In older children, especially where heal- ing has taken place, the " shaven beard" appearance is sometimes seen due to pigmentation. The ulceration rarely penetrates beyond the submucosa. This pathologic picture is in distinct relation to the milder character of the symptoms as met with in children. The mesenteric lymph nodes in the ileocecal region are enlarged. The spleen may be enlarged, congested, and soft. The mucous membrane of the bronchi and larynx are often involved in varying grades of inflammation. The kidneys quite regularly show cloudy swelling. The heart muscle shows mild grades of myocardial degeneration. 270 DISEASES OF CHILDREN. Symptomatology. — The prodromal symptoms are so irregular and so apt to be influenced by some one prominent symptom or symptom- complex as to lead the examiner astray. In infants the mode of onset is quite different from that of older children. The infant has an initial high fever which becomes irregular or remittent, and subsequently the symptoms resemble a gastro- enteric infection. Convulsions are the exception; older children who are able to describe their symptoms complain of headache and chilliness. Malaise and vomiting are frequently observed. Delirium at night, when the fever is high, is seen after a few days. Epistaxis is the exception. Cerebral symptoms may usher in the disease. A cough is often present quite early and serves to obscure the diagnosis. A careful physical examination of the chest by a process of exclusion may point the way to an early diagnosis. It will be well to take up the symptoms seriatim to give a picture of the varied manifestations of the disease, and these will be described in the order of their early assistance in diagnosis. Roseola. — These spots, which are macules fading on pressure and distinctly discrete, are observed in more than 60 per cent, of the cases. The eruption is seen as early as the fourth or fifth day, and, as a rule, is widely scattered. The abdomen, chest, and back may each show them. We have seen hemorrhagic areas on the abdomen, toes, and heels in severe or fatal cases. Spleen. — As a rule, the younger the child the less often is the en- largement felt early. It is distinctly palpable in the second week. The splenic enlargement often persists after convalescence has begun. There may be a relapse without an enlargement of the spleen. Mouth. — The rather characteristic tongue seen in adults is rarely observed in children, and it clears up much more rapidly. Sordes on the lips are common. The Stools. — These are not necessarily of the pea-soup variety; in fact, moderate constipation more often persists throughout the disease. The Temperature. — The temperature curve is only rarely typical. During the first week there is a gradual rise in temperature until the maximum point is reached. The fever now assumes a remittent type, but it is not unusual to have intermissions. Cases with cerebral symp- toms may have a hyperpyrexia for days. The temperature curve may last from two to six weeks; occasion- ally in protracted cases there is a gradual daily rise; but we feel that this fever may be solely due to the asthenia caused by a low diet. Complications such as bronchitis, pneumonia, otitis, or even constipa- THE INFECTIOUS DISEASES. 271 tion may influence the course of the pyrexia causing irregularities in the curve. Relapses produce a low-grade temperature after a period of normal or almost normal temperature. Laboratory Tests. — An early test and one which often gives results during the first week is the use of blood cultures made from freshly drawn blood. The Widal reaction (see p. 51) is present in 95 per cent, of the typhoid patients, and may be obtained as early as the end of the first week. The urine and feces contain the bacilli, and improved laboratory methods show their presence in 20 to 50 per cent, of the cases. The Ehrlich-Diazo reaction is sometimes present before the Widal reaction, and when obtained is confirmatory evidence of the disease, but not pathognomonic. The Blood. — The red blood-cells and the hemoglobin diminish as the disease progresses, but the leukocytes are quite uniformly low from the beginning. With the establishment of convalescence, the differential count shows an increase in the eosinophiles and mononu- clear lymphocytes and a corresponding decrease in the polynuclear neutrophiles. Pulse. — The relatively slow pulse is obtained only in older children, from ten to fifteen years. Infants and young children not uncommonly have a pulse rate as high as 150. • Irregularity is quite frequently noted, while the dicrotic pulse is rare. Pain. — It is seldom that this symptom is elicited in young sub- jects. In older children it is present in the ileocecal region in a good number of cases, and usually is accompanied by tympanites and probably is a result of ulcerative processes in the agminate glands or Peyer's patches. Hemorrhages. — It is rare to have hemorrhages in children. When they occur the amount is usually small and more easily controlled. The Heart. — Depending upon the amount of toxemia we have myocardial changes which may produce systolic murmurs. Treatment. Prophylactic. — If children live in vicinities having a suspected water supply, or remove to such a locality, precautions should be taken to boil the water and to supply an absolutely clean, uncontaminated milk. The excreta of the attendants should be examined for the possibility of the presence of the bacilli, especially if there has been a history of previous typhoid. Weaning or a wet- nurse are indicated if the mother herself is infected. Further experimentation may prove typhoid vaccination of value in institutions or in epidemics. Typhoid precautions should be scrupulously observed even in suspected cases. The feces, urine, 079 DISEASES OF CHILDREN. dishes, and clothing being disinfected with carbolic acid or chlorinated lime (as given on page 312). The napkins of infants should be made of cheap material and destroyed by burning. General Treatment. — Careful, capable nursing far exceeds the value of drugs in this disease. A well-kept chart recording the varia- tions in temperature, pulse, and respirations, every three or four hours, with notes upon the character of the pulse and stools is of great importance to the physician. The room should be as large as possible and one that can be well aired, and in which quiet can be maintained. Two beds so as to allow ready change of linen and position are preferable. Scrupulous attention should be paid to the mouth, tongue, and teeth, keeping them as free as possible from foreign material by the use of swabs dipped in mild antiseptic solutions, such as listerin or boracic acid. For disinfection of excreta, see section on Disinfectants and Disinfection. Feeding. — In mild cases in which the temperature is not high, and the digestive processes have been little interfered with, milk and lime-water, thin gruels, plain or dextrinized, broths made of mutton or chicken, orangeade, and lemonade form a list which will not be tiresome and which furthermore will fairly well keep up the patient's nutrition until he is able to take semisolid food in the beginning of convalescence. Severe cases with continued high temperature may require the peptonization of the milk or the discontinuance of milk entirely, if it causes tympanites. Dextrinized gruels, beef broths, and albumin water may be substituted. In convalescence, in addition to articles already permitted, zwieback dipped in broths, milk toast, junket, scraped beef, baked custards, and soft-boiled eggs are cautiously added to the diet. Mat- zoon and kumyss or home-prepared buttermilk are occasionally relished by the child and vary the monotony of his restricted dietary. Hydrotherapy. — The fever is in nearly all cases effectively con- trolled by sponging with alcohol and tepid water. We have dis- continued the use of tubbing. Any good effects of the reduction of temperature obtained are more than counterbalanced by the nervous excitement it produces. Therefore, a wet pack is preferable for high temperatures not controlled by sponging, the sheets being wrung out in water at 90° F. If at this temperature a satisfactory reduction is not obtained, the wrappings may be sprinkled with water at S5° or even 80° F. An ice-bag may be applied to the head, especially if there is headache or delirium, but it requires constant vigilance on THE INFECTIOUS DISEASES. 273 the part of the nurse who should be instructed to remove it if any cyanosis develops. Drugs. — With the exception of certain symptoms which will require control by the use of medication, no drugs should be given. Intestinal antiseptics and alcohol as routine measures are to be deprecated. The bowels are kept open with saline enemas which may be given cool if the temperature is high. Divided doses of calomel are indicated in the beginning of the disease. Tympanites should be prevented rather than treated by careful supervision of offending articles of diet, especially the milk. Headache and rest- lessness if not sufficiently allayed, by the hydrotherapeutic measures can be subdued by the use of the bromides. Alcohol is given in the form of sherry wine or whisky if the pulse is weak or the reaction is not good following a pack. Strychnia, grains 0-J--5, tincture of digi- talis or strophanthus, in two-minim doses, or brandy hypodermatic-ally are given if collapse threatens. If hemorrhage occurs, a light ice bag or coil is immediately applied to the abdomen and Dover's powder in maximum doses given. The treatment for perforation which would be evidenced by sudden pain, abdominal tenderness, and changes in the rational signs demands prompt surgical intervention. Influenza. (Acute Catarrhal Fever. La Grippe.) Definition. — An acute, specific, infectious disease affecting the respiratory or gastrointestinal tracts, and usually associated with marked prostration. Etiology. — While the disease is endemic, especially in damp, cold weather, it is very frequently seen in epidemic form. The immediate cause is a small bacillus first isolated by Pfeiffer in 1892. The bacillus may be localized in the mucous membrane of the nose, throat, or lungs. Other pyogenic bacteria may be present with the influenza bacillus, thus giving a mixed infection. Pfeiffer's bacillus resembles a diplo- coccus, having rounded extremities and staining markedly at the ends. Incubation. — From twelve hours to three days. Pathology. — There is some inflammation in nearly all the mucous membranes. In addition to this, complicating inflammations may exist in the heart, lungs, middle ear, mastoid process, kidneys, and gastrointestinal tracts. Meningitis has occasionally been reported as caused by the influenza bacillus. Tuberculosis may also follow an attack of influenza. A marked general depression often accom- 18 274 DISEASES OF CHILDREN. panying influenza is doubtless caused by the toxins secreted by Pfeiffer's bacillus. Symptomatology. — Although young infants are not particularly susceptible in contracting the disease, yet when they are attacked it is apt to assume a grave form with high temperature and great prostra- tion. The younger the child, the more severe is usually the infection. In older children the average clinical description of symptoms as affect- ing principally either the respiratory, digestive, or nervous systems will hold good. It is true, however, that these varying symptoms will often be found combined in a given case. Inflammatory disturbances of the respiratory tract predominate in children. There is marked coryza with an acrid discharge that may excoriate the upper lip. A general pharyngitis is also present, the mucous membrane presenting a thickened, spongy appearance. The tonsils may be swollen and show white points of exudation in the crypts. In a word, there is a severe general rhinopharyngitis present that is prone to involve the Eustachian tubes and middle ear, with a secondary enlargement of the lymph nodes that are connected with this region under the ear and back of the jaw. These disturbances are evidently more virulent than the ordinary inflammation met with in this region. This is not only seen locally, but in the disposition of the process to extend downward. In some ways this is analogous to the course of measles. The larynx, trachea, and bronchi are quickly involved, but in many cases the inflam- mation does not extend below the larger or medium-sized tubes. The cough may assume a paroxysmal character simulating pertussis. In others there is involvement of the small tubes and alveoli coming on soon after the onset of the disease. This type of broncho- pneumonia is much like the ordinary form as far as physical signs are concerned, but early prostration is more marked and the tem- perature is usually irregular and higher than the local lesion would seem to warrant. True lobar pneumonia is also not infre- quently seen, and, as in most influenza conditions, exhibits disturb- ances of temperature and circulatory and nervous depression out of proportion to what would be expected from the pulmonary signs. Perhaps the most frequent exhibition of pneumonia is seen in the form of irregular patches with sneaking invasion, when it is very difficult to decide the exact nature of the pneumonic process. Various grades of pleurisy are frequent accompaniments of pneu- monia, and empyema may be the terminal condition. This must be constantly borne in mind as this empyema is even more insidious than usual, especially in infants. THE INFECTIOUS DISEASES. 275 In cases where the gastrointestinal symptoms predominate there may be severe vomiting and the passage of loose, undigested stools. Nourishment is badly taken and after an interval the stools may con- tain mucus and even blood. The gastroenteric symptoms may ap- pear at the very beginning of the attack, or later during the course of the disease. While under proper dietetic and medicinal treatment these symptoms may not last beyond a few days, they naturally add to the prostration, and in young and feeble infants may predispose to a fatal ending. The cases in which pure nervous disturbances preponderate over the inflammatory symptoms do not seem to be so common in early life. Some severe cases may start with convulsions and simulate meningitis with photophobia, stupor, and, in older children, headache and deli- rium. In uncomplicated cases, however, these marked nervous dis- turbances do not last longer than a few days. Cases have been reported where true cerebral meningitis appears to have been caused by the influenza bacillus. The writer has seen a number of cases of plain clinical cerebrospinal meningitis where the fluid from a lumbar puncture showed neither the meningococcus nor the pneumococcus. It is possible that such cases are due to the influenza bacillus. Some of the clinical phenomena, aside from the types just men- tioned, may be noted. The fever is apt to be irregular and at times very high, especially in young infants. In some cases, fever and pros- tration will be the principal symptoms of the disease with little evi- dence of any local inflammation. In other cases, an irregular fever may last for several weeks and simulate typhoid fever. Here all the modern diagnostic methods must be employed in order to make a proper diagnosis. A further confusion will be caused by intestinal and diarrheal symptoms sometimes accompanying these prolonged cases. Some of the protracted cases are quickly relieved by change of air, particularly to a location where influenza is not so prevalent. The skin is sometimes involved, with various forms of erythema. This may at times simulate measles or appear in scarlet form. The irregular character and distribution of the eruption, with entire ab- sence of desquamation, and existing in connection with the various symptoms of influenza will throw light on its character. The urine will frequently show traces of albumin in influenza. It is probable that this has no great significance. Cases have been reported in which acute nephritis has supervened. Rachford states that if nephritis exists as part of the influenza attack the worse symp- toms occur early, and that if the life of the child is not destroyed 276 DISEASES OF CHILDREN. within the first week of the disease, a sure and steady improvement begins which leads to complete recovery. Diagnosis. — In diagnosticating this disease, the bacteriological aid is not so great in practice as it is in theory. The bacilli are difficult to discover, and frequently disappear early in the disease. Not only are they very hard to find in smear, but their culture requires a blood serum which may be difficult to procure. Accordingly, in the great majority of cases, the physician must depend entirely on clinical signs for a diagnosis. In some cases he has to rely largely on a process of exclusion. Wherever an illness quickly shows a prostration out of proportion to the apparent lesions, influenza may be expected. The tendency to spread through a family is suspicious, as the disease is highly contagious. This will be helpful in children, as adults usually contract the disease first, and the physician on being informed of this will be helped in making his diagnosis. There are nearly always inflammatory symptoms in the nose and throat to help the diagnosis. The onset of acute tonsillitis or pneumonia will often cause confusion. The former usually has a higher temperature and a more abrupt onset, while the latter should show physical signs early in the attack. A central pneumonia, however, may require several days for a differentiation from influenza where both are suspected. In some cases, the course of the disease, with presence or absence of local lesions, will be all that will clear up the diagnosis. When influenza is epidemic probably other conditions are oftener explained wrongly as due to this cause than vice versa. At any rate, a knoAvledge of its prevalence will put the physician constantly on guard in examining and diagnosticating obscure symptoms accompanied by prostration. Treatment. — The first thing called for is isolation of the patient as far as possible, to prevent the disease spreading through the family. The room should be well ventilated with plenty of fresh air, as this not only supports the patient, but tends to prevent reinfection as well as the direct spread of the infection to others. Close, badly ventilated rooms often seem to hold the infection for a long time. The child should be kept quietly in bed, even in mild cases, and simple, easily- digested nourishment given. When the fever is high, reliance should be placed rather on frequent spongings with cool or tepid water and alcohol than on the coal-tar derivatives. If there is much restlessness with the fever, small doses (one or two grains) of phenacetin with citrate of caffein may be given for a few doses at least. Where pain is evident, sulphate of codein, gr. ^ to gr. ^V- f° r an infant of one year may be administered every three or four hours. For support THE INFECTIOUS DISEASES. 277 and stimulation, sulphate of strychnin is most valuable, gr. 4^ to gr. 3^0 every three or four hours for an infant of one year. Prom ten to twenty drops of whisky or brandy may also be given when the pulse is weak. The bronchitis, pneumonia, or gastroenteritis are to be treated as when occurring as primary conditions except that sup- port and stimulation must be specially emphasized on account of the extra depression of the influenza. When the attack is prolonged or tending to constant recurrence, a removal to another section of the country may be the quickest way to recovery. Fumigation of apart- ments in which a patient has been long sick may also tend to prevent reinfection or the spread of the disease. Syphilis. Definition. — Syphilis is a communicable disease that may be acquired by inheritance or by direct contact after birth. In the latter case there is always an initial lesion, the chancre, followed by numerous secondary lesions, affecting principally the skin and mucous membranes, and by tertiary symptoms involving the bones, viscera, and the organs of the special senses. In hereditary syphilis there is an absence of the initial lesion and the disease shows itself in the secondary form from the beginning. Etiology. — The direct cause of syphilis is now generally believed to be the spirocheta pallida. In 1905 Schaudin described the spirocheta? in syphilitic conditions, stating that this germ was found constantly in smears stained by the Giemsa method. There is some danger of confusing the spirocheta with connective tissue fibrils, nerve endings, or elastic tissue. Buschke and Fischer demonstrated the silver spirochete in the organs of infants affected with congenital syphilis. They found them in a condyloma and in the liver and spleen of two cases of hereditary syphilis, and likewise in the kidneys and skin papules of another case. The parasites were found by them to be attached to endothelial cells of the blood vessels and they could be traced from the vessels into the surrounding tissue. The disease will here be considered in the order of hereditary or congenital syphilis, late hereditary syphilis and acquired syphilis. Hereditary or Congenital Syphilis. Definition. — This is a form of the disease in which the poison is derived from the father or mother or both, as it is lodged in the spermatozoa of the male or the ovum of the female. Method of Transmission. — Probably the disease is more often 27S DISEASES OF CHILDREN. transmitted by the father and the chances of this depend upon certain factors, such as the stage of the disease and the degree of its intensity, as well as the thoroughness with which treatment has been followed. There is danger to the fetus from syphilitic contagion up to the fourth year. If the father be subjected to early and thorough treat- ment, the possibility of transmission of the disease will be much lessened, and, in a great majority of cases such a possibility becomes lost after a reasonable lapse of time. If the father infect the mother, there will be a double syphilization of the offspring, which will prob- ably be still-born or soon succumb to an aggravated form of the disease. When the mother is suffering from acute syphilis, the disease is transmitted in an active stage to her child. The degree of such transmission depends, as in the case of the father, upon the stage and severity of the disease and the nature of the treatment employed. During periods of latency the mother may bear healthy children, followed by abortions or syphilitic infants caused by renewed manifestations of the disease. It has been considered that the power of transmission is practically lost at the end of six years. In some cases the mother remains apparently uninfected by syphilis, although the fetus may have been infected by the father. This immunity was noted in 1837 by Colles who wrote that "a new-born child affected with inherited syphilis, even although it may have symptoms in the mouth, never causes ulceration of the breast which it sucks if it be the mother who suckles it, although continuing capable of infecting a strange nurse." The substantial truth of this dictum remains unquestioned and is known as Colles' Law. Pathology. — The fetus may die any time during uterogestation with resulting miscarriages, or may live to term and then be still- born. When born alive, the lesions resulting from the disease may be broadly divided into those involving the skin and mucous membranes, the viscera, and the bones. There may be erythema, maculo-papules, or papules on the skin, or a vesicular and pustular eruption may occasionally be seen. Blebs or bullae often appear at birth in a severe type of the disease. Crops of boils, with well-defined, coppery- red bases are apt to be symmetrically arranged when many are present, or asymmetrically distributed if only a few are seen. The lesions of the mucous membranes may take the form of inflammatory processes, of mucous patches, or of superficial or deep ulcerations. The junction of skin and mucous membrane is a favorite seat for the syphilitic lesion. The viscera are more apt to be involved in hereditary than in acquired syphilis, the lesion taking the form of an interstitial hyperplasia. The growth of interstitial connective tissue, which, by gradual con- THE INFECTIOUS DISEASES. 279 traction, partially obliterates the parenchyma of the organ, may involve the lungs, spleen, liver, pancreas, and testicle. Usually a portion of a lobe, but occasionally a whole lobe of the lung may present a diffuse fibroid infiltration with a grayish-white color. The liver, which is not infrequently affected, is hardened and enlarged from a diffused sclerosis, although occasionally the affection may be cir- cumscribed. Gummata, in the form of small, circumscribed nodules may be found in the lung, liver, or other viscera. Bone lesions are quite common and some that were formerly referred to rickets or scrofula are now recognized as syphilitic. There are two principal ways in which the specific poison affects the bones in early life. In one instance the brunt of the disease and morbid change takes place at the junction of the shaft with the epiphysis — osteochondritis; in the other, the periosteum covering the long bones is principally affected with a resulting periostitis. Both of these varieties involve principally the long bones. Osteochondritis develops early in life, usually within the first month. It may, however, occur later, when it is not apt to become multiple, and may be unsymmetrical in dis- tribution. While epiphyseal swellings may be due to rickets as well as syphilis, such swellings are pretty surely syphilitic if they occur during the first six months of life and they are relieved by mercurial treatment. Again, the epiphyseal swellings of rickets are always symmetrical, while those of syphilis may be unilateral. Periostitis, occurs later in hereditary syphilis, usually after the child has begun to walk. It attacks by preference the femur, tibia, and bones of the forearm, occurring usually from the second to the fourth or fifth year. At an early stage of the disease the bones are attacked symmetrically, but later, circumscribed nodes may be placed unilaterally. A dactylitis attacking by preference the proximal phalanges of the metacarpal and metatarsal bones, enlarging them to several times their natural size, may occur. There is not much destruction of bone but after a time the skin may become inflamed and break down from the formation of an abscess. Craniotabes may result from the mal- nutrition of syphilis as well as from rickets. Symptomatology. — The symptoms vary greatly in severity from cases showing good nutrition and one or two slight lesions only to such severe infection as to produce early death. In the latter case, the fetus may be attacked in the uterus resulting in abortion more or less early in the pregnancy. As the disease lessens in severity in one or both parents the pregnancies will be longer in duration and finally an apparently healthy infant may be born. While there may be evidences of syphilis at birth, the onset is often delayed until weeks 280 DISEASES OF CHILDREN. or months afterward. In the majority of cases the primary symp- toms will be noted before the end of the second month. The earlier the disease manifests itself after birth, the graver will be the nature of the attack. Very early syphilis is usually accompanied by emacia- tion, severe coryza, cracked and ulcerated lips, eruptions of bullae, particularly upon the palms of the hands and soles of the feet, and evidences of visceral and bony disease. In the older cases there may be no apparent interference with nutrition, and possibly one or two muocus patches may be the only active manifestation of the disease. As noted in the pathology, almost any structure of the body may be involved in the course of the disease. Fig. 78. — Congenital syphilis. The skin rashes often develop rapidly and are apt to be less symmetrical than those seen in adults; they are likewise polymorph- ous, as several different forms of eruption may be exhibited at the same time in a given case. There may be first an eruption of small, round pink spots, disappearing on pressure, and usually appearing first on the lower portion of the abdomen. These may later take on a coppery discoloration. A papular syphilid may be seen in the form of small or large flat papules which are not so apt to group themselves into lines and circles as in older subjects. Neither are they so solid and deeply infiltrated as in the adult. Upon the palms and soles these papules may be very abundant and fuse together, presenting a thickened, dull-red surface. The vesicular syphilid THE INFECTIOUS DISEASES. 281 is not common; the vesicles may be associated with pustules, and appear in closely-arranged groups about the mouth and chin or various other parts of the body, especially the nates and hypogas- trium. Pustules may appear on the face, buttocks, and thighs. Pem- phigus is seen only in the severer forms of the disease and then pref- erably on the palms of the hands and soles of the feet. A smoky discoloration of the skin, seen most distinctly in the prominent parts of the face, such as the eye-brows, cheek-bones, and bridge of the nose may occasionally be the only manifestation on the skin. There is apt to be a dryness of the skin which may hang in loose folds from the general cachexia. Fig. 7i). — Condylomata about the anus in syphilis. The mucous membranes are early affected. One of the most typical symptoms is the coryza. At first there may be a serous discharge which gradually becomes worse until the nasal secretion takes on a purulent or even a bloody character with excoriations of the upper lip. The secretion may become inspissated, forming crusts, which may completely block up the nasal passage. There is often flattening of the bridge of the nose from interference with respira- tion. Mucous patches are oftenest seen in the mouth, about the nose, upon the scrotum, vulva, labial commissures, and occasionally at the umbilicus. Deep fissures sometimes form at the corners of the lips, even extending well out into the cheek. There may be enlargement of 282 DISEASES OF CHILDREN. the epitrochlear, cervical, cervicomaxillary, axillary, and inguinal lymph-glands but there is not a general adenopathy. Codylomata are sometimes found about the anus (Fig. 79). The long bones should be carefully examined for enlargement and thickening of the epiphyseal and distal ends. The epiphysis may even be separated from the shaft, when crepitation will be found upon care- ful handling. Dactylitis is usually confined to one phalanx which will be enlarged to double its normal size, but there is not apt to be much involvement of the soft parts; several phalanges are sometimes attacked. Onychia, often followed by ulceration around the nail, is occasionally seen. The first teeth are delayed, poorly developed, and will probably undergo early decay. A profound anemia is sometimes seen, characterized by a diminu- tion and alteration of the red blood-corpuscles, the appearance of megalocytes and microcytes and of nucleated erythrocytes. There is leukocytosis which may become extreme. There may be sufficient disturbance of nutrition to induce an atrophy of all the structures of the body, the infant presenting a weazened appearance. This is oftenest seen in bottle babies and some infants that are nourished on the breast may remain plump and well-nourished throughout the course of the disease with only a few mucous patches to give evidence of a mild infection. Diagnosis. — It is usually easy to diagnosticate the disease from some of the pathological or clinical manifestations just described. In cases of marasmus, if there has been no chronic indigestion, partic- ularly if the infants have been fed on the breast, syphilis may be sus- pected. Chronic coryza is suspicious and mucous patches will make certain a diagnosis. The following points are characteristic of syphi- litic lesions: They are general in their distribution, but ambulatory and changing, and usually present a reddish-brown tint; where crusts form they are fairly thick, with a tendency to accumulate in layers, and when cicatrices form they are smooth and long surrounded by a pigmented areola. The bony lesions of syphilis, tuberculosis and rickets may be confused. Morrow gives the following points of differen- tiation between syphilis and tuberculosis: 1. Syphilis exhibits a marked predilection for the long bones; its habitual localization is in the diaphysis, and almost always at its terminal extremity. Tuber- culosis is almost exclusively situated in the epiphyses, rarely affecting the shaft. 2. In syphilis there is a marked enlargement of the bone by more or less voluminous tumors or hyperostoses, with little or no involvement of the soft parts; in tuberculosis the tumefaction is due less to increase in the size of the bone than to edematous infiltration of THE INFECTIOUS DISEASES. 283 the soft structures. 3. In syphilis there is little tendency to suppura- tion and necrosis; in tuberculosis the pyogenic tendency is marked. 4. In syphilis, osteocopic pains, with tendency to nocturnal exacer- bation are a pronounced feature; in tuberculosis the pain is dull and heavy, not aggravated at night. 5. The osseous lesions of syphilis rarely react upon the general system, while those of tuberculosis often determine a marked impairment of the general health. Fig. 80. — Syphilitic dactylitis. In differentiation of syphilis from rickets, epiphyseal swellings under six months are very apt to be syphilitic. In syphilis the epiphy- seal swelling may be unilateral, but it is always symmetrical in rickets. In doubtful cases the swelling must be subjected to specific treatment. It is well to remember, however, that rickets and syphilis may coexist in the same case. 284 DISEASES OF CHILDREN. Prognosis. — The earlier the symptoms appear after birth, the severer will be the type and the worse the prognosis. Breast-fed infants have a much better chance than those artificially fed. If the digestion remains good and the manifestations of the disease are not severe, complete recovery takes place and the infant may grow up healthy and strong. The average prognosis, however, is bad. Kas- sowitz states that one-third of all syphilitic children die before birth, and among those who are born 34 per cent, die in the first six months of life. Treatment. — Parents who exhibit any specific symptoms or who have had syphilitic children should be subjected to specific treatment in the hope of avoiding infection of the fetus. Mercury is the specific remedy and may be administered to the infant either externally or internally. Daily inunctions of mercurial ointment, mixed with from two to eight times its quantity of vaseline or rose ointment, may be employed. A lump about the size of a small hickory nut may be rubbed on the inside of the thighs or in the axillae, the parts having previously been cleansed with soap and warm water. It is more cleanly to apply five drops of a 10 per cent, solution of oleate of mercury three times daily. Internally, mercury with chalk is one of the best preparations in doses of one-fourth to one grain three times a day. Calomel, in doses of Y V to i grain, three times daily, will have a more rapid action when such is desired. Or bichlorid of mercury ^io to ¥ V grain may be given, If the latter induce intestinal irritation, a men- struum, containing bismuth and pepsin, will usually allay it. When mercury is given for a long time it is well to occasionally change its form, although in syphilis it is a tonic, acting like iron in anemia. The nostrils must be kept clear, using, if necessary, some bland oil like albolin. Mucous patches and excoriations must be kept clean and dusted with calomel and bismuth, equal parts. It is usually necessary to give mercury for at least a year, with occasional intervals of tonic treatment. In visceral lesions and where the bones are involved and evidence of gumma in any part of the body appears, iodid of potas- sium, in doses of one to five grains, will be indicated. The general care and feeding is most important. While the infant should not, if possible, be taken from the mother's breast, it must never be given to a wet-nurse. Late Hereditary Syphilis. This form of syphilis comprises those cases in which earl}' evi- dences of the disease have either not existed or have been in such slight form as to have been overlooked. Late hereditary syphilis may mani- THE INFECTIOUS DISEASES. 285 fest itself either in certain active lesions plainly to be attributed to this condition or by certain developmental defects that may easily be confused with tuberculosis or rickets. The secondary teeth are affected in a way that has been consid- ered pathognomonic. The principal change is noted in the two superior middle incisors, which are small, peg-shaped with scooped-out grinding edges, and placed at such an angle that the cutting borders, Fig. 81. — Hutchinson's teeth. (Dr. FraucntliaVx case.) if continued, would meet. They may occasionally be deflected out- ward, and are known as Hutchinson's teeth (Fig. 81). Ulceration of the palate, usually, beginning in the center, may take place and be fol- lowed by caries or necrosis of the bone. There may be simultaneous or consecutive deep ulceration of the soft palate, pharynx, and naso- pharynx at any time previous to the age of puberty. Large, indolent mucous patches may exist in the mouth, and there may be ulceration about the lips leaving long scars, especially at the commissures of the lips. The nasal bones may become necrotic with depression of the bridge from destruction of the bony arch. 286 DISEASES OF CHILDREN. A periostitis, accompanied by a thickening on the surface of the bone, may involve the long bones, especially the tibia, ulna, radius, and humerus. The lesion may be multiple and symmetrical, although occasionally unilateral. Gummata, involving the bones and occasion- ally the soft tissues, may be seen, and, in the latter case, may break down with ulceration and leave large scars. Interstitial keratitis, without much congestion of the conjunctiva, is not infrequent, and is liable to be followed by corneal opacities; although primarily attacking one eye, it may involve the other. There may coexist an indolent iritis wuthout the usual severe pain and photophobia. A chronic form of otitis may be followed by deafness. Painless enlargement of one or both testicles may be caused by syphilis, but there will be apt to be lesions in other parts of the body to aid in the diagnosis when this occurs. In many cases all the evidence of syphilitic taint in child- hood will be found in arrested and perverted development. As an example, the testicles at puberty may be about the size seen in very early childhood, and in girls in absence of mammary development, delayed menstruation and a non-appearance of hair on the genital and axillary region may be noted. Treatment. — The treatment of the later forms of syphilis must depend on the activity of the morbid process. Mercury in some form should be exhibited when there is any evidence of active syphilitic disease. Iodid of potash is also to be given in fair doses, three to five grains. If there is no evidence of an active syphilitic process, the treatment will resolve itself into improving the nutrition of the child in every way. Good food, tonics, iron, cod-liver oil, and change of air when possible are all of value in aiding healthy growth and development in these retarded cases. Acquired Syphilis. The syphilis detected in early life, although usually hereditary, is not necessarily so, but may be acquired. A primary sore upon the genital tract of the mother can possibly infect the infant during birth. The nurse or attendant may have a primary lesion upon breast or lips. Much more common will be infection from some secondary lesion, especially a mucous patch upon the mouth or lips. There are many ways in which the blood or infective secretions of a syphilitic patient may come in contact with a solution of continuity in the skin or mucous membranes of an infant or child. A chancre will then appear at the point of contact, followed in due time by the later manifestations of the disease. Rarely, in older children, the disease THE INFECTIOUS DISEASES. 287 may be contracted by sexual contact. The symptoms and treatment present essentially the same elements as in adult life, and hence will not be considered here. The acquired disease in the infant or young child tends to be milder than the hereditary form in its symptoms and less apt to affect seriously the general health and development. Epidemic Cerebrospinal Meningitis. {Cerebrospinal Fever.) This form of meningitis is an acute infectious disease due to the diplococcus intracellulars, characterized by motor and sensory cerebral and spinal symptoms. Etiology. — The disease, without question, has its specific germ in the diplococcus intracellulars meningitidis, first fully described by Weichselbaum in 1887. This organism, fortunately of low resistance, gains access to the general system through the blood or through some local determination in the nasopharynx, ear, or eye, and in those with depleted vitality and lowered resisting force finds suitable soil for its propagation. It usually occurs in epidemic form, although occasional sporadic cases are seen from time to time, especially in the large centers. The spring of the year, after prolonged confinement to ill-venti- lated and superheated apartments, finds the greatest number of pre- disposed individuals. It is essentially a disease of the young. Our youngest case was twelve weeks old, although Rotch, of Boston, reports a case six days old. The second year claims the greatest number of victims. Pathology. — In making postmortem examinations of those dying with the disease, we find, as a rule, an exudative inflammation of the pia arachnoid of the brain and spinal cord. The amount of infiltration found, however, often does not correspond to the gravity of the symptoms observed during the life of the patient. The degree of infiltration varies from an intense hyperemia to a fibrinoplastic seropurulent or purulent exudate. This exudate is most marked at the base of the brain and along the fissure of Rolando and the dorsal portion of the cord. In the ventricles is found a cloudy or opaque serum and in a few cases pure pus. The effusion in the subarachnoid space (and it must always be kept in mind that there is more fluid in the subarachnoid space in children than in adults) is increased in normal amount. Frequently there is seen a parenchymatous degen- eration of the kidneys, degeneration of the heart muscle and the 288 DISEASES OF CHILDREN. muscles in general. There will also be found in a number of cases multiple abscesses, septic joints and ecchymoses of the skin as a result of complicating conditions. Symptomatology. — In cerebrospinal meningitis the symptoms vary according to the type of the disease present. The onset is usually sudden and abrupt. The malignant types are seen largely in the epidemics only, and are responsible for the large mortality record. Headache, vertigo, vomiting, and high fever are soon followed by coma and death. The symptoms in the sporadic cases will vary with the gravity of the local lesion and the intensity of the toxemia. This history of the prodromal period may be of material assistance in establishing the diagnosis; there is malaise, headache, chills, loss of appetite, body Fig. 82. — Cerebrospinal meningitis with marked opisthot< pains, and some rise of temperature. Later frontal headache is com- plained of and succeeded by vomiting, restlessness, and rapid pulse. Herpes on the lips and nose, retraction of the posterior cervical group of muscles, hyperesthesia and opisthotonos are observed. The general nutrition suffers severely and emaciation is stead}' and pro- gressive. Delirium, stupor, or profound coma develop. Convul- sions of a severe type (particularly in infants and younger children) are apt to occur at or near the beginning of the disease. The loss of flesh and strength is rapid and marked. Photophobia and irregu- larity of the pupils with loss of pupillary light reflex and nystagmus are quite regularly present. Neuroretinitis is found on ophthal- moscopic examination of the fundus in some cases. The respirations vary with the stage of the disease; they are increased when the fever is high, sighing and shallow when stupor begins and are irregular when coma develops. The blood shows a leukocytosis rarely under 25,000 to the cubic millimeter. The temperature curve is not char- acteristic and bears no relation to the prognosis. The excursions are THE INFECTIOUS DISEASES. 289 wide and varied. The pulse is rapid and sometimes irregular. Ecchy- motic spots and purpuric areas are seen in some of the fulminating cases, but a roseola or an erythema is more apt to occur in the "sporadic cases. The reflexes will help to establish the diagnosis, but must be interpreted with caution. The tache cerebrale is always obtained, but is only a minor confirmatory sign. The Babinski reflex, or extension of the great toe on irritating the plantar surface of the foot, is confirmatory, but valueless in children under two years of age, although negatively it may be of assistance. Kernig's, sign, which is obtained in nearly all the cases at some stage or other, is also present in all forms of cerebral irritation. MacEwen's sign, or the hollow note elicited by percussion over the parietal bone, is obtained only in those cases in which fluid has accumulated in accessive quantity in the ventricles. The rigidity of the neck with dilatation of the pupils when attempts are made to flex the neck is also a helpful and confirmatory sign of meningitis. The urine in the course of the disease often contains albumin and hyalin casts, the result of toxic substances in the blood stream. Loefler and Gourand, of France, have lately called attention to the fact that in the beginning of the disease large amounts of urine of low specific gravity are passed, containing a high percentage of urea. An examination of the blood will assist in making a differential diagnosis. Leukocytosis, principally of the polymorphonuclear cells, is present, while the mononuclear elements predominate in the tuber- culous type of meningitis. Lumbar Puncture. — Although the diagnosis can often be made from the clinical phenomena alone, confirmation and temporary relief from intracranial pressure symptoms are afforded by lumbar puncture, and it is also an aid in establishing the diagnosis and prog- nosis. The procedure is not difficult, and if performed with aseptic precautions and a due regard for the anatomy, is productive of no harm. The technic is as follows (see Fig. 16, page 52) : Infants in whom opisthotonos has not yet developed may be placed over a pillow at the end of a table, the spine and outlying soft parts being thus put on the stretch. The spine may be entered between the third and fourth lumbar vertebrae. This space is found by an imagi- nary line drawn across the iliac crests and intersecting the spine. In older patients, or those with opisthotonos, it is necessary to place them on their side and enter to one side of the median line. - The needle of an ordinary good-sized aspirating syringe cannot be improved upon for the procedure. A small trochar and cannula may also be used and 19 290 DISEASES OF CHILDREN. 10 to 15 c.c. (J ounce) should be withdrawn, provided the fluid flows freely, as this amount will include fluid from the cranial cavity and lead to more accurate bacteriological results. It is not wise to with- draw more than 30 c.c. or an ounce at a sitting. In infants with an open bulging fontanel, an amount can be withdrawn which will appreciably depress the fontanel. Dry taps, which occasionally occur, are usually the result of imperfect technic, the operator either not reaching the spinal canal, or the needle becomes obstructed with blood. If the exudative processes have occluded the connection between the ventricles of the brain and the cerebral and spinal sub- arachnoid spaces, as sometimes occurs in well-advanced cases, the open- ing may be partially occluded and the fluid flow very sparingly. In cerebrospinal meningitis the fluid obtained is generally clouded or turbid, sometimes it is purulent or again varies from time to time. In a small percentage of cases it is quite clear throughout. It contains the diplococcus intracellularis, and in some aspirated fluids in addition, staphylococci and streptococci are found. Polynuclear leukocytes predominate and contain the specific organisms. Complications. — Those which may be attributed more directly to the disease itself are those of the eye, the ear, the brain, and the joints. The drum frequently is infected and may result in deafness and the labyrinth is apt to be likewise involved. Chronic hydrocephalus develops in a number of cases beginning either during the acute stage or in convalescence. They are usually mentally deficient or idiotic. Rarely an arthritis develops in one or more joints. Differential Diagnosis. — As a rule, the symptoms are typical enough to make the diagnosis of meningitis, which is confirmed and further differentiated by lumbar puncture. The sudden onset, the headache, fever, vomiting, or convulsions in the face of an epidemic are especially significant. Meningitic symptoms in typhoid fever with rapid onset are often confusing. The blood examination for leukocytosis and the Widal reaction should be used to assist in the differentiation. Tuber- culous meningitis, especially in infancy, is often confused with spo- radic cases of cerebrospinal meningitis, and indeed the pathological examination of the spinal fluid may in some cases be absolutely necessary to differentiate them. The slow onset in tuberculous meningitis, the low leukocyte count, and the absence of hyperesthesia are distinctly helpful points. Prognosis. — We can base our prognosis on the following facts: Sporadic cases have a greater natural tendency to recovery. Initial symptoms' do not, as a rule, indicate the subsequent course. Mixed THE INFECTIOUS DISEASES. 291 infections as found in the spinal fluid indicate a general septic condi- tion and an unfavorable prognosis. The younger the patient the more unfavorable the outcome. Do not interpret as a sign of restora- tion to health a temporary remission with return of consciousness from coma. Widely dilated, rigid pupils, unvarying coma with slow pulse, sub- normal temperature, persistent opisthotonos, and convulsions are signs tending to a fatal termination. Treatment. — The germ and its toxins must be combated. De- tailed study of the portals of entry of the nfecting organism has thus far failed to establish much that is new. Care of the nasopharynx as insisted upon by Jacobi and Caille is a local measure productive of much good, especially in the crowded centers. School inspection and a higher standard of sanitary regulations in every district will do much to prevent epidemics of this disease. Serum Treatment. — The promising results that have been obtained from the use of Flexner's antimeningitis serum when used by the sub- dural method warrant its use in cases in which the diplococcus intra- cellularis has been demonstrated. If the bacteriological test is impracticable or would be unduly delayed, the serum injection is advisable in those cases in which a cloudy fluid is withdrawn by lumbar puncture. The earlier the serum is injected the better the results. By its use this long exhausting disease appears sometimes to be shortened and serious complications prevented. The serum is injected through the same needle after the withdrawal of at least 30 c.c. of spinal fluid. The serum is obtained in vials containing 15 c.c. each, and two of these vials warmed to body heat are slowly injected into the canal unless undue resistance contraindicates. The injections are repeated daily from four to six days, during which time smear preparations will give information as to the effect on the diplococci. If the temperature drops and the coma is lessened, the intervals are increased and the injections are repeated only when any aggravated symptoms return. In infants sometimes not more than 15 to 20 c.c. of serum can be in- jected, without producing pressure. In older children, on the other hand, when the pressure symptoms are intense and the fluid flows freely, as much fluid as possible should be allowed to escape and a cor- responding amount of serum injected. General Treatment. — A very important element of the treatment is conservation of the patient's strength by well-regulated nourishment and skillful nursing. Care of the excretory functions and relief of pressure symptoms are important elements of the treatment. The patient should be isolated in a well-ventilated quiet room, the eyes 292 DISEASES OF CHILDREN. shielded from the light, the head and the neck being raised upon a pillow to relieve in part the congestion of the brain. The bowels are kept open by calomel or enemas. The diet may be fluid or semi- fluid, of a stated quantity, and careful note kept of the amount in- gested. Forced feeding should be resorted to if necessary by gavage. Water should be given freely. An ice-bag should be applied inter- mittently to the head if the temperature rises above 101° to 102° F. Warm baths at 115° F. for twenty minutes, twice a day, with cold applications to the head, do much to produce comfort and allay pain. While in the bath the nasopharyngeal toilet can be made with normal saline solution. Colonic irrigations are used to eliminate the toxins, promote the flow of urine, and to stimulate the patient. When they are given at a temperature of 80° F. they also control the higher rises of temperature. The baths will also prevent in great measure the formation of bed-sores, and the necessary change of position will be beneficial to the pulmonary circulation. For the relief of marked restlessness or convulsions bromids and chloral per rectum are to be preferred to the opiates. Camphor in sterile olive oil hypodermatically (one grain to ten minims) is given when stimulation is necessary. Lumbar Puncture: This procedure will be indicated for (a) purposes of diagnosis; (b) in infants where there is a bulging fontanel or in children where MacEwen's sign can be elicited, and in any case to control convulsions or sudden onset of coma; in other words, symp- toms of intracranial pressure, and (c) for the injection of the anti- meningitic serum. Anterior Poliomyelitis. {Infantile Paralysis. Essential Paralysis of Children. Acute Atrophic or Wasting Paralysis.) Definition. — An acute inflammatory process taking place in the anterior horns of the spinal cord, accompanied by a sudden and com- plete paralysis of various groups of voluntary muscles, followed by a rapid wasting of the affected muscles. Etiology. — The onset, course, and symptoms suggest an infectious nature, but no microorganism as a cause of the disease has yet been discovered. The nerve centers of the brain and spinal cord, the fluid derived from lumbar puncture, and the blood have as yet been searched in vain for the specific cause. Special liability to the disease exists below the age of three years, fully half of the cases occurring during THE INFECTIOUS DISEASES. 293 this period. This is likewise the period of dentition, but it is doubtful if this bears any causative relation to the disease. Cases occur often- est in warm weather and boys are attacked oftener than girls. Oc- casionally the disease comes on after exposure to cold; it may also be seen in connection with certain infectious fevers, such as scarlatina and typhoid fever. The relation between these factors and the disease, as to cause and effect, is somewhat uncertain. The occurrence of occasional epidemics confirms the theory of the probable specific infectious nature of the disease. Pathology. — The inflammation that is localized in the anterior horns of the spinal cord seems to be induced by some toxin brought there by the blood current. There is dilatation and proliferation of the endothelial walls of the blood-vessels of the part of the cord affected. The central arteries of the spinal cord are intensely con- gested followed by those of the anterior median fissure. As the posterior horns are chiefly supplied with blood from the peripheral arteries, they are less affected when the inflammation is limited to the distribution of the central arteries. After engorgement of all the arterial twigs, diapedesis occurs and infiltration of the tissue by small cells and serum. According to Goldschreider, it is this choking of the gray matter by the inflammatory products that leads to the suspension of functional activity, and when, as in many cases, from impoverished nutrition the cells of the anterior horns are actually disintegrated by the inflammatory products, permanent destruction of the nerve tissue ensues. The ganglion cells soon show granular degeneration which may be followed by disintegration and atrophy. The cells in the anterior horns are arranged in groups having definite physiological motor and trophic functions. When these cell groups are finally destroyed and replaced by connective tissue, the parts they innervate will likewise undergo degenerative changes. The muscles become atrophied, and their fibrils replaced by connective or adipose tissue. Symptomatology. — The invasion is usually acute with evidences of general infection. There may be gastroenteric or nervous dis- turbances with fever. The disease often begins with vomiting, and diarrhea may occasionally ensue. In other cases, general convulsions are seen at the beginning. Very rarely stupor or coma may follow the convulsions and last for a day or so. The temperature is frequently high at first, perhaps reaching 104° or 105° F.; in other cases it is slight — not more than 100° or 101° F. In rare instances the initial symptoms may be so mild as to escape attention and the paralysis is the first thing noted. In the majority of cases, however, some initial symptoms, more or less marked, will last from one to four days before 294 DISEASES OF CHILDREN. paralysis is discovered. Occasionally pains in the limbs may precede and accompany the paralysis for a time, and thus simulate periph- eral neuritis, but such pains do not last long. The most obscure cases are those in which the child is suddenly found to be unable to stand or walk, perhaps after being taken out of bed in the morning. The paralysis is absolute, the affected part being completely flaccid. It develops rapidly, usually reaching its full extent in from twenty-four to forty-eight hours; in rare cases it may be slower in onset, so that a week or even longer may elapse before it appears to reach its maximum extent. There is then a more or less rapid sub- sidence of the loss of power, but little change is to be noted during the first three or four weeks after the beginning of the attack. Most of the improve- ment will take place during the first three months, and after this interval any paralysis remaining will usually be permanent. The paralysis most often takes the form of monoplegia, the right leg being oftenest affected. The left leg and the right or left arm may be- come involved with a frequency usually in the order named. In severe cases all four extremities may be involved and even the muscles of the back and neck so that the child cannot sit erect or hold its head up. In very rare in- stances the medulla and base of the brain may be attacked, as well as the anterior horns of the cord, forming the disease called by Striimpell polioencephalitis. The cranial nerves may then become affected and the patient shows signs of bulbar paralysis as well. These severer types are more apt to be seen when the disease is epidemic. In other rare instances there ma}^ be hemiplegia simulating cerebral paralysis. Paraplegia is rare. Many cases will only show a v paralysis involving one group of muscles, as the peroneal type. As the motor cells in the anterior horns are arranged in groups, the muscles involved will be found to have a coordinated physiological function. The limb affected is apt to be cooler than the other parts, and an atrophy soon affects the paralyzed muscles. The wasting may be noticed within a week or two. and at two or three months becomes very marked. Eventually Fig 83. — Foot-drop in anterior poliomyelitis. THE INFECTIOUS DISEASES. 295 various deformities result as the growth of bone is arrested and the whole limb becomes smaller. Where only one or two groups of mus- cles are affected by atrophy, the opposing healthy muscles will pro- duce other deformties. In old cases, where a whole limb has been affected, there will be various grades of subluxation from a relaxation of the muscles and ligaments around the j oints. The knee and shoulder are particularly apt to be involved in this way. The electrical reaction of muscles and nerves may prove helpful in recognizing the disease. While the galvanic and faradic responses may be increased in the first two days, there is soon a loss of response to the faradic current with a reaction of degeneration to the galvanic current shown by the anodal closure contraction being greater than the cathodal closure contraction. If the part affected responds to faradism within a few weeks it will probably not be permanently paralyzed. The reflexes are lost in the affected muscles. The commonest example of this is seen in loss of the knee-jerk. Complete recovery of all the muscles affected is extremely rare, although the permanent paralysis may be limited to only one or two groups of muscles. In very rare cases death may take place during the early course of the < lisease. The writer has known this to occur only in the epidemic form. Diagnosis. — It is impossible to make a positive diagnosis before the onset of the paralysis as the first symptoms resemble those of other acute infections. However, an absolute paralysis preceded by vomiting, fever or convulsions points to a spinal origin. In a few cases there may be early cerebral symptoms simulating cerebro- spinal meningitis, but paralysis comes later, if at all, in the latter dis- ease, and the stiff retracted head comes early. It is not always easy to differentiate a palsy as cerebral, spinal or peripheral. The follow- ing points may be considered as helpful: Cerebral (or motor projection fibers in spinal tracts) Peripheral (nerves) Onset sudden, with convul- Onset sudden, with fever sions. Usually affects entire limb and incomplete. Paresis. Affect muscular groups having coordinated functions and not sup- plied by simply one nerve. Total paraly- sis (rule). Hemiplegia (rule) Monoplegia (rule) leg . Monoplegia (rare) arm . . . . Hemiplegia (rare) . . . Paraplegia (very rare) ....'. Paraplegia (rare) . . . Onset gradual (1 to 4 weeks) . Affects muscles supplied by one nerve. Total paralysis (rule). Paralysis symmetrical. Paraplegia the rule. Upper, lower, or all four extremities. 296 DISEASES OF CHILDREN. Cerebral (or motor projection fibers in spinal tracts) Spinal (gray matter) Peripheral (nerves) Muscles stiff or rigid Sensory disturbance usually absent. If present, par- tial anesthesia No atrophy, or late from dis- use. Deformity early. Athetosis. Growth of part not much im- paired. Temperature of part little affected. Increase of all reflexes No reaction of degeneration. Mind often affected. Weak- ness or epilepsy. Muscles flaccid i Muscles flaccid. Sensation not affected; sometimes, but rarely general pains very early in disease. Association of sensory with motor paralysis. Numbness, tingling, sensations of heat or cold. Limb usually painful along course of nerves affected. Early and rapid atrophy Deformity late Growth much impaired. Growth not impaired Atrophy rapid. Permanent contractures rare. Some coolness in affect- ed limb. Slight coolness of mus- cles affected. Loss of reflexes Loss of reflexes. Always reaction of de- generation . Mind clear and no men- tal sequelae. Usually reaction of de- generation. Mind clear and no men- tal sequelae. Prognosis. — A more or less rapid lessening in the extent of the paralysis nearly always occurs during the first few weeks after the beginning of the attack. There will be little or no improvement after the third or fourth month. The prognosis for muscles that waste rapidly is poor. A reaction to the faradic current is a sign of beginning improvement. After a year the condition will be absolutely stationary as far as the paralysis and trophic disturbances are concerned. Complete recovery is exceedingly rare, and is more apt to be seen in the epidemic form. In some cases, however, so few muscles are permanently paralyzed as to simulate entire recovery. The prognosis for life is exceedingly good, although a few will occa- sionally die early in the attack in epidemics of the disease with symp- toms of severe infection. As there is no involvement of the brain, the mind will not be in any way affected, and there are no late sequelae such as epilepsy. Treatment. — If seen early, and the temperature is high, ice-bags may be applied to the spine. When this is discontinued, stimulating embrocations may be applied, such as one part of turpentine in two THE INFECTIOUS DISEASES. 297 parts of camphorated oil, sprinkled over a strip of flannel. The bowels should be kept open and a mild, unstimulating diet given. Any irritability of the nervous system may be controlled by bromid of sodium — from three to five grains, every three or four hours. During the stage of active congestion, in the first two weeks, from five to ten minims of fluid extract of ergot every four hours is supposed by many to have some effect in diminishing spinal congestion. Abso- lute rest, in an easy, recumbent position is very important during the first few weeks. No effort must then be made to stimulate the paralyzed muscles, and the parts must, if necessary, be kept in a natural position by straps or orthopedic apparatus to prevent early deformity by contractures. It is especially necessary in the case of drop-feet to raise and support these parts, after the symptoms of central nerve irritation have passed — usually in about three weeks; strychnin, massage, and electricity may be employed. If the muscles do not respond to the faradic current, galvanism may be employed. The late deformities of the disease come before the orthopedic surgeon for attempted correction. Tenotomy, various braces, and induced anchylosis for the " flail-joints" may all be required. Epidemic Paralysis in Children. The occurrence of epidemics of paralysis in children has been reported in recent years by a number of observers. They have generally been considered as cases of anterior poliomyelitis, and have natural y provoked renewed discussion as to the essential cause of this disease. The prevailing idea among recent writers appears to be that the spinal paralysis of children is an infectious disease, and occasional epidemics confirm this view. The abrupt onset, the fever, the gastric disturbance, occasional attacks of convulsions seen both in the epidemic and endemic forms of the disease point to its infectious nature. In the epidemic form, a considerable variation from the usual type of the disease has been noticed, some cases presenting the symptom-complex of Landry's paralysis, the infectious nature of which is known. It must be borne in mind, however, that while the microbic nature of poliomyelitis may thus by analogy be assumed, it has not yet been scientifically demonstrated. Medin reported an epidemic during the summer of 1887 in Stockholm with some fatal cases. In this country Dr. Caverly has reported an epidemic occurring in the summer of 1894 in Rutland, Vei mont. One hundred and thirty- two cases were reported, occurring oftenest in strong, healthy chil- dren. Many of the cases showed marked hyperesthesia of the skin 298 DISEASES OF CHILDREN. and others exhibited muscular rigidity of the neck or back. Eigh- teen of the cases were fatal, usually dying early in the attack. A curious feature of this epidemic was that domestic animals were affected by the disease. Horses, dogs, and fowls became paralyzed, and an autopsy on a horse and fowl showed the lesions of polio- myelitis. This epidemic occurred in a very dry season, and the same thing has been noted in most other epidemics. An interesting epidemic, reported by Dr. Chapin, occurred during the summer of 1889, at Poughkeepsie, N. Y., most of the cases being attacked betwean the middle of July and the middle of August. A peculiarity of this epidemic appeared to be the existence of severe pain in the parts affected by the paralysis. A number of the cases carefully examined showed absolute paralysis of the limbs affected, with loss of reflexes and apparently considerable pain on handling the part. There was such marked evidence of the action of some infectious principle that examinations of the blood from three cases were made by Dr. H. T. Brooks. These failed to give any positive results, although the specimens did show occasional minute micro- organisms (a diplococcus) to which, however, no etiological significance was attached because of the small number of specimens and also because the latter may have been contanrnatecl from the skin or other source. The prominent feature of pain and its more or less persistence in the affected limbs, brought up the question of neuritis. One of the cases proving fatal, a careful autopsy was made, and the nature of the disease in this particular case was proven to be poliomyelitis. It- seemed that while this epidemic was apparently of an infectious nature, in some cases the infecting principle attacked the anterior horn of the spinal cord, in others the peripheral nerves, and that possibly, in a few cases, both parts were attacked. Some of the cases were reported by the physicians in attendance to have made complete recoveries in from one to four months. In both the Stockholm and Rutland epidemics, polyneuritis was reported to exist in some of the cases with poliomyelitis. During the summer of 1907 an epidemic of considerable propor- tion existed in New York and the surrounding country. In this epidemic, pain in the extremities formed a marked feature, and in some cases marked cerebral symptoms were noted. Many of the cases showed great gastroenteric irritation at the onset of the disease. Occasionally headache and rigidity of the neck simulated cerebro- spinal meningitis. A few cases were reported n which symptoms of bulbar involvement occurred. A number of deaths were also reported THE INFECTIOUS DISEASES. 299 during this epidemic, the fatalities occurring early in the disease. It is believed that the following points will fairly represent the peculiar- ities of the epidemic form of paralysis in children: 1. The. disease is occasionally fatal, especially early in the attack. The endemic form is rarely, if ever, fatal in its ending. 2. There are great variations in the extent of the paralysis in the epidemic form. Many cases show very extensive palsy, involving all the extremities and the muscles of the back and neck as well. Other cases show a very slight loss of power, and the disease is doubt- less occasionally overlooked from this cause. 3. Pain seems to occupy a more prominent feature in the epidemic than in the endemic form. This pain may even last well along in the course of the disease. In the ordinary endemic disease if pain exists, it is not apt to last more than a day or so. 4. A certain proportion of cases in these epidemics seem to un- dergo a complete recovery. This rarely, if ever, happens in the endemic form. 5. The lesion tends to be more varied and extensive in the epi- demic than in the endemic form. It may include the following con- ditions: Polioencephalitis of Striimpell; poliomyelitis; peripheral neuritis, and occasionally meningitis. Acute Articular Rheumatism. {Rheumatic Fever.) Acute articular rheumatism is a febrile disease of the joints characterized by transitory inflammatory attacks which do not tend to suppuration. Etiology. — The infectious origin of the disease is accepted as a fact; although the direct etiological factor is still in dispute. The disease assumes certain characteristics in childhood which distinguish it from the adult type. The course is milder and shorter, while involve- ment of the heart is more frequent than in adults. Single epidemics and a succession of epidemics have been reported from time to time. Several members of the same family may be attacked simultaneously. The oral cavity and more particularly the tonsils have been re- garded by many as the portal of entry of the infecting organism. Predisposing factors are exposure and residence in cold damp apart- ments. Heredity seems to play a distinct part if the predisposing factors are present. The disease is not very common before the fifth year, although 300 DISEASES OF CHILDREN. cases have been recorded during the nursing period. One attack pre- disposes to subsequent attacks. Among the 76 cases studied clinically by Chapin the following were the ages: 6 mos. , 1 9 yrs., 9 11 mos. , 1 10 yrs., 5 20 mos. , 1 11 yrs. 8 3 yrs., 1 12 yrs., 7 4 yrs., 2 13 yrs., 9 5 yrs., 4 14 yrs., 4 6 yrs., 6 15 yrs. ,2 7 yrs., 3 17 yrs. 2 8 yrs., 11 Symptomatology. — An attack may be preceded by languor, loss of appetite, mild tonsillitis, abdominal pains, and indefinite pains in the joints. With the localized pain there is a febrile reaction of variable intensity, 102-104° F., and occasionally there is vomiting. The knee- and ankle-joints are, as in adults, most frequently involved. In chil- dren the hip and cervical vertebras and joints of the fingers and toes may be the areas attacked. Usually more than one joint is affected, but symmetrical involvement is not the rule. It is exceptional for the attack to persist more than a few days in any one joint. The joints, as a rule, are not exquisitely painful on active or passive motion, while the swelling, if any, is moderate. The fascia covering muscles may be attacked without any involvement of the joints. The sternocleido- mastoid muscle is especially liable to such attack. The acid perspira- tion so commonly observed in adults is rarely present in children A waxy appearance is observed in severe cases with insomnia, anorexia, and insatiable thirst. The blood findings are of no assistance in making the diagnosis. Mild, almost afebrile cases may, however, be followed by serious in- volvement of the heart. Complications. — These bear a direct relation to the toxins of the disease itself. Rheumatism in childhood is characterized by its cardiac complications; it thus must always be considered as a dis- ease of serious import. Nearly half of all the cases leave permanent cardiac effects. The mitral valve is most frequently affected. The involvement is accompanied by irregular rises of temperature and increased pulse rate. The symptoms accompanying valvular defects, however, may be the first indication for medical attention and lead to the discovery of. THE INFECTIOUS DISEASES. 301 their rheumatic origin. Pericarditis is present in 10 to 20 per cent, of all cases in children and is frequently associated with endocarditis, and is an important and often fatal ccmplication. Serous,, or sero- fibrous pleurisy, is a complication seen in severe and long-standing cases. Pneumonia and occasionally nephritis are rarer complications, in all probability due to mixed infection. A purpuric rash or an erethema may be seen as rheumatic manifestations. Chorea must be regarded as a distinct rheumatic manifestation and often may precede the disease. Involvement of the endocardium is not rare in cases of chorea. Rheumatic iritis is rare in childhood, but can be diagnosti- cated by a competent opthalmologist. Rheumatic nodules occasionally appear under the skin developing rapidly. They appear, as a rule, near the joints, and follow the course of the tendons. Sometimes they are painful on pressure. They may be from one to fifty in number, and may last for several weeks before absorption takes place. Prognosis. — Rheumatic polyarthritis in children tends to quick recovery. Relapses are common, and it is in these secondary attacks that the endocardium most often suffers. Fatalities may follow severe complications. Differential Diagnosis. — Septic arthritis as seen in scarlet fever and gonorrheal arthritis should be excluded, as should the rarer cases of pneumococcic arthritis. The history and the intense localization tending toward suppuration in the septic types will assist in making the diagnosis. A blood count in septic cases will show high leukocytosis. An exploratory puncture is often justifiable in establishing a prompt diagnosis. Scarlatinal polyarthriticles, as a rule, affect the wrist-joints first, then the shoulders, knees, and feet. They appear in the second or third week of the disease, and last about one week unless suppuration sets in. Pneumococcic arthritis is seen usually in the first and second years of life as a sequel of a bronchopneumonia, or a lobar pneumonia. The pus contains diplococci which stain by the Gram method. As a rule the affection is limited to one joint. Gonorrheal arthritis is rare in children, although often decidedly puzzling from a diagnostic standpoint, unless evidences of a previous gonorrheal mfection are obtained. It appears some weeks following the local attack. The knee-joints are as a rule, primarily involved, but in children it is very apt to be polyarticular. The articulations are extremely painful, there is a high irregular temperature and the effusion in the joints contains typical gonococci. 302 DISEASES OF CHILDREN. Syphilitic arthritis is symmetrical, and other evidences of the dis- ease may be present. Cases of epidemic poliomyelitis which complain of intense pain have been mistaken for rheumatism. The loss of the patellar reflexes and the electrical reaction will serve to distinguish them. Scurvy in infancy may occa- sionally be mistaken for rheumatic polyarthritis. The history, exami- nation of the gums, of the urine, the localization, and the X-rays will prevent a mistake in diagnosis. Treatment. Prophylactic . — Children predisposed to rheumatic fever or who have had an attack of rheumatic fever or chorea should avoid exposure to dampness or cold. The tonsils, if hypertrophied, should be removed. The diet must be carefully regulated and all forms of intestinal fermentation promptly treated. Management. — Rest in bed should be considered as the first and most important direction, and the patient should be kept in bed until all rheumatic manifestations have ceased. Wearing of woolen or merino undergarments is to be recommended. The diet may consist of milk, broths, paps, bread, and lemonade for the thirst. When the fever has passed, vegetables, eggs, and finally meats are allowed. Drugs. — The salicylates in the form of the sodium salts or, better still, novaspirin are effective remedies to control the attacks. Rest in bed and the early exhibition of the salicylates are the only weapons against the cardiac complications. Novaspirin in doses of 2 to 5 grains three to four times daily to a five-year-old child should be persisted in for a week or more. Salol, aspirin, phenacetin, salipirin, and salophen (see Dosage, page 64) may be substituted if the above remedies are not effective. Fig. 84. — Gonorrheal arthritis, com- plicating gonorrheal vulvo-vaginitis. Polyarticular in distribution. THE INFECTIOUS DISEASES. 303 The tincture of the chloric! of iron, five drops in water after meals in convalescence is beneficial. However, if the diagnosis be correct, aspirin or sodium salicylate will give speedy relief. The joints should be enveloped in cotton wool. Immobilization with splints, especially with restless children, will often give considerable relief. An ice-bag is applied over the heart for an unduly rapid pulse or endocardial involvement. Fig. 85. — Infectious arthritis. (Dr MncKenzie's case.) Infectious Arthritides. Following any of the acute infectious diseases, especially pneu- monia, scarlatina and typhoid fever, there may result an active inflammation in the joints or neighboring bony structures. These arthritides result from bacterial invasion in some instances, and in others are apparently the result of the toxic products of the under- lying disease. Suppuration may occur, as evidenced by fluctuation and tenderness. Aspiration is then indicated and, besides relieving the joint, assists in establishing the diagnosis from a bacteriological standpoint. These cases do not react to the salicylates or their 304 DISEASES OF CHILDREN. derivatives, and are to be distinguished by the greater degree and rapidity of the involvement and the tendency to suppuration. The temperature often assumes the wide variations seen in sepsis of any part of the body. Rheumatoids. Formerly these affections were classed under the head of chronic articular rheumatism, and much confusion has resulted from attempts to classify them as following or developing from rheumatic fever. One group of these cases often designated as villous ar- thritis results from thickening of the synovial sheath and an over- growth of the villi within the joint. This affection may be mono- or polyarticular, and spreads, if at all, only slowly from joint to joint. As a rule there is no fever, the joints assuming a swollen, waxy, shin- ing appearance. In cases of long standing the joints become more or less ankylosed and deformities result. Arthritis deformans sometimes occurs before puberty, but it is rare. The characteristic features are joint deformity, pain, and disability. The disease affects many joints at one time and progressively in- volves others. The joints of the fingers are, as a rule, the first to be affected. Later there is seen much atrophy of the soft parts and even of the bones themselves. These chronic forms must be differentiated from tuberculous and syphilitic arthritides. Syphilitic affections usually appear late in neglected cases and fortunately are rarely seen in children. There is an effusion of serofibrinous fluid into the joint accompanied by little or no constitutional symptoms. The history, and sometimes a specific inflammation of the cornea may definitely determine the diagnosis. Fig. 86.- Arthritis deformans in an eight- year-old girl. THE INFECTIOUS DISEASES. 305 Tuberculous arthritis is accompanied by bone changes and the X-ray should be employed to clear up a case that offers any difficulties in diagnosis. The tuberculin reaction, inoculation experi- ments in animals, or the tuberculin tests, cutaneous, percutaneous, and into the ocular conjunctiva, may also be employed as diagnostic aids. Treatment. — In the early stages, if there is any pain, rest in splints will afford much relief. As pointed out by Taylor, the diet should be nutritious and not restricted. Later massage and careful passive movements combined with baths sometimes lead to success. Ortho- pedic appliances and surgical intervention are often necessary to correct resulting deformities. Still's Disease. — This is a polyarthritis occurring in childhood which is as yet little understood. Clinically, it seems related to certain forms of chronic sepsis or tuberculosis. There develops an enlargement and partial ankylosis of the joint with some temperature of an irregular type associated with splenic hypertrophy, and quite general enlargement of the liver and lymphatic glands. As distinguished from the other rheumatoids. the disease does not tend to destructive changes in the joints, and in fact seems to be self-limited. Following the suggestion of Nathan, thymus extract in five- to twenty-grain doses three times a day may be given. Malaria. (Paludism.) Malaria is an infectious disease caused by the hemacytozoon of Laveran, and characterized by a periodic intermittent or remittent fever. Etiology. — The parasite is carried through the anopheles mosquito which is distinguished from the common mosquito or culex by the following characteristics (see Fig. 87) : Anopheles. Culex. 1. Two large palpi on side of 1. Small palpi, proboscis. 2. Mottled wings. 2. No spots on wings. 3. Body held at an angle 45° 3. Body held parallel. or more. Posterior legs often crossed over back. 4. More often found in the 4. More often found in cities. country. 20 306 DISEASES OF CHILDREN. The parasite of Laveran occurs in three forms: the tertian, quartan, and estivoautumnal. In the fall of the year the greater number of cases are seen. Regions in which much marsh land is found are favorable places for the breeding of the anopheles, and in these localities malaria is natur- ally more prevalent. Fig. 87. — A, Anopheles claviger; B, Specimen of culex; C, Different positions assumed by Anopheles and Culex when at rest. Pathology. — The tertian variety develops in the human organism in forty-eight hours. At first there is seen a small ovoid particle within a red blood-cell. Pigmentation appears as development pro- gresses around the periphery of the parasite. Ameboid movements may be noted. The hemoglobin of the red cell appears to be destroyed by the parasite. Segmentation now takes place, creating the spores which are freed in the blood stream and are ready to attack new red cells, and then pass through a similar cycle of development. THE INFECTIOUS DISEASES. 307 The quartan type completes its development in seventy-two hours, producing the characteristic paroxysms on the fourth day, in- stead of on the third as in the tertian type. It may be differentiated from the tertian by the lack of move- ment on the third day, and by the peculiar yellowish-green color of the cell, and by the rosette appearance on the fourth day. The estivoautumnal variety takes twenty-four to forty-eight hours to complete its cycle, and cresentic forms appear after a week of development. The parasite is sparsely pigmented and smaller in size. The gametocytes or sexually differentiated types develop only in the intermediate host. Sporozoids develop in the host or mosquito, and through its salivary glands infect the bitten individual where they develop into parasites and pass through one of the cycles as just described. In mild cases of malaria little alteration in the body structures may be found besides an enlarged spleen and changes in the blood. Malaria is rarely fatal in infants and children. In the pernicious forms both the liver and spleen are enlarged. In chronic malaria the spleen and sometimes the liver become hard and deeply pigmented. Symptomatology. — In infants (in whom it is quite rare) and in younger children the symptoms are irregular in form and the diagnosis often obscure. In older children the typical adult type is seen, pre- senting 1 ttle or no difficulty in diagnosis. A distinct chill or chilly sen- sations and sometimes a convulsion may usher in an attack. The child has been listless for several days or complains of being tired, stretches, and yawns. The extremities are cold, and the child seeks its bed for warmth. The common type in infants and younger children results from a double infection with the tertian parasite, producing the so-called quotidian fever. The temperature is high with a corresponding pulse rate. The estivoautumnal type is not often met with; it produces a very irregular form of fever with or without a definite paroxysm. The fever may be intermittent or even remittent in type; that is, a cont nuous fever with small excursions and no drop to the normal. In older children, as has been said above, the adult type is simulated. The period of chill is followed by the stage of fever and more or less perspiration. The temperature reaches 104° or 105° F. and is accompanied by headache, often vomiting and extreme thirst. A normal or subnormal temperature follows after the period of high 308 DISEASES OF CHILDREN. fever. The succeeding day a robust child may be willing to go about and play as usual. In the cities we see a subacute variety, usually in children, about the fifth year of age. They are brought because they are on differ- ent days listless, pale, and without ambition. The physical examina- tion often shows an enlarged spleen and characteristic blood changes. True chills are not experienced nor does one obtain a history of fever followed by perspiration. Malarial cachexia and the pernicious forms of malaria are rarely seen among children in the United States, at least in the North. In the cachectic or chronic type, the spleen is uniformly large and firm, sometimes extending to the crest of the ilium. In these cases the liver is apt to be enlarged. The child is extremely anemic, has a greenish- yellow tinge, and a poor complexion. Loss of appetite and constipation are commonly found. The urine is highly colored and may contain casts and blood. Differential Diagnosis. — Malaria must be differentiated from t}^phoid, secondary anemia, Banti's disease, and certain forms of neph- ritis. Repeated examinations of a fresh or stained specimen of blood, or both, should be made for evidences of the malarial organism. The therapeutic test with quinin may be made in suspected cases in which a blood examination is not feasible. The uniformly enlarged spleen found in malaria is a diagnostic feature of great importance. The spleen is said to be enlarged in a child when it can be felt. The Widal test and a differential blood count will often assist in fixing the diagnosis when a careful physical examination including the ears has been made to exclude other con- ditions. Treatment. Prophylactic. — The physician should be acquainted with the genus of mosquito in his locality. If the anopheles are present he should insist upon the authorities taking all possible measures to drain the swampy areas. The children's cribs should be closely screened. Water barrels and similar tanks must be protected by screens to prevent the development of larvae. The latter may be killed by the use of crude petroleum floated over infested pools. Therapeutic. — An initial purge with calomel is recommended. The early and continued use of quinin until a cure is effected is es- sential in any of the forms above mentioned. Relatively larger doses may be given to children than to adults. For infants and younger chil- dren, the soluble bisulphate is recommended. Its bitter taste is often less objected to by younger children than by their elders. The syrup of yerba santa best disguises its bitter taste if any addition is neces- THE INFECTIOUS DISEASES. 309 sary. Euquinin and tannate of quinin are tasteless preparations which may be given in mild cases. The sulphate of quinin in half- grain doses may be made more palatable by the use of chocolate in tablets or lozenges. The year-old child may be given one grain of the sulphate or bi- sulphate every three hours. A child of five years, three grains every four hours. Larger doses may be given on well days, and decreased or omitted during the paroxysms. Where the stomach is irritable and the quinin not retained, rectal injections of the bisulphate may be made, preferably in a mucilaginous suspension. Suppositories of quinin are not very satisfactory for continued usage. The hydrochlorate or bimuriate of quinin in cocoa-butter should be used for this purpose. The hypodermatic administration of quinin in children in this country is unnecessary and uncalled for. The chill is combated with a number of hot-water bottles, a hot pack or a hot bath. The oncoming fever is allayed with alcohol spong- ing and cool drinks in small quantity at frequent intervals. Quinin should be administered for at least a week following the last symptoms of malar' a. The elixir of iron, quinin and strychnia will do much to combat the resulting anemia, a half-dram three times a day after meals to a five-year-old child. Fowler's solution or Warburg's tincture are useful in the long-standing cases. Erysipelas. This is a constitutional infectious disease presenting a diffuse, rapidly spreading inflammation of the skin and subcutaneous con- nective tissue, and occasionally of the mucous membranes. Etiology. — No specific organism has been found in erysipelas, but a streptococcus is thought to be usually the active cause. It may occur in connection with a septic condition of the mother during or shortly after birth. The virus enters the system through an abrasion of the skin or mucous membrane. Symptomatology. — The disease is more apt to occur during infancy than childhood, and the earlier it appears after birth the more serious will be its effects. In robust infants the inflamed skin will present a deep-red color, while in feebler babies it will be lighter, pre- senting more of a pinkish appearance. The deeper tissues may likewise be involved in a phlegmonous inflammation in severe cases, and there may also be edema and finally some desquamation. In the newly-born the disease is apt to be contracted from some septic condition of the mother. It may then start at the umbilicus, in the 310 DISEASES OF CHILDREN. genital region, or from some point of abrasion consequent to the delivery. Where the umbilicus is affected, the disease is apt to extend inward, producing a peritonitis. In other cases pneumonia or empy- ema may ensue and hasten the fatal ending. In older infants the disease begins on some abrasion of the skin, frequently around the genital organs, but sometimes on the trunk, arms, or legs. It is not so apt as in adults to attack the face and scalp. The cutaneous redness Fig. 88 — Erysipelas, which began on the face and spread over the body. and subcutaneous infiltration spread rapidly, but with a sharp line of demarcation between the diseased and healthy skin. The affected part is usually hot to the touch. The constitutional symptoms are commonly severe, with evidences of prostration. The result of the pricking or burning pain is seen in great restlessness, disturbed sleep, and occasionally convulsions. The fever is irregular and high where much of the skin is involved. The pulse is usually rapid and feeble. There may be evidence of gastroenteric irritation, shown either by vomiting or diarrhea. In fatal cases death usually results from exhaustion or from some complicating disease, such as peritonitis or THE INFECTIOUS DISEASES. 311 pneumonia. Abscesses and even sloughing of tissues may accompany severe and deep-seated erysipelas. The tendency to spread is shown in some cases by the whole surface of the body becoming involved. There is frequently in infants a recurrence of the inflammation involving the same surfaces as were originally attacked. The disease may last from one to three or four weeks. Prognosis. — The prognosis will vary with the age of the infant and the extent of the inflammation. It is verjr fatal during the first month, and from that period up to the sixth month the outlook will be uncertain. After six months the prognosis is good. Constitutional symptoms are usually less severe when the arms and legs are involved than when the disease affects the region around the umbilicus or the neck and head. If the inflammation is superficial and spreads slowly, the prognosis is naturally more favorable than when it spreads rapidly and is more deep-seated with the character of a cellulitis. Treatment. — While the disease cannot be aborted, every effort must be made to sustain the strength of the infant by simple, nourishing diet. If the mother is septic, the baby must be removed from the breast, but otherwise maternal feeding offers the best chance for recovery. In bottle babies it may be necessary to weaken the formula or to peptonize when there are evidences of digestive disturbances. We believe that tincture of the chlorid of iron is beneficial, and an infant of a year old may be given three or four drops, well diluted, every three hours. As it is an asthenic disease, it is often necessary to stimulate, giving strychnin or whisky when the pulse is weak. Many cooling and antiseptic applications have been tried upon the skin, but with doubtful results. Ichthyol, a dram to the ounce, may be employed to relieve itching and burning and act as a local antiseptic. Infants with erysipelas should be isolated, particularly when near surgical cases or those apt to have any abrasion of the skin or mucous membranes. Their clothing and bedding should be disinfected at the termination of the disease. The polyvalent streptococcic serum may be tried in desperate cases, but our experience with its use prevents its recommendation as a general remedial measure. CHAPTER XXIII. DISINFECTANTS AND DISINFECTION. Disinfection has for its object the limitation of an infective process already begun, the protection of those already exposed and the pre- vention of the spread of the infection to others. The disinfectants commonly used may be divided into two groups, the aerial and the chemical. Aerial. 1. Formal dehyd. 2. Superheated steam. 3. Sulphurous acid (sulphur dioxid). 4. Chlorin. • Chemical. 1. Mercurial salts. 2. Carbolic acid. 3. Calx chlorata (chlorid of lime). 4. Formalin, etc. Formaldehyd gas is the best agent known at present for disinfec- tion of dwellings. If fairly concentrated, it kills bacilli and their spores. It acts rapidly, is less injurious in its effects on household goods, and is less toxic to the higher forms of animal life. To use formaldehyd, either of the following methods can be recommended. (a) Formaldehyd Generator. — A serviceable apparatus known as the Novy generator can be purchased for about four dollars. This consists of a copper boiler from which leads a tube; the latter is pushed into the keyhole of the door. About ten ounces of formalin solution (40 per cent.) is added to a quart of water in the boiler and an alcohol lamp or "Primus" blast lamp placed underneath and the whole boiled. On boiling, formaldehyd gas is liberated and led into the room through the tube. One thousand cubic feet of room space can be disinfected with the above amount. (6) Method of Houghton and Clark. — Place 240 gm. of potassium permanganate in a three-gallon pail and put this in a tub or on a large zinc stove; add 480 c.c. formol to this. Violent ebullition and foam- 312 DISINFECTANTS AND DISINFECTION. 313 ing results and formaldehyd gas is liberated. This will disinfect 1,600 cubic feet of space. The potassium permanganate can be mixed with 15 per cent, of Portland cement and enough water to make the mix- ture of sufficient consistency to mould into bricks. The action in this form will be slower and less violent, although just as efficient. Place the formol (480 c.c.) in the pail and add three bricks made as above, each containing 80 gm. of potassium permanganate. (c) If paraform is used, 1,000 grams are required for every 1,000 cubic feet of air space, the exposure lasting for at least six hours. Superheated steam is the most efficient measure for disinfec- tion known. Its use, however, is limited to institutions having an autoclave. Sulphurous acid results when sulphur is burned in air. Its potency is many times increased if the air is moist. When intensified in this way, this gas will destroy the non-sporing bacteria when in full con- tact. Spores are not killed even after long exposure. To fumi- gate by this method calk or seal the room with adhesive-plaster strips and have a pan of water boiling in the room to provide moisture. It will be necessary to burn four pounds of sulphur per 1,000 cubic feet and allow an eight-hour exposure. It is well to place the receptacle containing the sulphur on a low iron tripod which stands in a large pan of water. Two or three ounces of alcohol poured over the sulphur before igniting it will insure good combustion. The objections to this method are: (a) a good exposure of infected surfaces is difficult to obtain as in books, mattresses, carpets, etc.; (b) spores are not destroyed; (c) wall paper, pictures, and colored hangings are bleached or discolored; (d) all metallic articles are blackened by the sulphide formed. Chlorin is formed w T hen a strong mineral acid is mixed with chlorinated lime. Two pounds of the powder with an excess of the acid being used for 1,000 cubic feet of space. Chlorin is open to the same objections as the sulphur fumes when used as a disinfectant. Mercurial salts stand first among chemical disinfectants; the bichlorid, the biniodid, and the cyanid all being employed; of these, the bichlorid is the most potent and is most extensively employed. A solution of 1 to 1,000 will kill non-sporing bacteria in one minute and anthrax spores in ten minutes. Behring has shown that its effi- ciency is in inverse ratio to the amount of albuminous matter present in the material treated. With albuminous material, bichlorid forms an insoluable albuminate which prevents destruction of the inner portions. This feature makes bichlorid of mercury less suitable for use in disinfecting sputum, pus, or blood. 314 DISEASES OF CHILDREN. Carbolic acid in a one to twenty or 5 per cent, solution will rapidly destroy non-sporing bacteria, although their spores are not destroyed for several weeks. Albumin, if present, impairs its efficiency only slightly. Cresol, a derivative of carbolic acid, is also an excellent disinfectant. Calx chlorata (chlorid of lime) depends upon the formation of hypochlorous acid, for its efficiency. The alkalinity of the lime present renders a solution of this agent most valuable for disinfect- ing albuminous material, as it first disintegrates and then disinfects. For practical purposes, no other chemical can compare with this agent for the disinfection of sputum and feces. If equal parts of a dilute solution of acetic acid (1.25 per cent.) or vinegar and a saturated solu- tion of chlorid of lime are mixed together this agent will destroy spores in one minute. Chlorid of lime rapidly deteriorates if left uncovered, due to liberation of the hypochlorous acid. Herein lies the greatest objection to this agent, for much of the chemicals sold in the shops is too old to be efficient. Formalin is a 40 per cent, solution of formaldehyd gas in water. In solution its action is not as effective as would be expected, and there- fore it has not come into general use. As a gas, its potency is note- worthy and has been discussed under Aerial Disinfection. The Sick-room in Infectious Diseases. — Infection may be carried in the sputum, in the throat secretions, in discharges from the nose and ear, in skin debris, in exudations, in conjunctival or abscess dis- charges, and in the urine or stools. The sick-room should be stripped of superfluous fittings; it should be in a remote part of the house, and preferably on the top floor. A large room with plenty of ventilation and sunshine and with an open fire should if possible be selected. A gown and hood should be provided for the physician and hung in a separate outside closet where it can be later disinfected. All clothing worn by the attendants in the sick-room should be washable, and a com- plete change should be made before mingling with the members of the household. When changes in linen are made for the patient or atten- dant the articles are to be rolled up in a bundle and put to soak for twenty-four hours in a carbolic (1 to 20) solution before being sent to the laundry, where they are to be washed separately. When it is known that anyone has been exposed to an infectious disease, they should be isolated as soon as possible and given a bi- chlorid of mercury (1-5,000) bath and a complete change of clothing. Such individuals should be kept under close observation until the incubation period for that particular disease has passed. Scrupulous cleanliness with regard to the excreta and discharges of DISINFECTANTS AND DISINFECTION. 315 the patient is imperative. Soft Japanese paper napkins are most con- venient for wiping nose and throat discharges. They must be burned at once after use. Carbolated vaselin rubbed over the skin of patients suffering from variola, varicella and scarlet fever prevents the pus, exudations, and epithelial debris from drying and being scattered. Urine and stools should be treated with equal volumes of carbolic acid solution (1 to 20), bichlorid of mercury (1 to 1,000) or chlorid of lime (1 to 50), and allowed to stand three or four hours before disposing of them. Large masses in stools should be broken up to insure thorough disinfection. In cases in which the throat is involved, frequent gar- gles of chlorin water, potassium permanganate (1 to 300), formalin 1 per cent, or peroxid of hydrogen reduce the number of bacteria in the expired air besides having a beneficial effect on the patient. Dishes and utensils used by a patient are to be placed for an hour in a large receptable containing carbolic solution (1 to 20) and then boiled or scalded. The remains of one dying of an infectious disease should be em- balmed with a fluid which will stand the bacteriological test. Close all external openings of the body with absorbent cotton and give a thorough sponge bath (including the hair) using carbolic solution (1 to 20) or bichlorid of mercury (1 to 1,000). The following plan is recommended for the disinfection of the room where a patient with an infectious disease has been treated: 1. close all openings in windows, walls, and floors by calking or pasting strips of paper or adhesive plaster over them; 2. stretch out on a line all linen, blankets, and carpets contained therein; 3. spray with water the floors, walls, and all articles in the room; 4. introduce the disin- fecting gas and allow the room to remain closed up for twelve hours. CHAPTER XXIV TUBERCULOSIS. Tuberculosis is an infective fever caused by the toxins of the tubercle bacillus, and characterized by the formation of heteroneo- plasms called tubercles. Any organ or part of the body may be at- tacked. The disease may be confined to certain organs or may be generalized, occurring at the same time in many parts of the body. Etiology. — The tubercle bacillus upon which tuberculosis in any or all of its manifestations depends, is a rod-shaped, facultative, color- less bacillus, slightly bent and having rounded ends. In size it is about one-fourth to one-half the diameter of a red blood-cell. It is especially distinguishable for its staining properties. It strongly resists decolori- zation after having been stained with acid dyes. There are several varieties of the bacillus. We are mainly concerned here with the human and bovine types. The controversy regarding these types is not yet settled, but the distinction still seems to be a strong one between these forms. The bovine type of bacillus differs somewhat in form, being more irregular, thicker or oval in shape with blunted ends. The types may also be differentiated by cultural methods. This method, however, is suitable only for a laboratory specialist. The bacillus is easily destroyed by sunlight or heat, either dry or moist, but is not affected by low temperatures. The disease occurs at all ages — fetal tuberculosis has been re- corded (Jacobi, Wollstein, and others). The invading microorganism gains entrance to the body through three main channels, given in the order of their relative importance; through the respiratory tract, through the intestinal tract, and through wounds and abrasions of the skin. Infants and children are infected mainly through the respiratory tract. Hereditary predisposition is still the subject of argument, but the position held by Adami appeals to us. He believes that two possi- bilities may result from parental tuberculosis; the offspring may be- come especially susceptible if the germinal cells become weakened by progressive disease, or if the disease is well resisted the child may acquire an increased resistance to the disease. 316 TUBERCULOSIS. 317 Parental diseases, nutritional faults and developmental defects in the parents often leave the offspring with a lowered resistance to tuberculosis. A child with poor muscular development, with a flat and narrow chest and small abdomen is considered to have a disposition to tuber- culosis; we can add to this class children who are mouth- breathers and have defects of the nose and mouth. In childhood there is little resistance to the disease; the glands, meninges, bones, joints, and lungs are easily invaded and are believed by v. Behring often to remain latent and develop in later life into the pulmonary form. Again, in childhood the disease is not apt to develop at the site of infection as in adults, but extends to other tissues and forms tubercles there. The entity known as scrofula is still acceptable to Continental Europe; but in America the weight of opinion is that scrofula indicates tuberculosis, and we believe with Baldwin that it can be used to mean an important predisposition to pulmonary tuberculosis, which he says is associated with it in 25 per cent, of all cases. Measles, whooping cough, diphtheria, pneumonia, influenza and, in a lesser de- gree, scarlet fever, tonsillitis, and variola are often the precursors of tuberculosis, because of their effect on the mucous membranes and lymph-glands accompanied by the lowered resistance of the conva- lescent child. Rickets, too, is a disease favoring tuberculous infection when accompanied by defective nutrition and thoracic deformities. Finally, gastrointestinal diseases from their destructive action on the mucous Fig. 89. — Conformation of the chest com- monly seen in tuberculous children. 318 DISEASES OF CHILDREN. membranes lead sometimes to open infection and probably often to the latent form. The children of poor parents in unsanitary surroundings, whether in city or even in the country, are prone to the infection, which they may receive from the following sources: Human sputum, through food objects or dust, urine or feces on soiled clothing or beds. Milk of tuberculous cattle has been held as a distinct source of danger, but the case has not been fully proven. Certainly, bovine tuberculosis in our experience is a minor factor in the causation of the human form of the disease. Milk as a food, however, may be indirectly contami- nated by dust or infected containers. Infants at the breast have been infected by their mother's soiled hands or her kisses. Cornet reports infection by midwives who blew into the mouths of the infants to start up respiration. Children are intimately connected with the fact that tuberculosis is a " family disease" — 40 to 60 per cent, disclosing a history of other cases in the household; and this close contact is the great infecting method : the nursling infected by close touch with its mother, the creep- ing infant on the contaminated floor carrying all things to its mouth, the school boy trading toys — all show at a glance the numberless ways in which children may become tuberculous. Tuberculous Adenitis. This may be confined to certain groups of lymph-glands, as the cervical or bronchial, or there may be an involvement of all, or nearly all, the lymph nodes of the body. The glands become infected by access of tubercle bacilli through the lymph channels. The point of entrance may have been only a slight abrasion or some form of dermatitis. The glands may also become infected from tuberculous lesions in their vicinity. A cross section of a tuberculous gland shows the parenchyma swollen and hyperplastic, grayish in color, containing nodules varying in size, some of which are undergoing caseation. If the latter process is advanced, the gland is soft and the tubercles are found at the margins only. The glands most commonly involved are those at the root of the lung. The mesenteric lymph nodes are frequently infected in children and are the usual accompaniment of the miliary and general- ized forms. Symptomatology. — The subjects of tuberculous adenitis are, as a rule, anemic children of the blond type. The appetite is capricious or lost, the weight decreases, and at this time the parent may notice TUBERCULOSIS. 319 an enlargement of a gland or group of glands. They are not painful to the touch, growing slowly but steadily; sometimes there is a rise of fever, especially in the evening. Physical examination may show tuberculous lesions elsewhere in the body. If the cervical lymph nodes are involved the tumors are at first found in relation with the sternocleido mastoid muscle. At first they are freely movable, but the chain of glands increasing, they soon adhere one to the other, Fig. 90. — Tuberculous adenitis of the cervical and axillary glands. forming sometimes large masses which may even cause mechanical obstruction. Bilateral involvement is not uncommon. The overlying skin now becomes attached to the mass below, and when the glands caseate the skin is thickened and loses its normal color, often becoming purplish-red. If there is no surgical intervention the glands rupture through the overlying skin or dissect the fascial planes; the abscess may discharge at some distant point. Often several long-persisting fistulous tracts result. In the generalized form, the cervical, inguinal, and axillary 320 DISEASES OF CHILDREN. glands show the greatest and earliest involvement. The children are markedly anemic and often have a variable amount of temperature. Wasting slowly takes place and new foci are found developing in other parts of the body. Bimanual rectal examination will show the involvement of the retroperitoneal and mesenteric lymph nodes. When the bronchial lymph nodes are large, pressure symptoms may occur, causing a paroxysmal cough w r ith breathing signs of bronchial asthma. In advanced cases dyspnea is produced on slight exertion. Sometimes dullness is obtained on percussion over the manubrium wdiich extends over a varying area. This is usually accompanied by tubular breathing on the left side. Diagnosis. — The diagnosis of tuberculous adenitis is based upon the slow course and the absence of active inflammatory changes, such as heat or pain on palpation. Simple adenitis can usually be traced to some source of infection, as an eczematous area, caries of the teeth, etc. These glands subside when the focus of irritation is re- moved. If there are evidences of tuberculosis in other structures, tuberculous adenitis may be suspected. The tuberculin tests (p. 54) may be used to corroborate the diagnosis. Syphilitic glands are distinguished by their location. The epitrochlear glands show simultaneous enlargement w^ith other syphilitic manifestations in different parts of the body. Lymphosarcoma is sometimes confounded with generalized tuberculous adenitis. This disease usually primarily involves the retroperitoneal glands or those within the mediastinum. The growth here is rapid, invading neighboring structures, and often producing serious symptoms before the true nature of the disease is suspected. Course and Prognosis. — It is often difficult to predict the end- result of a tuberculous adenitis. The prognosis should always be considered seriously as a focus which may at any time spread the disease to the lungs or other structures. If the subject is young and can be placed in favorable sur- roundings, restitution to the normal may take place. Even degener- ated glands with fistulous tracts may eventually terminate in a cure under proper care. Treatment. — Immediate steps should be taken just as soon as the diagnosis is certain to remove the child, if possible, to the seashore, where it should live in the sunshine and fresh air. The diet should be as nourishing as possible, consisting principally of milk, eggs, cereals, and rare meats. Cod-liver oil, if well borne, should be given twice a day, after the midday and evening meal. If this is not acceptable, good results can be obtained by increasing the quantity of butter, TUBERCULOSIS. 321 cream, or top milks. Sometimes olive oil in two-dram doses twice a day can be substituted if the child prefers it. Surgical removal of the glands may be considered when they are superficial and movable. The dissection is often long, tedious, and dangerous when the glands are deep and are in proximity to the great vessels. General miliary tuberculosis may follow the removal of glands when a clean dissection is impossible. However, it is some- times necessary to resort to removal for the cosmetic effect or for the relief of pressure symptoms. Good results have been obtained in a number of cases from radiotheraphy and it would seem best to counsel non-interference until these measures have been given a fair trial. Thoracic Tuberculosis. It is only within recent years that the frequency of pulmonary tuberculosis in early life has been correctly appreciated. From a study of all necropsies in children under fifteen years of age, Harbitz at Christiana found tuberculosis in 42.5 per cent, of all. Denning shows that 70 per cent, of all infants and children who die from tuberculosis show tuberculous changes in their lungs. Pediatrists incline toward the respiratory tracts, while pathologists lean toward the alimentary tract as the principal portal of entry; the contro- versy, with much to be said on both sides, concerns us in regard to prophylactic measures to be spoken of below. Tuberculosis in early life increases rejgularly with the age. It is rare in the first three months of life, and then almost, month by month, the frequency increases steadily. The figures of Hamburger and Sluka, obtained from 2,557 necropsies on tuberculous children under fifteen years, report that tuberculosis was the direct cause of death in all those under six months of age; that it caused death in 75 per cent, of those in the second year of life, and in the children over two years old it became more infrequently the cause of death. Necropsy find- r ngs, however, are not absolute indications of the prevalence of tuber- culosis in early life since virulent bacteria may be present without producing demonstrable lesions. Tuberculosis in early life is a disease of the lymph nodes, but after the tenth year the pulmonary form is more prevalent; and again after adolescence the characteristics do not differ greatly from those seen in adults. Pulmonary involvement may occur by direct infection from ca- seous tuberculous glands through the blood stream or by emboli, and through the lymph channels from tuberculous lymph nodes, bones, or pleura. 21 322 DISEASES OF CHILDREN. Pulmonary Lesions. — The pathological anatomy does not differ greatly from that seen in adult life, but the areas involved are always greater; in other words, the disease is more diffuse. This is especially true in the first two years of life. In tuberculous bronchopneumonia, which is the predomi- nating and fatal form, there occur large caseating deposits usually to some extent in both lungs. When a mixed infection occurs the nodules are very apt to degenerate. True cavities of any size, however, are rarelv seen in early life. The glands at the root of the lung are invariably enlarged and often soft and caseating. The pleura is almost always involved. In miliary tuberculosis of the lungs, the tubercles are scattered over the surface of the lung, and in some cases have been found in the parenchyma. Patches of bronchopneumonia and congestion with edema may be present, or the lung may appear quite normal ex- cept for the superficial tubercles. Diagnosis. — The diagnosis of incipient tuberculosis of the lungs differs considerably in early life from that of adults. In the first place the apices of the lungs are not most frequently involved; it is the lower lobes or the lower part of the upper lobe that is primarily involved, which may often be accounted for by the proximity of the bronchial glands. The physical signs often do not differ from those obtained in bronchitis and bronchopneumonia, and the }^ounger the child the more diffuse will be the disease. Therefore it is necessary to employ every means at our command to perfect the diagnosis. The physical signs with the symptoms and the history then become of value. In obtaining a history in suspected children, it is especially im- portant to ascertain if the child has been in intimate or close contact with a tuberculous patient, or if there has been a slow convalescence from any of the infectious diseases, especially measles and pertussis. Gibson has called attention to a venous dilatation occurring over the chest, neck, and shoulders of children, and tending to converge above the sternum. This, when present, is a valuable sign, and it is probably due to tuberculous bronchial lymph nodes. If we could safely and surely diagnosticate enlarged bronchial lymph nodes we would have valuable confirmatory evidence. D'Espine says he has a reliable method in voice auscultation; in the healthy child the tracheal tone stops at the seventh cervical spine, but is heard below this point in pathological conditions. Later on, dullness over the seventh cervi- cal or first dorsal vertebra with intrascapular dullness may be elicited. Cavity formation is rarely recognized under three years of age, while TUBERCULOSIS. 323 alter eight the signs will simulate those in the adult. Expectoration is the exception in children, while under seven years hemoptysis rarely occurs and practically is never observed in those below five years old. Three groups of thoracic tuberculosis may be distinguished in children; the glandular, tracheobronchial, and the pulmonary. The symptoms are never so characteristic as in the adult; as a rule, there is a rapid development of symptoms. If we encounter steady emacia- tion, progressive muscular weakness, an irregular temperature with a fairly constant evening rise, enlarged superficial glands, with a per- sistent dry cough, we are justified in utilizing diagnostic aids to confirm the diagnosis. In adults, a diagnosis may sometimes be made by physical signs before the tubercle bacilli are found in the sputum. In infants and young children, however, we are pleased if we obtain any sputum to examine, and must be prepared to make diligent search for the bacillus. Among the methods used with success in obtaining sputum from in- fants is wrapping a piece of gauze on the end of the finger and irritating the epiglottis thus catching the sputum. We use an ordinary laryn- geal swab wrapped with cotton which is quite effective and does no damage to the delicate mucous membranes. The sputum being often swallowed, the vomitus or the feces will also contain the bacilli, but the search is more arduous. The opsonic index has been studied by numerous investigators in its relation to tuberculosis, and is considered of value in obscure cases. Clark and Forsyth have made careful studies, and base their diagnosis on the following variations: (a) the greater the fluctuation, the greater the certainty of diagnosis; (b) a persistently low index is diagnostic of localized tuberculous infection; (c) a persistently normal index does not exclude tuberculosis, but makes it less probable; (d) a persistently variable index is diagnostic of tuberculous infection with autoinoculation. Ross states that he has never found an index of 1.3 in a patient not definitely tuberculous. Ogilvy and Coffin, as a result of their studies, believe that the difficulty and tedious technic of estimating the opsonic index and the wide variation obtained by various observers make this procedure impracticable for diagnosis. Injections of tuberculin may be used diagnostically as a last resort if it is imperative that a definite diagnosis be made. In children the reaction is more favorable than in adults. Its use, however, is limited to those cases without temperature. The dose which is safe in children is one ten-thousandth of a c.e. of Koch's old tuberculin, one three-thousandths being the maximum dose. 324 DISEASES OF CHILDREN. The agglutination and the heated serum tests have been tried, and the reports are quite uniformly against their practical value. Other tests, however, have attracted considerable attention and they are especially applicable in children. Von Pirquet advanced the inoculation of Koch's old tuberculin into the skin in two areas, leaving one area for control. Von Pirquet uses one part tuberculin, diluted with one part of a 5 per cent, carbol- glycerin solution, and two parts normal saline solution, of this two drops are inoculated. The writer has used one part tuberculin to three parts saline solution freshly prepared. Butler sums up his extensive observations as follows: (a) a positive reaction is undoubtedly diagnostic; (b) failure may be expected in the terminal stages; (c) negative results may be obtained in obsolete foci unless repeated. He believes the method has distinct advantages over the hypoder- matic use of tuberculin. Calmette, simultaneously with Wolf-Eisner, proposed the ocular method in which a 1 per cent, solution of dry tuberculin in distilled w T ater is dropped upon the lower eye-lid of the eye. In three to five hours a reaction occurs, varying from a slight conjunctivitis to a purulent secretion. This test has been quite favorably received, and indeed is of distinct value in establishing an early diagnosis. Wolf-Eisner interprets a lively reaction as indicative of incipient tuberculosis, coupled with a favorable prognosis, for the organism is then active against the tubercle bacilli. He believes the eye test to be of greater value clinically than the cutaneous, but would use the cutaneous as a control. The presence of conjunctivitis, bleph- aritis, ulcers, or trachoma are contraindications for the use of the ocular test. The Moro test, described on page 55, is simpler to perform, causing no distress or unpleasantness except slight itching. It may be used alone or as a confirmatory test to the other methods. Pulmonary Tuberculosis. Acute and Subacute Forms. — Etiology. — Mainly through the bron- chial lymph nodes, the infection is carried to the lungs of infants and children; the lung may be more directly affected, however, through the impoverished mucous membrane following certain infectious diseases. Tuberculosis in other structures predisposes to lung infection. The generalized process in the lungs is part, and usually the termination, of a miliary tuberculosis, while the localized process is most often found close to the bronchial glands. Acute tuberculous bronchopneumonia in infants and young TUBERCULOSIS. 325 children does not markedly differ in its physical signs from the simple bronchopneumonia, but the period of illness sometimes lasting from two to six weeks must be suggestive. The fever is generally lower and with smaller excursions than in the ordinary form until the toxemia itself produces high evening rises up to 103° or 104° F. Loss of weight is slow but progressive. The appetite is capricious, the patient is irritable, easily tired and at times somnolent, the bowels are, as a rule, constipated, although diarrhea may periodically appear. The fever causes restlessness at night and in the morning. The body and clothing may show that sweating has taken place. The cough is paroxysmal in character, and is apt to be more frequent upon awakening. As the disease progresses, circulatory changes are evidenced by cyanosis in the finger-tips and lips. Dyspnea is easily caused by slight exertion or coughing. Hemoptysis is exceedingly rare in children. If death does not supervene, the affection may appear elsewhere, as in the brain, intestinal tract, or in the glandular structures. Physical Signs. — These may not differ from the ordinary broncho- pneumonic type of the disease. Occasionally only are there signs of cavity formation, or well-developed signs of bronchial and peri- tracheal glandular hypertrophy. The latter signs, if obtainable, are of distinct diagnostic importance. The examination of the sputum, obtained with a laryngeal swab or from the stomach contents, urine, and feces, may reveal the pres- ence of tubercle bacilli. Chronic Pulmonary Tuberculosis. This form is rarely seen under five years of age. In the cases that have come under our observation, the tuberculous process was extremely diffuse in character. The physical signs do not markedly differ from those of the adult type. Progressive loss of weight, night-sweats, extreme anemia with high leukocytosis, and frequent attacks of gastroenteritis are the symptoms which finally precede death. At any age the pleura may become involved in the tuberculous process, and an empyema result. The pus in these cases is thinner and more watery in consistency, and only rarely can the tubercle bacilli be isolated. These cases do not tend to recovery; further lung involvement takes place, and death often results with meningeal symptoms. 326 DISEASES OF CHILDREN. Course. — The course of the disease in early life varies with the form. There is a latent form in which the characteristic features are irregular fever, rapid emaciation, and late pulmonary signs. The affection runs a speedy course, terminating sometimes in a few days to a fortnight. The child with the bronchopneumonic or the more usual variety may live several weeks. In exceptional cases the patient has lived six months. The chronic form, under favorable circumstances, such as the modern sanatorium treatment gives a more favorable prognosis; that is, there is a tendency toward arrest of the process. Fig. 91.— Clubbed fingers in chronic pulmonary tuberculosis. Acute Miliary Tuberculosis. This is an acute general infection with tubercle bacilli, occurring at any period of childhood. As a rule, it is secondary to some primary focus in the body, which may have been dormant for some time. Etiology. — Measles, whooping-cough, and tuberculous lymph nodes are the exciting causes. The disease occurs quite commonly in early life, especially the meningeal form or tuberculous meningitis. McCrae had forty-three cases of generalized miliary tuberculosis in 417 autopsies on tuberculous individuals, among these were fifty-five children. The meninges were involved in twenty-one, and the tho- racic lymph nodes in thirty-three cases. Two forms of the disease are recognized — the general and local — based upon the symptoms. In the general form the symptoms in the early stages are such as to simulate beginning typhoid. There is irregular fever with no characteristic curve malaise, loss of appetite, slow emaciation at first, TUBERCULOSIS. 327 becoming more marked as the disease progresses. The pulse is in- creased out of proportion to the temperature. Rapid, shallow breathing is later followed by the Cheyne-Stokes type as the disease progresses, or if meningeal symptoms intervene. Vomiting is often an early symptom. The spleen is enlarged almost invariably and the liver, too, is often increased in size. A disturbing slight cough is generally present. The urine contains traces of albumin and hyalin casts, and occasion- ally tubercle bacilli can be found. Inoculation tests from the blood may confirm the diagnosis. The younger the child the more often does the meningeal form bring on a rapid termination. Delirium, stupor, and coma denote cerebral involvement. The usual course is from three to six weeks. The prognosis invariably is hopeless. Differential Diagnosis. — The Widal test and the more typical tem- perature curve, with the characteristic eruption, plus the relative increase in the mononuclear elements in typhoid, must be depended upon to distinguish this form of tuberculosis from typhoid, although this is sometimes extremely difficult. In miliary tuberculosis, besides the tuberculin test, an ocular examination may, especially in the later stages, show tubercles in the choroid, or fluid withdrawn from the spinal canal may show tubercle bacilli. Local Manifestations. — Miliary involvement of the lungs usually occurs after measles or whooping-cough, or is secondary to a broncho- pneumonic process. The physical signs offer no help in differentiation. The diagnosis in children is extremely difficult until the disease has progressed to some other structure, as the brain, when more character istic symptoms are obtainable. Tuberculous Meningitis. The tubercle bacilli spread from some focus of infection through the lymph channels or blood current to the meninges, and usually form an eruption of miliary tubercles at the base of the brain, spreading up to the vessels in the fissure of Sylvius. An inflammatory exudate is almost invariably found in the space between the optic chasm and the peduncles. The exudate is yellowish-green in color, tenacious and adherent to the pia mater. The ventricles are more or less distended with fluid, in some instances forming a distinct internal hydrocephalus. The ependyma if carefully amoved is found to be rough, edematous, and may be infiltrated with tubercles. The pia mater is injected with a serofibrinous or seropurulent infiltrate. Not infrequently the tubercles are seen in the choroid plexus. Occa- 32$ DISEASES OF CHILDREN. sionally there is only a slight amount of exudate, and the infection is found to be localized in the form of one or more nodules, some the size of hickory-nuts which are known as solitary tubercles of the brain. Etiology. — Tuberculous lymph nodes which have become diseased as a result of the acute infectious diseases, especially peitussis and measles, play the principal role in the causation. A latent tuberculous focus may set free the tubercle bacilli into the blood stream. A tuber- culous osteitis or an infection in the uropoietic system may be respon- sible for the meningeal involvement. A number of cases seem to be traceable to a chronic otitis media. Unsanitary surroundings, espe- cially in a tuberculous environment, predispose to the disease. On the other hand, it occurs among the well-to-do, and may attack a child that has been considered exceptionally healthy. It commonly occurs below the age of five years. Infants of five months have been reported who have died of the disease. (Rilliet). In Koplik's series of fifty- two cases, eleven were less than one year old, while the average age was slightly over four years. Symptomatology. — It is impossible to give a typical description of the symptoms of this disease, so varied are its manifestations. The prodromal symptoms usually come on gradually and insidi- ously. A previously healthy child becomes irritable, morose, and refuses to play. Lassitude, coated tongue, loss of appetite and occa- sional vomiting are, as a rule, attributed to digestive disturbances. If the child is old enough, headache, dull in character, is complained of. Progressively the symptoms grow more marked until signs of cerebral irritation appear. Occasionally the onset is abrupt with fever, vomit- ing, and pressure symptoms. The diagnosis may not be suspected until the child refuses to leave the bed. The pulse rate in infants is usually increased; in older children it may be irregular in character. Vomiting occurs irregularly and with no regard to the food ingested. The temperature is not high, rarely over 101° F. and may be normal during the morning hours. The mentality is dulled and the child is aroused with diffi- culty. The food is taken without protest or interest. Infants may show increased tension by a bulging fontanel. A high-pitched scream, which if once heard is easily recognized and known as the hy- drocephalic cry, often accompanies the headache which may now be intense. Except in infants the abdomen becomes flat or sunken in the later stages, forming the so-called scaphoid abdomen. Con- stipation is the rule. Rigidity of the muscles of the neck may be noted, but distinct retraction may never occur or only in the final stages. There may now supervene irregular or associated ataxic movements. TUBERCULOSIS. 329 The respirations are slow and irregular, with the inspiration prolonged and sighing. The pupils may be unevenly contracted and react slowly or not at all to light. Nystagmus may be an early symptom, while conjunctivitis, strabismus, and ptosis usually appear in the final stage. Marked apathy with delirium and coma supervene. Occa- sionally convulsions may occur. The pupils are now almost constantly dilated. The extremities are rigid or spastic, although paralyses, mono- plegic or hemiplegic in type, may appear before the terminal stage. Fig. 92. -a, Tuberculous meningitis; patient semi-comatose; b, tuberculous meningitis; last stages, coma absolute. The respirations tend now to the Cheyne-Stokes type. The final stage is usually known by the frequent convulsive seizures. The emaciation is now rapid, the pulse becomes small and irregular until the agonal stage. The eyes are sunken. Edema of the lungs may be found on physical examination. The rigidity of the neck is supplanted by paralyses in various parts of the body. Examination of the fundus usually shows an optic neuritis. The urine and feces may be involun- tarily passed. The temperature toward the end may rise to 105° or 106° F., or there may be a sudden drop to subnormal. The reflexes are usually inhibited in this stage. Kernig's sign and the Babinski reflex are present in about 50 per cent, of the cases. MacEwen's sign, or a tympanitic note on percussion over the ventricles, is obtained in those cases in which there is an internal hydrocephalus. If obtained in children over two years of age, it is of value in establish- ing the diagnosis. 330 DISEASES OF CHILDREN. Lumbar puncture is of great importance in making the diagnosis and sometimes is the only practical method of making the specific diagnosis. In this form of meningitis the fluid frequently flows out under increased pressure; it usually is clear and contains a greater amount of protein than normal. Fehling's solution occasionally is reduced by the fluid. If the proper technic is followed, the presence of tubercle bacilli can be demonstrated, although such expert labor should be placed in the hands of a trained pathologist. Inoculation experiments into animals may also be made for confirmation. Mononuclear cells, sometimes over 90 per cent., are present in the fluid. Course. — The duration is usually from three to four weeks. Occasionally there are periods of apparent improvement, which may give rise to a false hope of recovery. On the other hand, cases have remained under our observation for many weeks with slow and pro- gressive emaciation, finally terminating fatally. Diagnosis. — The slow onset, the lack of hyperesthesia, the slower pulse and respiration, and the type of temperature curve, with the aid of lumbar puncture, are the only definite means of differentiation from the cerebrospinal type. Some intracranial diseases may in their incipiency lead to con- fusion unless the characteristic symptoms of a meningitis are sought for. Prognosis. — Although there have been several reported cures in cases in which tubercle bacilli were found after repeated lumbar punctures, the disease must be regarded as quite hopeless. Treatment. — Quiet and rest, with bromids for the relief, of the nervous symptoms, and lumbar puncture for the relief of intra- cranial pressure, with frequent repetition of this procedure if followed by amelioration of the symptoms, are indicated. The diet, usually liquid, is taken in a bottle or may be given by gavage. Iodid of potash and inunctions of mercury have proved valueless in our hands. Tuberculous Peritonitis. Tuberculous peritonitis is a comparatively rare affection, although this variety of peritonitis is more frequently seen in childhood than the non-tuberculous forms, and a diagnosis, first as to the condition itself, and then as to its particular variety, is of importance because of the direct bearing on the prognosis and surgical treatment. The peritoneum may become involved from a tuberculous focus in any part of the body. The disease is nearly always secondary and the TUBERCULOSIS. 331 infection is carried through the lymphatics or blood stream. Bovaird in 125 cases of general tuberculosis found the peritoneum involved in 7 per cent. From an anatomical standpoint four forms are usually recognized. Miliary, miliary with ascites, the ulcerative, and the fibrous variety. The miliary, form is met with in cases of general infection. It is practi- cally impossible to make antemortem diagnosis of this form. The tubercles are found scattered over the peritoneum and intestines in large or small numbers. Adhesions form, binding the viscera to themselves, to the neighboring organs, and the abdominal wall. On opening the abdominal cavity a serous or seropurulent fluid is found. The peri- toneum is clouded and streaked with lymph. In older cases adhesions form. The Ulcerative or Caseating Form. — Postmortem findings in this variety show caseating foci in the peri- toneum. Lymph or pus takes the place of ascitic fluid. The intestinal coils are matted with fibrinoplastic deposits. The abdominal wall may also be found ad- herent to the intestines. Tuberculous masses are found scattered over the parietal and visceral peritoneum, while in some cases ulcerations occur. The glands are usually greatly enlarged, and may be found in sacculations filled with purulent fluid. Fistulous tracts may occur and perforate at or near the umbilicus. The fibrous form rarely gives evi- dences of an effusion. There is an abundance of lymph on a thick- ened peritoneum, studded with miliary tubercles. The peritoneal cavity may be completely obliterated by the dense matting and firm adhesions. Rolls of omentum are occasionally seen, covered with fibrous tissue. The intestines themselves adhere to each other. The characteristic of this form is a tendency to the formation of cicatricial tissue. Fig 93. — The ascitic form of tuberculous peritonitis. 332 DISEASES OF CHILDREN. Symptomatology of the Special Forms. — Ascitic Form. — The symptoms may be very insidious. There is a slow but steady increase in the size of the abdomen, and constipation alternates with diarrhea. There may be vomiting, the appetite is capricious or lost. Careful examination may now elicit fluid in the abdominal cavity. The superficial veins over the abdomen and lower chest are prominent. There is an evening rise of temperature, and progressive emaciation is noted. Rectal examination may disclose peritoneal nodules and enlarged mesenteric glands. An acute form is occasionally seen in which the symptoms simulate an inflammation of the small and large intestines. The fever is quite high, the abdomen rapidly becomes distended with fluid. The prognosis is better in the insidious form. Ulcerative Form. — The symptoms are those of various grades of enteritis. There is vomiting, constipation or diarrhea, abdominal pain, loss of appetite, with occasionally bloody stools. The fever is quite high, irregular in type with occasional sweating, especially on exertion, and considerable prostration. Percussion shows areas of dullness or flatness, alternating with areas of tympany. Bimanual rectal examination may give strong evidence of the matted condition of the intestines. Occasionally the stools contain blood. Pus may be discharged through openings near the umbilicus. Emaciation is extreme, and the end comes through asthenia. Fibrous Variety. — The symptoms come on very gradually with some colicky pains in the abdomen. The bowels are usually constipated. There is some distention of the abdomen. Nausea and vomiting or symptoms of obstruction may lead to a careful examina- tion of the abdomen, and the masses or rolls of omentum with some intraabdominal fluid may assist in establishing the diagnosis. Diagnosis. — A child between the ages of one and six years who has lived in an environment of tuberculosis or whose vitality has been lowered by an infectious disease, and who is languid, peevish, and has an evening rise of temperature with some enlargement of the abdomen, should be carefully examined for tuberculous peritonitis. The child may present the phthisical habitus or only appear to have lost some flesh. The skin is almost constantly dry and harsh. Passing the hand lightly over the abdomen, subcuticular nodules about the umbili- cus are often felt. Fluctuation may be readily made out, or a sus- picion of fluid only may be found on palpation and percussion. Bi- manual rectal examination in the semirecumbent position should now be made to confirm the presence of fluid and to further ascertain the TUBERCULOSIS. 333 condition of the intestines, whether they are free or bound by a fibrino- plastic exudate. One accustomed to the normal conditions as found by the examining finger in children will appreciate the changes pro- duced by a plastic exudate, and may furthermore feel hypertrophied mesenteric lymph nodes and a band of adhesions running transversely across the abdomen. If the process has so far advanced that rolls of omentum, or agglutinated masses of mesentery and intestine have formed, palpation over the abdomen and the finger in the rectum will readily reveal the presence of these tumors. The abdomen may then appear flat or gas-distended, and Thomayer's sign of dullness on percussion on the left side of the abdomen, with a tympanitic note on the right side, may be obtained; in this latter condition fluid is rarely made out before operation, and only small quantities are seen on opening the abdomen. In the early stages of the ascitic form we should if possible exclude circulatory, renal and hepatic disturbances, and abdominal growths. The general nutrition may still be fairly good. The fluid readily gravi- tates to the dependent section on change of position. Corrobora- tive evidence may be obtained by finding Marfan's symptom, that is, the presence of pleuritic friction rales at the base of the lungs, sometimes associated with small exudations into the pleura. Pain is rarely obtained on palpation, but indefinite colicky pains are com- plained of. If, coupled with the above symptoms, the skin is harsh and dry, and subcuticular nodules are present over the abdomen, the diagnosis, now fairly certain, should be confirmed by laboratory and tuberculin tests. The frequent use of the thermometer showing pre- dominating small evening rises and the presence of large numbers of lymphocytes always tend in favor of a tuberculous process. In a tuberculous peritonitis the mononuclear leukocytes are generally increased. Cytological study of the tapped ascitic fluid may also assist in confirming the diagnosis. The diagnosis in the first form is not always certain without further tests, and even the last-described variety may cause confusion. If a chronic peritonitis of the tuberculous variety is suspected, a very thorough examination of the entire body should be made for possible tuberculous disease in other organs not only to confirm the diagnosis, but to determine what shall be the character of the treat- ment and the prognosis. For if the lungs are involved and the spleen and liver are enlarged, general miliary tuberculosis is in all probability present, and the patient is beyond the hope of recovery. Whether or not the peritoneal process is tuberculous may be confirmed either by the skin-inoculation test of Von Pirquet, by the Moro reaction (i.e., a 334 DISEASES OF CHILDREN. 50 per cent, tuberculin ointment) or by the Calmette test; but this is not recommended if there is any possibility of corneal involvement. The catheterized urine may be centrifuged for the presence of tubercle bacilli, or inoculation tests can be made with guinea-pigs. Treatment. — The trend of opinion, buoyed up by some successful re- sults in recent years, tends toward operation in all cases of tuberculous peritonitis, especially as the operation is comparatively simple and not dangerous to life. If more regard had been paid to the general ex- amination and only selected cases operated upon, the statistics would have been steadily in favor of operation. The ascitic form of local- ized tuberculous peritonitis does well under laparotomy, the plastic form rarely does well; fistulae are apt to form, and the lungs frequently show early involvement following the laparotomy. Again, if the di- agnosis can be made early in the ascitic form non-operative interference may be counseled provided the circumstances are such that all the anvantages accruing from life at the seashore, rest and nutritious food are possible. Otherwise the child should be watched, and if the exudate is on the increase operation should be recommended. A life in the fresh air, confinement to bed while an active process is going on, food high in proteids and fats, with the addition of cod-liver oil and the syrup of the iodid of iron are indicated after laparotomy, and for the inoperable cases. Bone and Joint Tuberculosis. {Caries of Bone.) This affection is the result of the invasion of tubercle bacilli in the spongy portion of the bone. Usually beginning as a single focus it spreads and often involves the whole epi- physis.. Tubercles are formed which later may degenerate, forming many necrotic areas which may merge to form a caseating area. Granulation tissue is found at the periphery. In some instances a sequestrum forms or an abscess results. The joints are infected through the cartilage, and the disease rapidly spreads to the synovial membrane where ulcerations form. When the cartilage be- comes detached, destruction begins in the bare bone. In this way deformities so common in and about the joints are produced. Fig. 94. — Tuberculous dactylitis. TUBERCULOSIS. 335 Etiology. — The infectious diseases, especially measles and scarlet fever, are probably more often the direct cause of tuberculous joint diseases than traumatism. Any devitalizing disease, however, must be considered as a factor. The affection is extremely rare in infants. After the third year it is distinctly a disease of childhood. Tuberculosis of the Vertebrae. (Pott's Disease; Caries of the Spine; Spondylitis.) This affection is the result of a tuberculous osteitis in the spongy portion of the bodies of the vertebra. It is extremely common in early childhood, and, according to Taylor, more than half the cases occur under six years of age. The dorsal region is most often affected; the cervical less commonly. Diagnosis. — If careful physical examinations were oftener made with the child completely undressed, the diagnosis would more frequently be reached in the early stages. The abnormalities which should attract attention are the rigidity of the spine, and in walking a deficient mobility of the spinal column when tested by the examiner. Deformities due to necrosis of the bone will be apparent on observation, often form- ing the familiar humpback. The peculiar attitude and gait assumed may attract attention, even before the child is undressed. In cervical Pott's disease, wry-neck may be the first symptom complained of. The differential diagnosis from other forms of torticollis is sometimes very difficult. The slower onset, the posture, and the general muscular fixation serve to distinguish it. Dorsal Pott's disease is distinguished by the erect military gait, the lateral deviation, with a bony deformity, which can be palpated and usually easily seen. Lumbar Pott's Disease. — Here the attitude of lordosis should Fig. 95. — Torticollis, due to cervical Pott's disease. (Bradford and Lovett.) 336 DISEASES OF CHILDREN. attract attention, especially if accompanied with deviation to one side, and a careful abnormal gait. Hyperextention of the leg in the prone position elicits the sign of psoas contraction. Paralysis. — This may occur at any time in tuberculous spinal disease, although as a rule it occurs as one of the later symptoms. The patellar reflexes are in- creased, ankle clonus may be pres- ent, and the pain, if absent before, is now present or increased in severity. A rachitic spine is often mistaken for Pott's disease. The curve, however, is rounded and the spine is supple. If the child is raised with the hands of the examiner in the axilla the curva- ture tends to disappear. Other bony changes or the symptoms of rickets may be present. The de- formity in Pott's disease does not disappear when the child is raised or is in the prone position. Treatment. — This is mainly orthopedic and involves the use of apparatus to promote spinal rest (Fig. 98) and the correction and prevention of deformities. The medical treatment encompasses dietetics and hygienic manage- Fig. 96 — Dorsal Pott's disease. ment. Tuberculous Disease of the Hip. (Hip-joint Disease; Morbus Coxa; Coxalgia.) This affection is due to a tuberculous osteitis of the head of the femur, of the acetabulum, or both. The disease usually begins gradually, the parents first noticing a limp. Night cries occur, but pain is a very variable symptom. The attitude assumed is one with a little flexion of the knee of the affected side and a slight tilting of the pelvis. In later stages of the disease much can be learned by testing TUBERCULOSIS. 337 the child for freedom of motion, picking up objects, mensuration, pain and swelling. The classical symptoms upon which a diagnosis can be based with certainty are limit of motion, muscular spasm, pain, swelling, attitude, shortening and atrophy of muscle. The X-rays and the tuberculin tests may be required in difficult cases. Fig. 97. — Lumbar Pott's disease. Treatment. — Immobilization and protection of the joint by casts, traction, and later, braces; a life in the open air and good food do much to assist the orthopedic measures. Osteotomy and excisions are performed only in desperate cases. 22 33S DISEASES OF CHILDREN. Tuberculous Disease of the Knee. (Gonitis Tuberculosa; White Swelling.) The epiphyses are nearly always primarily involved. It is most commonly observed in children, and, after the spine and hip involve- ment, it occurs most frequently. The diagnosis is usually quite readily made, as the knee-joint easily lends itself to examination. Swelling, with lameness which may be intermittent, are the first diagnostic symptoms. Stiffness and pain follow. Muscular spasm on passive motion may be observed. The knee may be held in a posi- tion of flexion. Infectious synovitis is distinguished by the more rapid onset, temperature, and signs of localized inflammation. Chronic synovitis is very slow in its course and is not accom- panied by much lameness or pain. Sometimes crepitus may be ob- tained. Eventually a true tumor albus may result. The X-rays. tuberculin, and inoculation tests may be made if necessary. Treatment. — The medical treatment does not differ from that of tuberculosis elsewhere. The joint should be encased in a splint Fig. 98.— Infant with Pott's disease on which will prevent joint motion of a Bradford frame. the knee and foot. Treatment of Tuberculosis in General. Prophylactic. — There are but few diseases in which prophylaxis can accomplish so much for the child as in tuberculosis. Upon the physician and health officer the duty devolves, and it begins even before conception. It is largely a problem of sociology and preven- tative medicine. Laws which have lately been passed in many States prohibiting the sale of tuberculous milk and meat, tenement-house inspection, TUBERCULOSIS. 339 health-board notification, and the educational exhibits will all tend to decrease the spread of this disease. Tuberculous mothers should not nurse their children because of danger in the close contact. Milk for infant feeding should be obtained from tuberculin tested cows, or should have the stamp of approval of a medical commission as being "certified." Where this is not possible the milk may be pasteurized. The children of tuberculous parents should be brought up, if possible, in the country and early trained to live an outdoor life. Such defects as adenoids or carious teeth should be removed. They should be especially guarded from measles and whooping-cough. School houses should be so arranged that proper ventilation can be obtained in rooms with ample air space and sunlight. Teachers, who as a class are particualrly susceptible to the disease, should be frequently examined. Knoff has formulated the following valuable set of rules for school children: Do not spit except in a spittoon or a piece of cloth or a handker- chief used for that purpose alone. On your return home, have the cloth burned by your mother or the handherchief put in water until ready for the wash. Never spit on a slate, floor, sidewalk, or playground. Do not put your fingers into your mouth. Do not pick your nose or wipe it on your hand or sleeve. Do not wet your fingers in your mouth when turning the leaves of books. Do not put pencils into your mouth or wet them with your lips. Do not hold money in your mouth. Do not put pins in your mouth. Do not put anything into your mouth except food and drink. Do not swap apple cores, candy, chewing-gum, half-eaten food, whistles, bean-blowers, or anything that is put into the mouth. Peel or wash your fruit before eating it. Never cough or sneeze in a person's face. Turn your face to one side and hold a handkerchief before your mouth. General. — Reports from the sanatoria would indicate that the child over four years of age afflicted with tuberculosis in the incipient stage has a better prognosis than the young adult. This is borne out by our own dispensary cases which have had but in different oppor- tunities, and still have shown gratifying results. The diet for these children should consist principally of milk, eggs, and fats; such as butter, cream, olive or cod-liver oil, and meat 340 DISEASES OF CHILDREN. for older children. The syrup of the iodid of iron should be given. If the appetite fails a change from inland to seashore or vice versa may be proposed, or if this is not feasible the tincture of nux vomica with the compound tincture of cardamon can be given before meals. Medication directed to the disease itself is useless and often harmful. In hopeless cases the symptoms are alleviated as they arise. The tuberculin treatment is again being tried in children's hos- pitals and with more success. Good results are obtained in localized conditions and some cases having pulmonary involvement have been benefited. The former unsatisfactory results are attributable to our meager knowledge of its action, and probably to overdosage, which seemed to produce harmful results. Children in whom the disease seems to be arrested, as shown by absence of temperature and increase in weight, aie especially suitable f >r the tuberculin treatment. The injection in these quantities may be given twice a week until a tolerance is reached when the dosage may be slowly increased by 0. 1 mg. , depending upon the effect produced. T2W0 to -g-^o^ mg. of T. R. tuberculin is given to a child one year old. 40V tf m g- f° r a child five years old. -gwo m £- f° r a child ten to twelve years old. Its effect on the opsonic index should be watched, and a dose given every two weeks. If obtaining the opsonic index is not feasible, the weight and general progress of the child must act as guides. SECTION VII. DISEASES OF THE RESPIRATORY TRACT. CHAPTER XXV. DISEASES OF THE UPPER RESPIRATORY TRACT. Acute Rhinitis. This is quite commonly seen in infants and children, and is due to bacterial infection as a result of a temporary or prolonged lowered resistance. This is made possible by keeping the child in superheated apartments, sudden changes of temperature, or exposing it to direct infection from a member of the household. There is at first a constant serous and later mucopurulent discharge from the nares, with irri- tability, restlessness in sleep, loss of appetite, and a slight temperature. In infancy the symptoms are of greater import than in childhood, as it may seriously interfere with nursing and thus add to the lowered resistance through malnutrition. Sleep is broken, feeding rules are interfered with and disturbances of the gastrointestinal tract may re- sult. Older children complain of fullness in the head and chilliness. Children who have frequent attacks of rhinitis are ofttimes sufferers from adenoids. Treatment. — While rhinitis is a self-limited disease, lasting from one to two weeks, it should not be left untreated. The infection may spread to the lower respiratory tract and end disastrously. If pos- sible, remove the indirect cause, as, for example, badly heated and unventilated rooms. The child is best confined to one room, especially if there are other children. Locally liquid albolin with camphor gr. i to the ounce may be instilled into the nose. A solution of adrenalin chloricl 1 to 5000 in infants and 1 to 1000 in older children gives tem- porary relief before suckling and at bedtime. Morse found it neces- sary to introduce a small rubber catheter into each nostril in a serious case to enable it to breathe. Small supportive doses of strych- nia yts t.i.d. are sometimes necessary to assist the child in ridding itself of the infection. The ears should be examined daily, as an otitis is very likely to supervene by extension. Epistaxis. Bleeding from the nose is not often seen in infants, although not uncommon in children; when it occurs in infants it is usually a result 341 342 DISEASES OF CHILDREN. of adenoids, syphilitic rhinitis, or an ulceration of the nasal mucous membrane, commonly found on the anterior and inferior portion of the septum. Children are liable to nose-bleed because of their tendency to acquire turgidity of the nasal mucous membrane. Traumatism, ade- noids, foreign bodies, and purulent rhinitis are among the more common causative factors, while a nose-bleed is also seen in the course of many of the infectious and blood diseases of early life. A history of frequent epistaxis should lead one to think of and examine for adenoids, ulcers, or cardiac disease. Treatment. — Keep the child in the upright position and apply pressure with the ringers against the septum, meanwhile having an ice application held over the cervical spine. If bleeding still persists pack the nose with cotton which has been dipped in a 1-2000 adrena- lin solution. As soon as feasible, make a careful examination for the underlying cause. If an ulcer, cleanse and apply a 20 per cent, solution of nitrate of silver. If adenoids are present, they must be removed; this is especially true in infants who have frequent nose-bleed. Warning should be given the attendant as to the significance of swallowed blood from a nose-bleed, which may occasion unnecessary alarm when vomited. Foreign Bodies in the Nose. In children, usually between two and five years, it is not uncom- mon to find that they have placed various objects in their noses. These may cause immediate symptoms of annoyance or distress or, becoming lodged, cause a unilateral nasal discharge that is persistent. Closer examination shows a partial or total occlusion of that side of the nares, a mucopurulent discharge, occasionally blood-tinged, and, with some objects, an odor of putrefaction. We have removed peas, pearl buttons, shoe-buttons, paper, and a kernel of corn. Treatment. — Place the child in a good light and use a small nasal speculum. The object if in situ for some time may be covered by mucous membrane or altered in appearance so as to be unrecogniz- able. If there is still doubt, a probe slightly bent can be inserted and the obstruction recognized; wipe out the discharge and with a nasal forceps, snare, or hook remove it. If the object has been recently inserted and is not high up, causing the child to sneeze by tickling the opposite side has succeeded easily in effecting its dislodgment. The rhinitis induced clears up rapidly after the offending material is removed. DISEASES OF THE UPPER RESPIRATORY TRACT. 343 Examination of the Throat in Infants. A careful inspection of the throat should be made as part of the routine examination of the sick infant. Many attacks of fever and illness in infants are due to inflammation of the throat, such attacks being not infrequently attributed to some other cause. The principal reason for such a possible error lies in the diffi- culty in getting a satisfactory view of the fauces. This is especially true in very young infants. The tongue is high and the soft palate and pillars of the fauces low down, so that it is extremely difficult to get a clear view of the parts. Unless a satisfactory view is obtained at the first attempt it becomes increasingly difficult, if not impossible, to see clearly at all. The opening is so small that a little mucus produced by the irritation of a second or third examination com- pletely obstructs the view. In addition to this some milk is apt to be regurgitated from the stomach, and then it is abso- lutely impossible to see the real condi- tion of the mucous membrane. The writer has had such difficulty at times in satisfactorily examining the throat in young infants that he has de- vised a tongue depressor for this purpose (see Fig. 99). Most of the tongue de- pressors in use are not only too large, but do not have the proper slant for the infant's tongue. As a result, the back of the tongue, not being properly held, arches up and obstructs the view of the fauces. The depressor here presented is small enough for the youngest infant's mouth, and is intended to curve over the tongue to the base of the epiglottis. It can likewise be used in older subjects. By exercising a little pressure downward and forward the parts will come into clear view. Of course the infant should be properly held and placed before Fig. 99. — Chapin's tongue depressor (straight). 344 DISEASES OF CHILDREN, a good light (Fig. 101). When everything is in readiness the left hand is used to steady the head while the right hand manipulates the depressor. These details will naturally suggest themselves to the careful physician but are often overlooked, with the result of unduly fretting the infant and failing in the examination. Pharyngitis and Tonsillitis in Infants. — In infants, tonsillitis, as distinct from pharyngitis, is rare. The whole mucous membrane of the pharynx and tonsils is involved in the inflammation. The tonsils may be somewhat enlarged and are covered with very fine pin- head points of a whitish exudation. These points can be recognized only when the fauces are well exposed in a good light. In rare instances Fig. 100. — Chapin's tongue depressor (curved). the uvula is swollen and infiltrated. The secondary forms of pharyn- gitis seen in most infective diseases will not be here considered. The primary form is apt to be overlooked from the absence of symptoms referable to the throat, and the inability of the infant to call attention to the affected part. The swelling of the lymph-glands of the neck, so often noted in diphtheria and scarlatina is not usually present in primary pharyngitis. The two most common predisposing causes of primary throat inflammation in infants are: (1) disordered stomach and (2) exposure to cold. The frequent mistakes in the feeding of infants, especially overfeeding, produce an acid fermentation in the stomach. By direct continuity the mucous membrane of the pharynx and mouth may become irritated and inflamed. When the latter happens the temperature keeps up instead of subsiding when the stomach is relieved of its contents by vomiting or by their passage into the bowel. Exposure to cold is likewise a common predisposing DISEASES OF THE UPPER RESPIRATORY TRACT. 345 cause. Many infants, especially among the poor, are too warmly clad, especially about the neck and chest. As a result the skin is constantly moist. Such infants live and sleep in overheated rooms. In these cases an ordinary exposure to the cold air of draughts will induce throat inflammation. It will be noticed that the causes here given are mentioned as predisposing. Most, if not all, forms of tonsillar and pharyngeal Fig. 101. — Method of holding; infant for examination of the throat. inflammation are due to the presence of microbes. In health and under good hygienic conditions the mucous membrane of the throat may not be unfavorably affected by microbes, but under depressing conditions, particularly when the digestive tract is in an irritated condition, the throats of infants are vulnerable. It is quite possible that many impurities may likewise find their way to the mouth and throat by means of dirty fingers or objects which are given to infants as toys and which quickly find their way to the mouth. 346 DISEASES OF CHILDREN. Treatment. — The treatment consists in removing the cause, whether it be a deranged stomach, defective action of the skin, or faulty hygienic surroundings. The recurrence of attacks of pharyn- gitis in infants is the most common cause of postnasal rhinitis in children. The repeated irritation induced by these attacks causes hypertrophy of the adenoid tissue at the vault of the pharynx which is the invariable accompaniment of rhinitis in the later years of childhood. The immediate treatment consists in opening the bowels with a mild laxative, such as castor oil or calomel, followed by small and frequent doses of tincture of aconite, one-quarter to one-half a drop every two hours. If restlessness is a prominent symptom, a grain of phenacetin may be given every three hours for a few doses. As the acute form of the disease is self-limited, it is not well to give drugs very freely, especially those that tend to upset the digestion. The importance of recognizing the condition consists in taking steps to prevent its recurrence. Acute Pharyngitis. Definition. — An acute inflammation of the pharynx and neigh- boring structures. Etiology. — Sudden exposure to inclement weather which is dust and germ laden predisposes to the affection. It is present in the early stages of many of the acute infectious diseases and may accom- pany gastric disorders. Exposure to chemical irritants in the form of vapors which produce a pharyngitis. Children with obstructions in the respiratory tract, especially adenoid growths are liable to repeated attacks. Symptomatology. — Locally there is seen a reddened congested pharynx with the uvula and tonsils sharing in the inflammatory process. The larynx and nasopharynx may also be involved. There may be a rise of pulse and temperature, but this is rarely high. The child complains of sore throat and difficulty in swallowing. Under appropriate treatment there is a rapid subsidence of symptoms. Diagnosis. — With high temperature and vomiting scarlet fever must be kept in mind. Measles will show the presence of Koplik's spots, while a diphtheritic process will show a beginning membrane and give a positive culture. Treatment. — Prophylactic treatment resolves itself into the re- moval of any obstructions to proper breathing and the maintenance of proper resistance against infections. Locally. — Cold compresses applied every half-hour. Mild anti- DISEASES OF THE UPPER RESPIRATORY TRACT. 347 septic gargles for older children, such as the Liq., antisepticus alka- linus N.F. or Dobell's solution, one part to eight of water will suffice if used every two hours. Constitutional. — An initial laxative, such as the citrate of magnesia or calomel, should be prescribed. If there is high temperature and much discomfort, phenacetin with salol 2 grains of the former to 1^ grains of the latter for a five-year-old child will be efficacious. The diet should consist of cool demulcent preparations, such as oatmeal or barley gruel, junket or ice-cream. Acute Follicular Tonsillitis. (Acute Amygdalitis.) This is a self-limited disease of short duration, usually bilateral, with constitutional symptoms and a marked local infective process involving the tonsillar crypts and the entire glandular structure. Etiology. — Children with rheumatic tendency or of a strumous type are prone to acute attacks; those with chronically enlarged ton- sils being particularly susceptible. In these latter cases, slight exposure to cold often brings on an attack. One infection predisposes to a second, presumably because of the presence of bacteria in the crypts or their accessibility to the tonsil through the mouth and nose. Symptomatology. — The onset of tonsillitis is sudden; a chill or chilly sensations often being the first evidence. This may be followed by marked prostration, malaise, and vomiting. The temperature is high, frequently rising to 104° or 105° F. At first the tonsils and soft palate are reddened and swollen, and in a few hours cream-colored isolated spots appear on the tonsil plugging the mouths of the crypts. These spots are about the size of a pin-head, though at times they coalesce, forming a pseudomembrane which can be easily wiped off with a swab without producing a denuded or bleeding area. The membrane does not spread io the soft palate nor to the pillars of the pharynx. Frequently the glands at the angle of the jaw are enlarged and these together with the inflamed tonsils produce considerable dis- comfort and pain on swallowing. A routine examination of the throat in all cases will often disclose a tonsillitis which has produced no subjective symptoms. Course and Prognosis. — The inflammatory condition is active for at least three or four days even under treatment, but because of the constitutional symptoms convalescence may be slow; ten days usually elapsing during this stage. The prognosis is good if the patient is well 348 DISEASES OF CHILDREN. cared for, though the danger of endocarditis and the possibility of peri- tonsillar abscess must not be forgotten. Differential Diagnosis. — At the onset, tonsillitis may be confounded with malaria, pneumonia, scarlet fever, or influenza. A careful his- tory and blood examination will usually eliminate the first; a careful physical examination and absence of disturbed pulse-respiration ratio would differentiate it from pneumonia, while further observation for twenty-four hours will render the diagnosis more certain on account of the more characteristic appearance of the tonsils. From diphtheria, the absence of Klebs-Loeffler bacilli, the sudden onset and initial chill, the position and character of the local lesion, the high temperature and the absence of a history of exposure to diphtheritic infection point strongly to the diagnosis of follicular tonsillitis. (See Plate XI.) In ulceromembranous tonsillitis, the constitutional symptoms are much milder; the pain in the throat more severe, and enlargement of lymph-glands more marked. The local lesion is usually one-sided, the affected tonsil being covered with a dirty yellowish exudate closely resembling the membrane of diphtheria. Treatment. — Rest in bed is imperative on account of the great danger of endocarditis. Depletion by calomel gr. y-g- every half-hour for ten doses will reduce the intoxication. Hot fomentations or cold compresses to the throat will give relief from pain. Alcohol sponge baths when the temperature is high will add materially to the comfort of the patient. During the first twelve to twenty-four hours the following may be given to a child two years old. 1^ Phenacetini gr. h Salol gr. j Oleosacchari anisi, q.s. M. Ft. pulv No. j Misce et signa. — One every three hours. For young children who have not learned to gargle, a very effi- cient local application to be used on a swab every two or three hours is the following: 1$ Tincturae iodini tij> iv Argyrol gtt. iij Aquae q.s. ad. 3ss Misce et signa. — Swab on tonsils every two to three hours. Older children may gargle with the Liq. antiseptic, alkalinus (N. F.) or any of the equally efficient mild antiseptic solutions. Ulcero-membranous Tonsillitis. (Vincent's Angina.) Clinically, this affection closely resembles a mild diphtheria; bacteriologically, the findings show the presence of an elongated DISEASES OF THE UPPER RESPIRATORY TRACT. 349 fusiform bacillus and long wavy spirilli. The general symptoms are mild or absent except for the pain in the throat which is severe. The lesion is a superficial ulcer on the tonsil the size of a dime, usually unilateral in location, of a dirty yellow color, and exhibiting no great tendency to spread. The ulceration is deep, and upon attempt to pull off the membrane the underlying surface bleeds slightly. The cervical glands are enlarged and the muscles along the side of the neck are stiff and tender. The pulse and temperature are moderately increased, the latter closely resembling the temperature in diphtheria. As a rule, the breath is foul and there is much drooling. Hot antiseptic gargles and mildly astringent applications (see p. 348) locally combined with hot or cold external applications are very efficient measures of relief. The disease runs much the same course as a follicular tonsillitis. A smear and culture should be made in all suspicious cases for purposes of differentiation. Chronic Tonsillar Hypertrophy. A condition of chronic enlargement of the tonsils is seen in many children giving a history of repeated attacks of tonsillitis, or as a result of the infectious diseases. Adenoid vegetations and hyper- trophied tonsils are associated in many cases. Symptomatology. — There is impaired phonation and the train of symptoms which are associated with adenoids, the distress being especially produced at night during sleep. Restlessness and snoring are more marked. Treatment. — Chronic enlargements should be removed. For children the guillotine is preferred, a size suitable for the patient being selected. Cocain as an anesthetic should not be used. If adenoids are present remove the tonsils first. In unruly children an anesthetic is necessary, and the child should be prepared as for the adenoid operation. The head may be slightly raised and the assistant should gently press the tonsils from the outside, toward the middle line. The results obtained do not seem to warrant complete excision with special instruments as has been advocated by some throat specialists, but complete enucleation with the finger is often desirable and produces less traumatism. 350 DISEASES OF CHILDREN. Adenoids. (Hypertrophy of the Pharyngeal Tonsil.) This term is applied to a hypertrophy of the lymphoid tissue normally found in the pharyngeal vault. Etiology. — Adenoids are found at all ages and are far from infrequent in infants. Children who have lived in a poor hygienic environment or whose parents have chronic diseases seem to inherit a tendency to adenoids. They are usually associated with enlargement of the faucial tonsils. Rickets and the condition known as the lymphatic diathesis predispose to adenoid vegetations. Kerley believes that the pernicious use of the so-called comforter with the constant sucking is directly productive of adenoids. Fig 102. — Typical adenoid face. Symptomatology in Infants. — The symptoms differ considerably in infants, and therefore will be described separately. The babe may be brought because it cannot suckle without frequently stopping to breathe through its mouth. Sleep is broken and the infant cries and almost chokes when it drops into a deep sleep. A persistent rhinitis is commonly observed, and sniffling may be the most prominent symp- tom. The expression is not changed as in older children. In Children. — In early cases the child is brought for examination because of frequent " colds in the head" associated with troubled sleep DISEASES OF THE UPPER RESPIRATORY TRACT. 351 and snoring. In more aggravated conditions, mouth-breathing, snoring at night with tossing, restless sleep, and occasional night terrors should lead, to a careful nasopharyngeal examination. In typical cases, the vacant expression, fish-like face, and open mouth, often with a high arched palate, are readily noted. The face in these mouth-breathers has been visibly deformed (Fig. 102), and the following characteristics make the diagnosis simple: partly pursed mouth, pro- truding lower jaw; narrowed long face; V-shaped palate; enlarged tonsils; narrow alae nasi; dull eyes; pale mucous membranes; narrowed chest, sometimes otitis and evidences of general malnutrition. These children have a nasal twang to the voice and are poor scholars. They tire easily, do not eat well, and may suffer from incontinence of urine. There may be partial deafness from obstruction of the Eustachian tube. If a granular pharyngitis with plugs of mucus hanging from the posterior nares is observed, adenoids are usually present. A useful test generally indicating nasal obstruction due to adenoids is to request the child to repeat the words "clapham common" which he cannot enunciate without a nasal twang. Examination. — In infants it is a difficult procedure, but may be occasionally accomplished with care and patience; the little finger must be used for exploration as the space is so small. In older children the finger properly protected should be passed into the nasopharyngeal space and the amount and character of the adenoid tissue appreciated. Soft pendulous masses or firm growths may be felt and, if the vault is found to be occluded with hypertrophied tissue, operative interference should be resorted to. Occasionally it is necessary to give a whiff of chloroform before the examination can be made, or this can be deferred until ready to operate. Treatment in Infants. — If the symptoms of obstruction are such as to interfere with the infant's nutrition, the adenoids should be carefully and completely removed by an expert. Palliative measures are ofttimes successful in less aggravated cases, and we have found the instillation of a mixture such as the following to be of benefit : 1$ Camphorae gr. j Menthol gr. ] Resorcini gr. ij Benzoinol §j Misce et signa. — Five drops every three hours into the nose with a medicine dropper. or 1$ Adrenalini inhalantis 3ss Liquidi albolini q. s. ad oss Misce et signa. — A few drops in nose, night and morning. 352 DISEASES OF CHILDREN. In Older Children. — Palliative measures here are useless. The operation should be performed under a general anesthetic if there are no contraindications, such as bronchitis, acute tonsillitis, etc. The adenoids, and if present, the enlarged tonsils are removed at the same time. The after-treatment is to break up the habit of mouth- breathing by careful instructions in proper breathing and corrective exercise. (See page 79.) Peritonsillar Abscess. {Quinsy.) A retropharyngeal abscess is more common in infancy than peri- tonsillar abscess. Older children, however, have abscess formation in the peritonsillar tissue, accompanied by fever, chilliness, and difficult swallowing. The mouth is opened with difficulty and the tonsil on one side is seen to bulge forward. The finger elicits fluctuation when the condition is at its height. Treatment. — In the early stages calomel or effervescent citrate of magnesia may be given for the bowels. Salol and phenacetin, one and a half grains of each, may be given every three hours for a five-year- old child. Cold milk sucked through a tube is agreeable and keeps up nutrition. Incise with a guarded scalpel, and drain as soon as a diagnosis of an abscess is made. A gargle and occasional digital pressure for evacuation of the pus made over the affected site serve to prevent reinfection. Retropharyngeal Abscess. This abscess is seen not rarely in infants and children below the age of two years. Ill-nourished children are more prone to it because of their lowered vitality, and infection takes place from the organisms commonly found in the mouth. Symptomatology. — The infant is usually brought for examination because of difficulty in breathing. In the early stages there is mainly an inspiratory dyspnea, but as the abscess grows larger difficulty is experienced both in inspiration and expiration. During sleep there is a persistent rattling snore and the child frequently awakes to change its position. The child refuses nourishment or takes it with great difficulty. The temperature is irregular and fluctuates from 100° to 103° F. When the head is bent forward, the dyspnea is increased. DISEASES OF THE UPPER RESPIRATORY TRACT. 353 Inspection with a suitable tongue depressor will show a rounded reddened mass protruding almost from the center or on one side of the pharyngeal wall. The examining finger detects fluctuation. Treatment. — It is imperative that the abscess be opened and thoroughly drained. The child's head should be held well forward and then downward when the abscess has been opened to prevent as- piration of the pus. Strychnin and whisky are usually indicated to combat the septic absorption. In a few of our cases it has been neces- sary to feed the child by gavage for a few days following the evacuation of the pus. Acute Laryngitis. (Spasmodic Croup; Spasmodic Laryngitis; False Croup; Catarrhal Croup.) Etiology. — This is usually due to bacterial infection made possible by sudden exposure to cold or wet. It is most commonly met with from the second to the fifth year of life and is apt to recur. Laryngitis occasionally antecedes the eruption in measles. Children with naso- pharyngeal obstructions are predisposed to the affection. Symptomatology. — The attacks usually come on in the evening or at night. The child has appeared to be quite well during the day, and no symptoms have been observed except a slight rhinitis. With- out warning a croupy harsh and brassy cough develops, accompanied by loud croupy breathing, heard with inspiration, expiration being quite noiseless. The patient is alarmed and the sleep is restless. The cough thoroughly alarms the mother and her fright is communi- cated to the child. In severe attacks the patient must sit up in bed to breathe; the suprasternal notch and diaphragmatic groove are re- tracted. After the attacks the child is exhausted and wet with per- spiration. There may or may not be any temperature. The attacks even if uninfluenced by treatment, subside toward the morning hours, the harsh breathing ceases, and the child quietly rests. On the succeeding day the patient is ready to play and the cough while present is not annoying. For several nights there will be a repetition of the dyspnea and croupy cough. Diagnosis. — Laryngeal diphtheria must be excluded. In diph- theria the breathing slowly becomes worse with no remissions. The constitutional symptoms are more marked and the inspiratory stridor may be present without the croupy cough. Seek safety in a culture, and if the weight of evidence leans toward diphtheria give antitoxin. 23 354 DISEASES OF CHILDREN. Differential Diagnosis. Acute Laryngitis. Diphtheritic Laryngitis. Sudden onset. More gradual invasion. Dyspnea intense from start but Dyspnea slowly but progressively evanescent. worse. Cough resonant and brassy Cough muffled and suppressed. (barking). Voice, usually normal. Voice muffled and almost lost. Inspiratory and expiratory stridor. Inspiratory stridor. Inspiratory more marked. Albumin rarely in urine. Albumin commonly found. Xo membrane seen. Membrane may be seen in pharynx and tonsils or coughed up. For differential diagnosis, from Laryngismus Stridulus, see p. 356. Retropharyngeal abscess will be differentiated by the increase in dyspnea when the head is dropped forward and by directly palpat- ing a fluctuating mass. Prognosis. — Distinctly favorable, never fatal, but recurrences are common. Treatment. — Place the child in a warm, moist room. In mild cases an emetic dose of the wine of ipecac, half a dram every half-hour until vomiting ensues, may be sufficient to give relief. A warm mustard bath aids the result. An enema should be ordered if the bowels have not recently moved. In severer cases a croup tent (see page 103) should be made over the crib and a croup kettle started in which has been placed a dram or two of the compound tincture of benzoin. Emesis should be brought about as rapidly as possible. Antipyrin gr. 3 for a three-year-old child acts as an anti- spasmodic. If there is cyanosis and serious obstruction intubation may be necessary, however a smear and culture should be made in these cases to exclude diphtheria. The succeeding day should be spent quietly, a light diet given and the bowels kept open. If there are adenoids present, these should be removed at a later date. Edema of the Glottis. (Submucous laryngitis.) Definition. — This is an infiltration of serum into the submucous layer of the glottis and the neighboring aryepiglottic folds. Etiology. — Serous infiltration may result from the irritative DISEASES OF THE UPPER RESPIRATORY TRACT. 355 action of corrosive drugs accidently swallowed, from foreign bodies, or it may occur during the course of nephritis, syphilis, the infectious diseases, streptococcic inflammation of the larynx or its neighboring structures by extension. It occasionally occurs in severe cardiac affections and with extensive edema of the lungs. Tumors, such as papillomata, have produced the condition. The angioneurotic type of edema of the glottis is extremely rare. Fig. A 03.— Croup tent. Symptomatology. — The striking symptom is the inspiratory dysp- nea which results. There is usually some stridor and a muffled voice. Pain and dysphagia are present when the edema is the result of a local inflammation resulting from trauma, hot steam, acids, etc. Inspection shows an enlarged mucous membrane, swollen epiglot- tis, and narrowed rinna glottidis. The folds of mucous membrane may overhang the glottis. The edema may be felt by the finger or seen by the laryngeal mirror. Course and Prognosis. — The course and prognosis are directly proportionate to the severity of the underlying disease or to the 356 DISEASES OF CHILDREN. amount of trauma that has been caused. Unrelieved cases of edema of the glottis often terminate fatally. The milder types due to the infectious diseases and kidney disease improve with the amelioration of the primary cause. Treatment. — In mild cases attention should be directed principally to the underlying disease. Diaphoretics and diuretics are distinctly helpful. Dover's powders will allay pain and restlessness until more heroic measures are taken. Scarification is occasionally successful in giving relief when performed by a specialist. Tracheotomy is to be preferred to intubation in desperate cases when suffocation is imminent. Laryngismus Stridulus. Laryngismus stridulus is a neurotic disease of infancy, charac- terized by spasmodic attacks affecting the glottis and the neighboring laryngeal muscles. Etiology. — Rachitic infants and those with adenoids are especially predisposed. Exposure to irritating gases or vapors, or badly ven- tilated apartments may bring on an attack. Symptomatology. — This varies with the severity of the disease and with the particular spasm. In some cases the spasm is but momentary ending with an inspiratory crow; again it may recur every few moments with but slight inconvenience to the patient. In severe attacks the crowing inspiration is distinctly audible, the infant becomes spastic, and the efforts to breathe are marked. Lividity of the face ard a gasping expression are observed. Carpopedal spasm and in some instances convulsions follow severe attacks. In the intervals the breathing may be quite free and unobstructed, with no constitutional symptoms. Fatal cases are rare, but have been reported. Laryngismus Stridulus. Spasmodic Croup. (Acute Laryngitis.) Ill-nourished infants under two Commonly from two to five years. years. No pyrexia. Some pyrexia, No cough or rhinitis. Brassy cough and coryza. Attacks momentary and recur Attacks usually at night, last often. longer and have longer periods of remission. DISEASES OF THE UPPER RESPIRATORY TRACT. 357 Treatment. — In the severe cases, emesis with wine of ipecac in half- dram doses every half-hour until vomiting ensues may be employed, with cold sponging of the face and chest. A cleansing enema in a badly-fed rickety infant is often effectual. The underlying cause must be removed or combated in the interval. Adenoids should be removed, and the infant placed on a properly proportioned diet. This alone is curative in certain babies fed on the proprietary foods. A quiet atmosphere and a well-regulated dietary will cure the majority of cases. Congenital Laryngeal Stridor. {Congenital Infantile Stridor. Thymic Asthma.) This congenital condition is rare and is often confused with laryngismus stridulus. Etiology. — There is still confusion as to the causation. One theory is that it is due to a poorly coordinated action of the respira- tory muscles involved in the act of breathing. The epiglottis is deformed as a result, and inspiration then produces the peculiar crow- ing respiration of the affection. (Thomson.) Sometimes a narrowed, infolded and thinned-out epiglottis is found which can be observed by laryngoscopic examination to cause the peculiar sounds. Variot claims that the condition is found in the lymphatic diathesis and that it is caused by an enlarged thymus, his observations being confirmed by X-ray examinations. Others believe it to be a pure neurosis dependent upon an underlying nutri- tional defect. Symptomatology. — From birth there is heard mainly on inspira- tion a high-pitched rasping croak; with expiration this is heard only with difficulty or not at all. Crying or excitement of any kind increases the stridor and even retraction of the thoracic spaces. On the other hand, it is rarely audible during quiet sleep. The voice is not affected even in crying. There is no cyanosis produced by obstruction. Diagnosis. — This is founded upon the inspiratory stridor present since birth in a child otherwise unaffected as to development and who is not made sick or uncomfortable by the condition. Laryngoscopic examination or a direct examination of the epiglottis can be quite often made in infants with a correctly-shaped tongue depressor. Laryngismus stridulus (p. 356) is found mainly in rachitic children, is rare before the dentition period, and is often associated with tetany. New growths of the larynx should be ruled out by careful examination. 358 DISEASES OF CHILDREN. Course and Prognosis. — Up to the end of the first year the condi- tion is at its worst; then amelioration begins and at the second year it quite disappears. The physical condition is not affected, but super- added diseases of the respiratory tract are apt to have a fatal issue. Treatment. — The condition does not lend itself to any form of treatment, but the intubation tube and instruments for tracheotomy should be on hand if any respiratory disease complicates it. New Growths of the Larynx. Papillomata. — Although by no means common, they are not rare. They may be congenital or attributed to the specific fevers. Distinct continued hoarseness is the prominent symptom. As the growth later on causes obstructive symptoms, dyspnea or suffocative attacks follow. The diagnosis may be made or confirmed by the use of the Killian's tube (bronchoscopy). Intubation may be practised for immediate relief and then an endolaryngeal operation may be per- formed. If this is not feasible, tracheotomy must be resorted to. Fibromata are rarely seen in early life. CHAPTER XXVI. DISEASES OF THE LUNGS AND PLEURA. Acute Bronchitis. This is an acute inflammation of the mucous membrane of the large and medium-sized bronchi. It is a frequent disease in early life. Etiology. — Bronchitis results as an infection following lowered resistance from exposure, malnutrition, rickets, enlarged tonsils, adenoids, valvular disturbances, or following the infectious diseases. Irritating gases or dust particles may also cause a form of bronchitis. The bacteria found in the secretions are many and varied and of the types commonly found in the bronchial tract. Symptomatology. — The symptoms usually begin with a coryza, or follow an obstinate rhinitis or tracheitis. There is a hard, dry cough which soon becomes loose as more mucus is produced. The pulse and temperature are slightly elevated, rarely over 101° F. during the ds^y, but may be a degree or two higher in the evening, while the respirations are always higher than normal. The child, as a rule, does not com- plain and may be quite willing to be about; infants, however, are often restless and irritable and vomiting may result from an attack of coughing. The stools are rarely normal, either constipation or loose stools being observed. It must be recollected that the sputum is swallowed by infants and children up to five years of age. The disease tends to recovery in from five days to a week. Severer forms are seen which are due to involvement of the smaller bronchi (formerly termed capillary bronchitis) in which the symptoms are more pro- nounced and there is some dyspnea. The pulse and respiratory ratio may be somewhat disturbed and a pneumonic process result from infection of the alveoli. Physical Signs. Inspection. — Breathing is quickened, and there may be recession of the softer parts of the chest wall especially in rickety children. Percussion. — No changes from the normal. Auscultation. — Exaggerated puerile breathing and rales of varied character, according to the location of the inflammation, are found. 359 360 DISEASES OF CHILDREN. Large, coarse rales (ronchi) over the larger tubes and moist rales with finer rales over the smaller bronchi may be noted. Tactile fremitus is often distinct in infants when the secretions are viscid. Diagnosis. — The differential diagnosis is to be made from broncho- pneumonia, in which the temperature is higher with a disturbed pulse and respiration ratio, by the grunting respiration and dyspnea. The physical examination does not elicit dullness and subcrepitant rales as in pneumonia. In pulmonary collapse there is dullness on percussion and absence of respiratory murmur and subnormal temperature. Prognosis. — This is usually good except in cases of rickets and after the infectious diseases, when pneumonia is likely to follow. Young infants, however, may die from a simple bronchitis when the tubes become obstructed with mucus followed by cyanosis. Treatment. — Rest for the patient and fresh air are necessary requirements. A change to a different climate will often alone effect a cure. The bowels should be opened with a grain of calomel in divided doses or one or two drams of castor oil. The diet is to be restricted and water freely given. If the temperature is unduly high and is causing discomfort, an alcohol rub is indicated. The use of hot poultices and jackets are mentioned only to be condemned, and the same may be said of the so-called syrupy cough mixtures. If the secretions are persistently dry and the cough harassing, the Liq. ammonia anisatis in 3 to 5 drop doses in water to a child of five years or in the following mixture will prove useful, and will not disturb the digestive apparatus. R Liquor ammonii anisatis oj Potassii iodidi gr. iv Glycerini 5ss Aquae qs. ad. §ij Misce et signa. — 5j every three hours. or the aromatic spirits of ammonia in five to ten drop doses, diluted, is also effective. Do not give muriate of ammonia to children. If at night a sed- ative is necessary to allow the child to sleep, appropriate doses of any of the following drugs may be given: Codein, Tincture opii camphorata, Antipyrin, or Sodium bromid. The room is to be kept well ventilated and the temperature not above 70° F. An enforced rest in bed with no further treatment than a free catharsis is often alone curative. If the child has adenoids DISEASES OF THE LUNGS AND PLEURA. 361 and enlarged tonsils, these should be removed at a later date to prevent subsequent attacks. Chronic Bronchitis. Etiology. — This may result from repeated attacks of the acute form. Children suffering from disease of the heart, kidneys, or liver are prone to pulmonary congestion, and thus acquire a chronic bronchitis. Rachitic children, those with a tendency to lymphatism and adenoids, and those with a tuberculous diathesis are often afflicted with chronic bronchitis. Symptomatology. — Fever is rarely observed and the child is not incapacitated from its play. The cough is often mistaken for per- tussis and is worse at bedtime and upon arising. Older children expectorate an abundant frothy mucoid secretion, while younger children may swallow or vomit it. The physical signs are more marked when there is an accumulation of mucus and almost disappear in the quiescent stage. During the warmer months the cough may entirely disappear. Diagnosis. — From pertussis the differential diagnosis is made by the course and the paroxysmal attacks followed by vomiting. Tuberculosis may be differentiated by the recent tuberculin tests, the absence of fever, and the physical signs. Prognosis. — The prognosis bears a distinct relation to the etiologi- cal factor. If this can be remedied, as adenoids for example, much improvement may be expected. If there is glandular enlargement present or a tuberculous tendency, the outcome is not as hopeful. Treatment. — First remove if possible the underlying cause. Climatic treatment is often productive of good results. Tonics such as the syrup of the iodid of iron and cod-liver oil are serviceable. Carbonate of guaiacol in 3 to 5 grain doses in sugar of milk is beneficial for the cough. Pulmonary Collapse. Collapse of small areas of the lung occurs frequently and quite easily in infancy. The condition may occur in cases of bronchitis and in obstruction or stenosis of the upper respiratory tract or the bronchi. Children with rickets are particularly predisposed, as the condi- tion is dependent upon the yielding nature of the thoracic walls in early life. 802 DISEASES OF CHILDREN. Symptomatology. — Superficial areas cannot be detected by phys- ical examination, nor do they produce any noticeable symptoms. Larger areas give rise to very marked and sudden symptoms. The child's condition suddenly changes to one of cyanosis; his restlessness is dependent upon the inability to get air; the breathing is extremely shallow and gasping; the supraclavicular spaces show marked recession with each effort of breathing. A fatal issue may be preceded by convulsions. Physical Examination. — Dullness, or dullness to flatness, over the collapsed area is noted. On auscultation, the breath sounds are en- tirely absent. The crying voice is diminished. Areas of compensatory emphysema are present, usually in the upper portion of the chest. These signs, with the history of sudden onset, in a child suffering from a previous pulmonary condition should cause no confusion in the diagnosis. Treatment. — A full hot mustard bath followed by artificial res- piration may be employed in desperate cases. Holding the infant by the heels may succeed in producing an effort at deep inspiration, and will dislodge any considerable amount of mucus that may have acted as the cause of the collapse. The production of emesis by the intro- duction of the finger in the throat should be tried. If the secretions are still found to be considerable in amount after amelioration of the col- lapse, a hypodermatic injection of atropin sulphate -3-^ gr. will be efficacious. A trained attendant should be placed in charge. Emphysema. Emphysema in some degree occurs very frequently in infants and children suffering from bronchial affection. Acute emphysema occurs most frequently in bronchitis, broncho- pneumonia, pertussis, stenosis of the larynx, and pulmonary collapse. It is produced by overdistention of the weak elastic tissue of the alveoli when the glottis is closed in violent efforts of coughing. Children suffering from chronic bronchitis frequently have an accompanying emphysematous condition which does not recede until some time after all evidences of the bronchitis have disappeared. This condition of chronic emphysema is not often seen in child- hood. The diagnosis is based upon the abnormally full and rounded chest, the hyperresonant note on percussion, the diminution of the area of relative cardiac dullness and the sonorous and sibilant rales heard all over the chest with unduly prolonged expiration. The prognosis and treatment are mainly those relating to the underlying conditions. DISEASES OF THE LUNGS AND PLEURA. 363 Bronchial Asthma. This is a disease not common to early life and is due to a spasmodic contraction of the bronchial tubes as a result of some form of patho- logical stimulation of the bronchial muscles. Etiology. — Salter records 225 cases, among which 11 began the first year of life, and 60 as occurring from the first to the tenth year of life. Bronchitis is, in the majority of instances, the predisposing disease. Nasal obstructions, especially adenoids, are important etiological factors. They were present in 47 per cent, of La Fetra's cases. Symptomatology. — The attack may begin with a fairly pronounced bronchitis which lasts for several days; then there may be suddenly superadded dyspnea with its accompanying rapid respiration, anxious expression, and rarely cyanosis. Inspection of the chest during the paroxysm shows retraction in the suprasternal and supraclavicular spaces, and the activity of the accessory muscles of inspiration. Auscultation. — Sibilant and sonorous rales are heard both during inspiration and expiration all over the chest. Percussion. — A hyperresonant note is elicited during the height of the attack. There is rarely any temperature unless the attack has closely followed an acute bronchitis. It rarely rises above 102° F. Blood examinations may be of assistance from the standpoint of differential diagnosis. Polymorphonuclear eosinophiles are increased in number, while in prolonged subacute cases a relatively lower eosinophilia is found. Treatment. — Adenoids, enlarged tonsils, and other obstructions to proper breathing must be removed. Attacks of bronchitis are to be guarded against. A careful process of hardening by hydrotherapy or a change of environment may be necessary to prevent repeated attacks. Careful oversight of the diet must be observed and indiges- tion avoided. The indication for the treatment of the acute attack is the relief of the bronchial spasm. For this purpose a combination of the iodids and bromids is of distinct service. The bowels should be emptied with a soapsuds enema, and if there is any history of indiscretion in diet, an emetic dose of the wine of the syrup of ipecac given. Nitroglycerin T i^ to T fa of a grain, or atropin -gfa of a grain for a two-year-old child may be necessary for relief in severe cases. The syrup of the iodid of iron is valuable following the attack. 364 DISEASES OF CHILDREN. Acute Bronchopneumonia. {Lobular Pneumonia, Catarrhal Pneumonia, Capillary Bronchitis.) This is perhaps the most common disease of infancy and is very often a secondary manifestation. Bronchopneumonia occurs most frequently in early life, and is secondary to an involvement of the bronchial tubes. It is most often met with during the first two years of life, and is rarely seen after the sixth year. Bronchitis, the infectious diseases, especially measles, pertussis, influenza, diphtheria, and scarlet fever are the predisposing causes. Children with nckets, marasmus, syphilis, nephritis, and gastroenteritis, especially if they are in bad hygienic circumstances, have their resistance lowered, and are thus predisposed. Infants in asylums and institutions are especially prone to the affection. The pneumococcus of Frankel, Friedlander's bacillus, strepto- and staphylococci, and the bacterial flora of the nose and mouth are the exciting causes. Pathology. — The pneumonic areas result from extension of the inflammation through the bronchial walls and from the bronchial walls themselves into the peribronchial tissue. Thus not only the alveoli to which the bronchial tubes lead are involved, but also those which surround the tube. The alveoli become invaded by the bacteria and distended with white blood-cells, and contain some fibrin and red blood-cells. The small patches soon coalesce and become the size of a half-dollar or even in exceptional instances involve the greater part of one lobe. On cut section, the bronchioles are found partly dilated and a mucopurulent exudate flows out on pressure. The bronchial glands at the root of the lung may be infiltrated and an increase in the interstitial tissue is found in the older cases. Pleuritis is seen with any considerable area of pneumonia. Accumulations of fluid, small in amount, are not uncommon at autopsy. The same may be said of emphysema, gangrene, and multiple lung abscesses. Symptomatology. — There are few diseases in which the symptoms may be so varied as in bronchopneumonia. The following descrip- tion will show how varied the symptomatology may be, and what wide differences are found in the physical signs. The disease may be ushered in with vomiting or high temperature. On the other hand, fever may be absent or extremely low throughout the disease. There usually is restlessness, rapid breathing, and a cough which may be severe or scarcely noticeable. If the disease follows, as it usually does, an attack of bronchitis, all the symptoms which were present are exaggerated while the breathing becomes labored and the tern- DISEASES OF THE LUNGS AND PLEURA. 365 preratue increases. The cry is stifled and an expiratory grunt which is quite characteristic of acute lung involvement is heard. The pulse rate is much increased, rising to 120 or 180, and is small in character. The respirations are increased to 60 or 80, and the efforts made to get enough oxygen are shown at the peripneumonic groove and by the dilated alse nasi. If a considerable portion of the lung is involved, cyanosis in the lips or finger-nails is observable. The child feels distinctly sick; it may refuse food, but usually takes water eagerly. The tongue is dry and coated. The dyspnea increases, and the cough may be harassing and suppressed. The pulse becomes weaker, and the hands and feet are cold. Sleep is fitful and constantly disturbed by efforts to cough. If the disease progresses and the temperature remains persistently high, stupor, delirium, or even coma may ensue. The pulse may become irregular. The heart action may give indi- cations of myocardial changes and convulsions may precede a fatal termination. Improvement or retrogression of the affection is shown by a decreased number of respirations and a more normal pulse- respiration ratio. The character of the pulse improves, the infant takes some interest in his surroundings, sleeps more, and finally takes nourishment eagerly. Physical Signs. — The objective symptoms vary as greatly as the subjective signs. The examiner must not be astonished if he finds signs not commensurate with the degree of prostration. Palpation. — Little or no satisfactory information is obtained. However, the apex beat of the heart may be located and pain on han- dling appreciated. Inspection. — Rapid, labored breathing is noted. The alse nasi are dilated, and there may be some degree of cyanosis visible. Re- traction of the peripneumonic groove is observed in advanced cases. Auscultation. — Auscultation with inspection are of the greatest value. A pause between inspiration and expiration occurs, and can be appreciated if the child is, quiet or sleeping. The bronchitis present will be revealed by coarse moist rales, often sonorous in character. Subcrepitant and crepitant rales with diminished breathing heard at the end of inspiration over a limited area reveal the location of the pneumonic involvement. These are best heard when the infant is crying or during coughing. The examination should not cease without sufficiently forcible respiratory efforts on the part of the infant. Prolonged expiration and bronchial breathing are obtained when the area of the pneumonia is recent. Vocal fremitus may be heard while the child is crying, over larger areas of consolidation. The examiner must not faT to use a stethoscope with a small bell, and 300 DISEASES OF CHILDREN. must not omit in his search the axillary region, for the first signs are often found there. Percussion. — Light percussion is a desideratum. Dullness may be appreciated if present and points to consolidation. Areas giving a hyperresonant note are obtained over portions of the lung in which a compensatory emphysema has occurred. The Important Symptoms in Detail. Temperature. — As a rule, the temperature is high in the beginning, 103° to 104° F., although periods of remission are not uncommon. The disease ends by lysis and the curve shows the gradual return to the normal. No typical temperature curve can be presented because of the intermittent and remittent character of the fever. Sudden high rises may indicate a complication or an added area of pneumonia. Marasmic infants frequently are seen with little or no fever, or they may even have a subnormal temperature. Respirations. — The normal ratio of pulse and respirations, 1 to 3, or 1 to 4, may be so far disturbed as to reach 1 to 2.5 or 1 to 2. The severity of the dyspnea can be judged by the amount of recession at the sternal space and diaphragmatic attachments. The breathing may be irregular or simulate the Cheyne-Stokes type. Coughing or crying markedly accelerates the respirations, and if pain is present it is increased. The expiratory grunt is almost pathognomonic. It is produced in early life by only three conditions, namely, pneumonia, pleurisy, and a very acute indigestion. In rachitic children the respirations are especially increased and extremely shallow. Heart and Pulse. — The pulse is small and frequent. When the temperature is high the pulse may be as rapid as 180 to 200. Its numerical value is not of as much moment as the character of the pulse compared to the action of the heart. The second sound is often accentuated, and anemic murmurs are heard during convalesence. Digestive Tract. — Especially to be feared is the distention of the abdomen with gas. The meteorism impedes the movements of the diaphragm and adds greatly to the discomfort of the infant. Vomit- ing is often one of the initial symptoms. Diarrhea is more frequent in the nursling, while constipation is the rule with the artificially fed. Occasionally stupor is seen from the first day of the disease. A convulsion may usher in the disease or purposeless movements may appear at any time in its course. Meningitis may be in consequence suspected. True symptoms of cerebral involvement may precede a fatal termination. The ear should be examined in suspected cases, and lumbar puncture made for purposes of verification. Clinical Forms of the Disease. — Disseminated bronchopneumonia DISEASES OF THE LUNGS AND PLEURA. 367 is the form in which there are small areas scattered over different parts of the lung. They do not coalesce, and varying physical signs are found in the several patches. The asthenic form is frequent in marasmic or rachitic infants, and it generally accompanies a gastro- intestinal infection. There is little or no fever in this type, and the course is protracted and often ends in death. Bronchopneumonia Complicating the Infectious Diseases. — With Pertussis. — To the symptoms of bronchitis present are added the objective signs of a pneumonia usually of the disseminated type. The temperature rises abruptly and often to 105° F. The dyspnea is marked and cyanosis appears early. The complication seriously affects the prognosis. Tuberculosis may follow in its wake if the child recovers. The course is usually long and tedious, remissions being very common. During the course of the pneumonia the spas- modic or paroxysmal character of the cough is not so marked as in uncomplicated pertussis. With Measles. — If, after the eruption of measles when the fever has subsided, there is an abrupt rise of temperature and on physical examination there are found crepitant and subcrepitant rales over localized areas, bronchopneumonia may be diagnosticated. The cough is increased; it is more frequent and dyspnea is more marked. The pulse and respirations are increased. The somnolent and apathetic state is again present. With Diphtheria. — The pneumonia is more apt to occur in cases having laryngeal involvement, especially those which have neces- sitated operative interference. It is one of the commonest causes of death after intubation. Bronchiectasis or pulmonary abscess may develop in the more chronic forms. With Other Exhausting Diseases. — As a terminal infection, bronchopneumonia may occur in a variety of diseases common to child- hood, more especially those that are of bacterial origin, such as typhoid and gastroenteritis. Where a general sepsis is present, it is sometimes only discovered at necropsy. Complications. — As has been stated above, the disease is in it- self mainly secondary to some other process. During its course there may develop an involvement of the ear, heart, peritoneum, pleura, or meninges. Following cases of delayed resolution, brochiectatic cavities, abscesses, and fibroid changes may develop. Differential Diagnosis. — From acute bronchitis it may be dis- tinguished by the milder symptoms, the lower grade of temperature and pulse, and the less disturbed pulse-respiration ratio. No localized area of bronchial breathing, bronchophony, or fine crepitant rales 368 DISEASES OF CHILDREN. will be found. Instead there will only be present numerous coarse and fine bronchial rales. From Lobar Pneumonia. — If occurring in an infant, and there is a history of a primary infectious disease, bronchopneumonia is rather to be suspected. In the lobar type the temperature is more constantly high and drops by crisis, while the course is invariably shorter. The physical signs may not be distinctive until consolida- tion has taken place. Leukocytosis is higher and persists until the temperature falls at crisis. From Tuberculosis. — A bronchopenumonia of long duration is often regarded as a tuberculous process. It is to be differentiated by the tuberculous aspect of the child, the greater wasting and possibly by the signs of tuberculosis elsewhere. The various tests described on page 54 should be made as an aid to the diagnosis. Course and Prognosis. — The course varies from two to six weeks, as a rule, and only rarely ends by crisis, lysis being the rule. A pneumonia superimposed on gastroenteritis or other debilitating diseases is apt to be prolonged and to leave the child in an extremely emaciated and asthenic condition. This is always a very serious disease. The prognosis is always unfavorably influenced when it complicates poorly nourished infants with infectious or constitutional diseases. The younger the child the more unfavorable the prognosis. Artificially fed infants in institutions and those with rickets or whoop- ing cough must be regarded as especially unfavorable. The signs upon which the practitioner may base a favorable prognosis are undisturbed heart sounds, absence of marked dj^spnea, willingness to take nourish- ment, and undisturbed gastrointestinal tract. On the contrary, if vomiting and diarrhea, irregular breathing, meteorism, and cerebral symptoms develop, the outlook points to a fatal issue. Treatment. — The high mortality of this disease will be reduced if the disease is treated rationally. The vital resistance of the infant must be supported or increased so that the self-limited disease may terminate favorably. Fresh air, proper diet, hydrotherapy, and stimulation, when appropriately used, will conserve the resisting powers. Aerotherapy. — The patient should be placed in its crib in a large sunny room, the widows of which are opened to admit an abundance of fresh air. Light and warm clothing should be worn in the colder months, hot-water bags or an electric thermophor being placed at the child's feet if the extremities are cold. A screen may be used to shield the patient from a direct draught. The diet should be a modification of the previous feedings. "With DISEASES OF THE LUXGS AXD PLEURA. 369 the breast fed, reduce the intervals and give water before nursing. The food of the artificially fed should be reduced with gruel. Older children are allowed milk, gruels, broths, albumin water, and orangeade. The temperature should be controlled by hydrotherapeutic measures if it is causing unrest, insomnia, or cerebral symptoms. A temperature of 104° F. in one infant may cause less distress than a tem- perature of 101° F. in another child. A daily cleansing bed-bath should be given in all cases. The milder measures for the reduction of temperature should be first attempted — for example, an alcohol sponge-bath (one part to four) will usually reduce the temperature a degree or two, and also has a tonic effect upon the patient. The water may be luke-warm, but its alcoholic strength may be increased if the desired effect is not obtained. The naked infant is wrapped in a flannel blanket and one portion of the body after another is sponged, and by gentle friction the liquid made to evaporate, and thus the cooling effect is obtained. Such a bath should take from ten to twenty minutes and is often followed by relaxation and a refreshing sleep. Compresses wrung out of water at 90° F. may be placed about the chest and renewed hourly almost without disturbing the patient. The cold pack will be required in sthenic cases with high temperature and delirium. Ice-bags to the head, while effective in reducing tem- perature, are dangerous unless cautiously employed under the direct supervision of a competent nurse. Weak, badly nourished infants or those with a subnormal temperature are preferably given a hot mustard bath with the water at 105° F. A cheese-cloth bag containing an ounce of mustard is drawn through the water and the infant is removed when the skin reddens from the counterirritant. Local Applications. — Mustard pastes are especially effective in the beginning of the disease and should be applied directly over the affected area in the strength of one part mustard to six or seven of flour. Directions should be given as to the size and frequency of the application. When the skin' is well reddened the application should be removed. If the area becomes blanched within four hours a second application may be made. Warm poultices and oiled silk jackets are only mentioned to be deprecated. Medication. — No drug, however harmless, should be prescribed without a distinct indication. The symptoms will in greater part be relieved by sponging and local applications. If the bowels are con- stipated an .initial calomel purge in divided doses or an enema may be given. Sedatives for the cough as a routine measure, especially in the form of syrups tend only to produce fermentation and retard 24 370 DISEASES OF CHILDREN. progress. A stimulating expectorant in the form of the ammonia preparations, as the aromatic spirits or the Liq. ammonise anisati, will promote freer secretion if required and also tend to support the heart. A harassing purposeless cough which prevents sleep can be profitably controlled with small doses of Dover's powder (^ gr. to one- year-old child, q. 4 h.). Judicious stimulation of the heart is one of the most essential parts of the treatment. The physician must be guided by the action of the heart when the child is quietly sleeping. A rapid feeble pulse rate, weakness of the heart sounds, and signs of failing compensation are indications for drug assistance. Strychnin well meets many of these indications, unless the nervous symptoms are a prominent feature. One three-hundredth of a grain may be alternated with another suitable cardiac stimulant every four hours for a year-old infant. The tincture of strophanthus in drop doses every three to four hours is an effective remedy having no ill effects on the digestive tract. Alcohol in the form of brandy, if used at all, should be given well diluted, but never continued for any length of time, as nausea or vomiting almost invariably results. If the right heart needs assistance, nitroglycerin preferably given in the form of the spirits of glonoin (gr. -^ to a year-old child) meets this in- dication. It must be frequently given, usually every two hours. Camphor (grs. 1 to 10 minims of sterile olive oil) should be used hypo- dermatically in desperate cases. If the stomach does not retain food or medication, the needle must be used if stimulation is imperative. Hypostatic Pneumonia. This form of pneumonia is found as a secondary affection in many poorly nourished children, and especially in those who are brought to children's hospitals for treatment. It is no doubt a result of lowered vital resistance. The postmortem examination shows an area of dark solid or semisolid lung tissue along the posterior borders of the lung; on cut section it is dark, grumous, and edematous. A serosanguinolent fluid exudes on pressure. The symptoms are those of a low r -grade pneumonia. Treatment. — -Combat the accompanying asthenia with stimulants, such as strychnia and nitroglycerin, and treat the original condition. All such children need particularly to be removed for a few hours from the sick-room and their position in the crib is to be frequently changed. They often breathe better if the chest is elevated on a pillow. DISEASES OF THE LUNGS AND PLEURA. 371 Lobar Pneumonia. (Croupous Pneumonia.) A pneumonia affecting a lobe or a considerable part of a lobe and is caused by the diplococcus of Frankel. Etiology. — This form is more commonly seen in children of two or more years of age and is rarely secondary, as is bronchopneumonia. Pathology. — The apices are in our experience more frequently first affected in children, and then the bases. The disease passes through the four stages just as it does in adults; i. e., congestion, red and gray hepatization, and resolution. Symptomatology. — The onset is sudden, most frequently with a chill or chilly feelings or convulsions, followed rapidly by high fever and rapid breathing. In some cases the nervous symptoms mask the pulmonary condition, simulating meningitis. The temperature rises to 103° or 105° F., and remissions are only slight and usually take place in the morning. In severe cases the prostration is complete, with delirium and semicoma. The child refuses food, is thirsty, and may complain of pain on coughing, or of abdominal pain. The cough may be slight or even absent for a few days, but toward the end is quite marked. In older children rusty sputum is sometimes ob- served. The disease ends by a crisis, but this is not always sharply defined. It may end also by lysis, especially in those children who have previously been enfeebled. Physical Signs. — Inspection. Flushed face, dilating alae nasi, and rapid respirations. Auscultation. — Bronchial breathing is noted in the early stages and later fine subcrepitant rales; when resolution takes place, broncho- vesicular breathing and many moist rales may also be present. Percussion. — Dullness over the affected area diminishing as the disease progresses and resolution takes place. Palpation. — Increased fremitus. Complications. — More or less pleurisy of a dry character is present in nearly every case. Meningitis is often secondary in the grave or fatal cases. Otitis is not rare, while pericarditis and peritonitis are sometimes seen. Empyema should always be considered. Diagnosis. — The sudden onset, more constant high fever and phy- sical signs of consolidation differentiate it from a bronchopneumonia. A centralized pneumonia is often puzzling and causes a suspicion of typhoid fever or malaria. A blood examination will then assist the diagnosis. In the central pneumonia the process is enclosed in healthy lung tissue, and the physical signs may not appear for several 372 DISEASES OF CHILDREN. days, but the rational signs plus the fairly characteristic symptoms will fix the diagnosis. The pain referred to the abdomen has led to a mistaken diagnosis of appendicitis. Examine the lungs. Prognosis. — The prognosis is very good. Ninety-six per cent, of all cases recover. Treatment. — This has already been spoken of under Broncho- pneumonia. It is essentially the same, but may be more vigorously pursued, as the cases are generally of a more sthenic type. Com- plications by extension into the ear must be guarded against. Re- peated examinations of the ear-drums may be necessary. Pleurisy. Dry Pleurisy. — This is an inflammation of a localized area of the pleural surface, usually in conjunction with a pneumonic process, over infarcts or extension from a tuberculous pneumonia. These lesions are seen frequently postmortem; the pleural surface is found to be dull and lusterless with the adhesions firm or fibrinous. Symptomatology. — To these adhesions the pain accompanying a pneumonic process may be ascribed (a pleuritic friction rub is heard on auscultation over the consolidated area). The pain is sharp and lancinating, and usually produced or noticed after coughing. In older children it is evidenced at the end of a deep inspiration. Treatment. — Outlined under Serous Pleurisy. Serofibrinous Pleurisy. This form also results from extension of infection from a tubercu- lous or pneumonic process. The fluid is usually found to be sterile on ordinary culture media, but in cases in which perfected methods have been employed the tubercle bacilli may be found. Infants rarely have this form of plurisy; it is more commonly found after two years of age. The weight of opinion inclines to the belief that previously infected bronchial lymph-glands are the source of infection. Pathology. — On the surface of the pleura is found a fibrinoplastic exudate, sometimes thick, but usually thin and soft. The fluid which exudates is yellow or yellowish-green in color. The lung may be found collapsed in whole or in part. Sacculated effusions of serous fluid are not as common as the purulent. The bases of the lung form the common site; occasionally both bases are affected simultaneously. DISEASES OF THE LUNGS AND PLEURA. 373 Symptomatology. — For several days there is fever, cough, chilli- ness and more or less pain referred to the chest. Gradually the child is seen to play less, is listless and apathetic. The temperature is irreg- ular, fluctuating from 101° to 102° F. Difficult breathing is now ap- parent. The pain, it should be recollected, may be referred to the abdomen. Headache, constipation, and coated tongue are usual manifestations. The respirations and pulse are accelerated, but the ratio is not seriously disturbed unless the effusion is large. In the latter event pain is usually diminished or absent. Loss of flesh is now apparent, dyspnea is marked, and the child prefers to lie on the affected side. Physical Signs. — Inspection. Movement may be impaired if the effusion is large. The cyrtometer may show greater measurement on the affected side. Palpation. — Vocal fremitus is diminished in large collections. Auscultation. — The respiratory murmur is diminished and bron- chial breathing, distant in character, may be heard, and over the base all breath sounds may be absent. The breath sounds, if heard at all, diminish from the spine toward the axilla. Friction rales may be heard at or above the fluid in older children. The vocal resonance is diminished over the fluid itself, but does not assume the character- istics observed in adults. Percussion. — A dull or dull to flat note is elicited by percussion together with a sense of resistance to the percussing finger. Above the fluid a tympanitic note may be heard. Large effusions may displace the heart, liver and spleen especially in older subjects. Aspiration confirms the diagnosis. (See article on Empyema, p. 374.) Prognosis. — The fluid has a tendency to spontaneous absorption, provided purulent changes do not take place, and death rarely results from the effusion itself. The prognosis is unfavorably influenced if the fluid is due to a tuberculous focus. Treatment. — Rest in bed is imperative. If the fluid is small in amount, free bowel action, plus the use of diuretics as the Liq. ammonii acetatis with a moderately dry light diet may suffice for a cure. In large effusions, aspirate at once, then follow the plan outlined above. The Liq. ferri et ammonii acetatis serves very well as an after-treatment combined with a life in the sunlight and fresh air. Aspiration should be performed according to the directions given under Empyema on page 374. If the effusion is copious a Potain aspirator or the siphonage method advocated by Huber will be found advantageous. 374 DISEASES OF CHILDREN. Empyema. Empyema is known to be much more frequent, both relatively and absolutely, in infancy and childhood than in adult life. Statistics show us that 40 per cent, of pleurisies in infancy and childhood are purulent, while only 5 per cent, result in a suppurative pleuritis in adults. Yet in spite of this fact it has been mainly studied patholog- ically and clinically from adult life. The great majority of cases of empyema follow pneumonia in children, either the form known as pleuropneumonia or broncho- pneumonia. Although the infectious diseases and pyemia may be complicated by it, some inflammatory process in the lung or pleura has generally preceded the suppurative process. The pneumococcus we find present in the greater number of cases in almost pure culture. The staphylococcus and streptococcus occur in cases from which thin pus with little fibrin is withdrawn. We are as yet uncertain as to the number of cases due to the tubercle bacillus; as this organism is difficult to find in the exudate, and is often reported as absent when the subsequent course would clinically stamp the case as of the tuberculous variety. Bovaird believes that six per cent, of all cases are tuberculous. The pus found in the average case of empyema is quite thick, creamy and odorless, with masses of fibrin of varying consistency floating in it. The fluid exudes quite slowiy at first, and there is in the beginning an attempt made by nature to wall off this fluid by fine adhesions, with the result that small pockets or sacculations are formed; as the fluid accumulates in greater quantity, these septa are broken down and merged, and thus the fluid may fill the entire pleural cavity. Sacculation is frequent in children and it is important to be able to recognize the condition at this stage, and treat the case early before much damage has been done. The fluid in cases of pleurisy with effusion slowly becomes slightly turbid, then seropur\ilent, and finally assumes pure pus characteristics; this change being accompanied by a corresponding increase in the number of bacteria present. A study of the charts of the empyema cases at the Post-Graduate Hospital in New York shows that the empyema develops about the fourth week after pneumonia, and that the average amount of pus is small (5 to 8 oz.). The most frequent complications were peritonitis, meningitis, pericarditis, and sepsis. Symptomatology. — If, in a case which has recovered from a pneu- monic process or from an infectious disease, there is not a steadv im- DISEASES OF THE LUNGS AND PLEURA. 375 provement in physical well-being, but instead a low-grade temperature, with increased number of respirations, accompanied by a slight hacking cough, pallor, sweating of the head, steady emaciation, and a marked leukocytosis, our suspicions should be directed to fluid in the chest. In spite of these warning rational signs there is probably no other equally great pathological change anywhere in the body so often un- suspected or overlooked. The physical signs of fluid in the chest of infants and children differ grossly from those of the adult. In the examination the pos- sibility of encapsulated or sacculated effusions must be kept in mind which, as has been pointed out, may contain but little pus and still give marked subjective symptoms. In infants the chest may contain fluid and we may still obtain normal or practically normal breath and voice sounds. Confirmatory physical signs above the fluid, at the level of, and over the fluid cannot always be obtained in young patients. Ellis' curve and obliteration of Traubes' space cannot be depended upon for assistance. Skoda's resonance may or may not be present. The main signs upon which reliance must be placed are marked dullness or flatness on percussion over any area usually resonant, bron- chial breathing, and marked resistance to the percussing finger, as distinguished from a corresponding point on the opposite side. These physical signs coupled with the rational signs above enumerated should be sufficient justification for the introduction of the needle. An early diagnosis is of the utmost importance, and no diagnosis of empyema should be regarded as complete without exploratory punc- ture. If in addition to these physical signs we can elicit bronchial breathing over the area of flatness; relative immobility of the affected area and bulging, with displacement of the apex beat — then omission to puncture would "be unjust to the patient. Exploratory Puncture. — The exploring syringe and needle should be of good caliber and length, as the pus may be thick and contain clots of fibrin. After proper sterilization of the syringe it should be tested to ascertain if it is still in good working order. The skin hav- ing been thoroughly cleansed over the affected area, the needle can be inserted somewhat above the lowest point of flatness. If the whole side is involved we can select the most favorable points; viz., in the sixth interspace in the posterior axillary line on the left side and the fifth interspace on the right side. If we keep in mind that the diaphram rises higher in children than in adults and that the liver must be avoided on the right side we have a fair field for exploration. 370 DISEASES OF CHILDREN. With the child held in the upright position, and its arm extended above its head, we can thrust the needle directly forward — noting at the same time the amount of force necessary to penetrate the pleura and partly withdraw the plunger. If no fluid appears point the needle upward, and then if necessary downward, and you will have explored the suspected area thoroughly and avoided the possibility of escaping encapsulated pus or penetrating a thick fibrinous mass. This method, if a strong needle is used, presents no dangers, and saves the child from repeated explorations, w T hen we feel morally certain that fluid is present but fail to get it with the syringe. If possible, examine the exudate for bacteria, as the bacteriological findings, coupled with the duration of compression, the amount of pleural thickening and ability of the patient to resist the effect, will determine the prognosis. When a clear, strong-colored fluid is with- drawn we can afford to wait and watch for signs of recession of the fluid. If this does not occur, or the temperature curve later shows septic character- istics, puncture again, and the fluid will now proba- bly show purulent changes. When the first ex- ploration shows a seropurulent or purulent dis- charge operative interference should not be delayed. Treatment. — Bouveret in his classical treatise in 1888, of nine hundred pages on Empyema, still advocated aspiration as the treat- ment in children. From two to thirty aspirations were made (in one case 122), which indeed led to cures, but the mortality was high. This form of treatment is now rarely resorted to and we believe it finds few advocates. We would not treat an acute abscess by aspira- tion, and what is an empyema but a pleural abscess? Aspiration, then, should be employed for temporary relief of dyspneic symptoms only. Incision and drainage aseptically performed under light general or local anesthesia gives better results, and this method is sometimes used. The operation of rib resection is preferable in all cases of empyema except in very young infants whose physical con- dition warrants any operative interference. The general subperiosteal operation of the eighth or ninth rib in the postaxillary line is no more dangerous than incision and can be as quickly performed, especially when we recollect that in the former operation we are often obliged to pass the finger through the incision to free the fibrinous masses. By resection we secure ample drainage space, are not hindered with Fig. 104.— Aspi- rating syringe suita- ble for thoracentesis DISEASES OF THE LUNGS AND PLEURA. 377 clogged tubes, and what is most important we hasten the time of recovery of the patient. No permanent deformity results, as it is necessary to remove only one inch of the rib and the periosteum is preserved. The mortality is reduced also to one in seven. Instead of the double drainage-tube the writer uses the spool tube (see Fig. 105) of suitable size for the patient. This has the advantage of being least irritating to the pleural surfaces, and in action simulating a valve, allows the lung to expand with coughing efforts, and further- more can be easily cleansed without painful removal. This tube should be removed as soon as the dis- charge becomes serous. The sinus will then still be fresh and tend to close, leav- ing surprisingly little deformity. Irriga- tion except in extremely fetid neglected cases is not to be employed. The dressings are pads of sterile gauze (not iodoform gauze), applied over the opening in the tube and held to the chest by a Bender's. elastic bandage (in which * a '2S*^d£^^ each thread is a twisted one). This allows freedom of chest movements of the unaffected side and greater degree of cough impulse, thus favoring the expansion of the compressed lung. The child should be allowed to get up as soon as possible, and early encouraged to blow through some musical instrument, or to make soap bubbles. This plan, coupled with proper tonic, dietetic, and hygienic treatment should give good results. In long standing or neglected cases of empyema in which there are many and firm adhesions with or without collapse of the lung, Lloyd advocates digitally breaking up all the adhesions and allowing the lung on the opposite side to inflate the collapsed lung after the anesthetic has been temporarily stopped. Pneumothorax. Pneumothorax or air in the thoracic cavity is an exceedingly rare condition in early life. It is usually tuberculous, but may also result from traumatism, foreign bodies in the bronchi, rupture of a bronchiectatic cavity, pulmonary abscess, empyema, or caseating lymph nodes. Cases have also been reported following pertussis, diphtheritic and laryngeal stenosis. Symptomatology. — The symptoms begin very abruptly; dyspnea, cyanosis, thoracic pain, and a rapid thready pulse being the cardinal 378 DISEASES OF CHILDREN. symptoms. Percussion elicits a tympanitic or hyperresonant note, as a rule, but a dull note is occasionally obtained if the pleura is disturbed. Vocal fremitus is absent. Voice sounds are distant, and metallic succussion may be obtained over the tympanitic area. If both air and fluid are present, the viscera may be displaced from their normal relations. We have observed sacculated pneu- mothorax resulting from a pyothorax in which the onset was gradual and the symptoms proportionately less intense. Prognosis. — This is, as a rule, unfavorable, owing to the severity of the underlying causes. Treatment. — Absolute rest to body in the prone or semirecumbent position must be insisted upon. Stimulation and chest strapping are indicated. The recent experiments with positive pressure and the Sauerbruch box for intrathoracic operations offer some hope for surgical procedure in these cases. Pulmonary Abscess. This is a rare condition resulting from the invasion of pyogenic bacteria, following aspirated foreign bodies in the lung, pneumonia, pulmonary emboli, or caseating Lymph nodes. Symptomatology. — The symptoms develop slowly, following what appears to be a protracted convalescence. Often they are not distinctive in character. The emaciation is progressive, the tempera- ture, if followed closely, shows a septic curve. Profuse sour sweating is the rule. If combined with the above description we have thick purulent sputum containing leukocytes and elastic fibers, and if on blood examination, a marked leukocytosis (50,000 to 60,000 per cm.) is found, abscess of the lung should be considered and a diagnosis made by excluding tuberculosis, encapsulated empyema and gangrene of the lung. In selected eases surgical treatment may be of avail. Gangrene of the Lung. Pulmonary gangrene is a rare condition in children, resulting from pyogenic bacteria infecting a necrotic portion of the lung. It is a secondary condition following pneumonia, the infectious diseases, bronchiectasis, the aspiration of foreign bodies, gangrenous stomati- tis, or necrosis of the petrous portion of the temporal bone. The diagnosis is more often made at necropsy than during life. Diagnosis. — This is founded upon the putrid expectoration of a dirty greenish color, which on examination is found to contain shreds of pulmonary tissue. The child's breath is almost always offensive. DISEASES OF THE LUNGS AND PLEURA. 379 There is progressive emaciation, prostration and an irregular tem- perature. The cough is somewhat paroxysmal, followed by the expec- toration of a good quantity of the characteristic sputum. Even young children will expectorate who are suffering with pulmonary gangrene. Follow! ng the evacuation of the pus we may be able to obtain the cavernous signs indicating a cavity. Hemoptysis sometimes follows after a severe attack of coughing. Course and Prognosis. — The prognosis is invariably grave. Careful supervision and aerotherapy may so far improve the patient's general condition that surgical meas- ures may be justifiably attempted with the chance of a permanent cure. Treatment. — Until operative measures can be instituted, forced feeding, stimulation and cod-liver oil should be used. Inhalations of the compound tincture of benzoin, tur- pentine, or the oil of eucalyptus will mitigate the foul odor. Bronchiectasis. This disease results from a weakening of the bronchial wall following a number of pulmonary conditions, the most important of which are interstitial pneumonia, chronic bronchitis, emphysema, pulmonary collapse, tuberculosis, and foreign bodies. The dilatations are cylindrical or sacculated or small and diffuse, and always contain a large number of bacteria. Symptomatology. — Added to the symptoms of the underlying disease, or during convalescence therefrom, the patient begins to expectorate a quantity of mucopurulent sputum. This cough is paroxysmal, and may be induced by changing the position of the patient from the diseased to the normal side. The collected sputum has a dis- agreeable odor, is thin, grayish-brown, and separates into a frothy, a watery, and a granular layer. The fever is moderate, as a rule, Fig. 106. — Shaded area over a bron- chiectatic cavity. 380 DISEASES OF CHILDREN. although exacerbations in which may occur high fever, night-sweats, diarrhea and pulmonary hemorrhage, are not uncommon. Physical Signs. — In a typical case, with a well-developed cavity, cavernous or amphoric breathing with diminished vocal resonance may be heard over the affected area. After a free expectoration, nu- merous coarse mucous rales with bronchophony may be obtained. On percussion a tympanitic note is heard. Other evidences may be found in the clubbed fingers, emphysematous areas, or the develop- ment of a pulmonary gangrene. Diagnosis. — The paroxysmal coughing occurring on change of position, with large quantities of expectoration, with the general con- dition not proportionately affected, tend to differentiate it from the more acute condition of pulmonary gangrene which causes marked prostration and shows in the sputum portions of lung parenchyma. The needle may distinguish it from abscess, and the sputum examina- tion from pulmonary tuberculosis. Course and Prognosis. — The disease may extend over many months or years, but complete recovery is extremely rare. Complica- tions are easily acquired leading to a fatal result. Treatment. — This should be directed toward conserving the strength of the patient by the use of nourishing food and a protracted sojourn and life in the mountains or at the sea-shore. The inhalation of the volatile balsams, such as benzoin, turpentine, or eucalyptus, are indicated. Quincke's postural method, raising the foot of the bed; or the method of expiratory compression may be used if the cavity does not thoroughly empty itself after coughing. Terpene hydrate or guaiacol carbonate may be administered internally. Resection of the ribs, collapse, and drainage of the cavity has been attempted, but thus far with indifferent results. Foreign Bodies in the Respiratory Tract. Various objects may find their way into the larynx, trachea, or even into the bronchi by accidental inspiration at the time of coughing or laughing when the foreign body is in the mouth. Among the objects we have collected are an upholsterer's tack, the glass eye of a doll, fish bones, and a carrib bean. Symptomatology. — A sudden violent fit of coughing or choking follows the aspiration and cyanosis results; extraordinary efforts are made by the child to breathe. Occasionally the paroxysm is so slight as to be mistaken for whooping cough or croup. If the object DISEASES OF THE LUNGS AND PLEURA. 381 is sharp, as a fish bone for example, there is some local irritation or later symptoms of obstruction. The attacks may be followed by periods of comparative quiet and rest. If the object is small and smooth and is not coughed up at once, it will eventually find its way into a bronchus. It passes usually, owing to its position, into the right bronchus. Diagnosis.— If a history is obtained and the symptoms of the initial suffocative attack are well described, the diagnosis maybe made, without the knowledge that an object has been aspirated. When the symptoms come on gradually, the diagnosis may be entirely obscured. However, a bronchiectatic cavity, pulmonary collapse, or abscesses should lead to a careful investigation with this diagnosis in mind. An X-ray examination may materially aid in clearing up a suspected case. Treatment. — The finger or the laryngeal forceps may succeed in removing a recently aspirated object. If unsuccessful, tracheotomy may be necessary in cases which would otherwise suffocate, surgical measures for the removal of the foreign body being later employed. Direct laryngobronchioscopy with Killian's instrument has rendered excellent service in the removal of objects from the bronchi. Subphrenic Abscess. This consists of an accumulation of pus between the liver and the diaphragm on the right side, or between the stomach, spleen, and diaphragm on the left side. Downward extension of an empyema through the diaphragm is the usual cause in children, although it may result from intraabdominal disease. It may also complicate conditions such as appendicitis and acute pneumonia of the septic type. Empyema is most often diagnosticated and the real condition discovered at operation. Rarely the abscess contains air, and pyopneumothorax may be suspected. Symptomatology. — Beside the symptoms of the primary con- dition there may be added chills, rapid pulse, remittent fever, localized pain and tenderness, nausea and vomiting with impeded respirations. In a case seen by one of us there was a moderate amount of bulging, and the liver was raised upward by the pus. Treatment. — Prompt surgical intervention with the establish- ment of drainage is imperative. The prognosis should be guarded. SECTION VIII. DISEASES OF THE CIRCULATORY SYSTEM. CHAPTER XXVII. DISEASES OF THE HEART. Two factors in early life contribute to the vigor of the circulation : (1) The strength of the heart muscle itself and the readiness with which it hypertrophies when compensation is required. (2) The elasticity of the arteries. It is frequently not appreciated how im- portant a function the arteries play in the round of the circulation. By their tonicity they aid the heart in propelling the blood in a con- stant stream to the various parts of the body. If the arteries are healthy and elastic great help is thus afforded the heart in the equable distribution of the blood. Even a crippled heart acts to much better advantage when the arteries can perform their full share in the work of the circulation. Thus in early life when the arteries are nearly always in a sound condition, a lesion of the heart may produce com- paratively little discomfort, especially when compensatory hyper- trophy is satisfactory, as is very apt to be the case. When, however, middle age approaches and a stiffening of the arteries ensues from atheromatous change, we will soon encounter dyspnea and other evidences of a failing circulation. The blood pressure itself, as registered by the sphygmomanometer, is lower in children than in adults. The normal limits of systolic pressure at different ages have been given as follows : Infants, 75 to 90 mm. Children, 90 to 110 mm. Young adults, 100 to 130 mm. Older adults, 110 to 145 mm. In a series of observations made by us at the Postgraduate Hospital with the Stanton sphygmomanometer, the above figures were confirmed; and observations were made in diseased conditions; but while of interest, it was not found that this instrument was of much practical value in early life. The Heart. The infant has relatively a larger heart than older children and adults, and it assumes a more horizontal position from a greater 382 DISEASES OF THE HEART. 383 breadth. The apex beat in early life is in the fifth intercostal space and is sometimes a little external to the mammary line. With in- creasing age the apex beat deflects a little downward and inward, reaching well within the mammary line. Enlargement of the heart may be noted by the position of the apex beat and by an increased area of dullness on light percussion. The space for such percussion is situated between two parallel lines, one line running through the middle of the sternum and the other through the left nipple. Absolute heart dullness will be noted in a small triangle formed by the left border of the sternum, the lower border of the fourth rib and a line running from the fourth rib just within the mammary line to the third costal cartilage near the left border of the sternum. The dullness caused by the left ventricle will be marked out by percussing inward from the mammary line over the second, third, fourth, and fifth ribs; that caused by the right ventricle will be located by percussing over the fourth interspace beginning outside the right sternal line and percussing toward the sternum. Dullness caused by the apex may be noted by percussing from the middle of the sternum along the fifth interspace to the ante- rior axillary line. The heart beats with great rapidity in early life and it is often puzzling to determine accurately the character of the sounds heard. The pulmonic second sound is accentuated throughout the early years and a certain arythmia is often observed. The pulse is fre- quently irregular and its rapidity is greatly influenced by any dis- turbing conditions, such as crying; it also varies much during waking and sleeping hours. The following may be considered as a fair general average : Newborn, 120 to 140. First year, 110 Second year, 100 Fifth to eighth year, 90 Congenital Heart Disease. (Cyanosis; Blue Disease.) New-born infants sometimes exhibit a persistent blueness due to malformation of the heart. This defect usually takes the form of deficiency in the interauricular and interventricular septa. The great vessels may likewise be involved in the malformation, especially the pulmonary artery. Dr. J. L. Smith found in over half of the 162 cases he examined at autopsy that the pulmonary artery was absent, 384 DISEASES OF CHILDREN. rudimentary, impervious, or partially obstructed. He also found the following lesions : Right auriculoventricular orifice impervious or con- tracted; orifice of the pulmonary artery and the right auriculoventric- ular aperture impervious or contracted; right ventricle divided into two cavities by a supernumerary septum; one auricle and one ventricle; a single auriculoventricular opening, with interauricular and inter- ventricular septa incomplete; mitral orifice closed or contracted; aorta absent, rudimentary, impervious, or partially obstructed; aortic orifice and left auriculoventricular orifice impervious or contracted; aorta and pulmonary artery transposed, the vena cava entering the left auricle; pulmonary veins opening into the right auricle or into the vena cava or azygos veins; aorta impervious or contracted above its point of union with the ductus arteriosus; the pulmonary artery wholly or in part supplying blood to the descending aorta through the ductus arteriosus. It is obvious that with any of these grave central lesions not only the peripheral circulation, but the nutrition as well must suffer. The blood is deficient in oxygen and has an excess of carbon dioxid. The blueness is most pronounced in the prominent parts of the face, such as the eye-brows, cheek-bones, nose, and lips. The hands and fingers are also prominently affected. The color varies from a light to a very deep purple, the discoloration being aggravated by crying or other dis- turbing influence. While the infants at birth may be well developed, there are soon evidences of failure of nutrition, and they are very susceptible to inter- current diseases. The action of the heart is rapid and tumultuous, and the respiration is correspondingly disturbed. Various bruits are heard upon auscultation of the heart, especially a systolic murmur at the base. The right heart is usually enlarged. The infants suffer from lack of sufficient animal heat, and because of this and pulmonary con- gestion they easily contract pneumonia. They are apt to be carried off by any intercurrent disease, and whooping-cough is especially badly borne. In a majority of cases of congenital heart lesion, the general blueness is noted immediately or very shortly after birth. In a minor- ity of cases, however, the lividity is not noticeable for an interval of time, varying from a few weeks to a few months after birth. A few cases have been reported where even a few years have elapsed before the blueness has become marked. The defect occurs more frequently in male than in female infants. While this peculiarity has been noted by most observers no explanation can be given of it. Most cases do not survive the first year, but occasionally a case will live through infancy and childhood. It is very rare to find one surviving adoles- DISEASES OF THE HEART. 385 cence. Those that survive infancy present a stunted appearance, although well formed at birth. The chest becomes deformed, with a projecting sternum, and the fingers and toes bulbous from the slug- gish circulation. Anasarca may occur toward the end of life, to be noted in the face or ankles, and rarely in other parts of the body. Death may take place from exhaustion, during a paroxysm of dyspnea, from convulsions or from a feeble resisting power in some intercurrent disease. Diagnosis. — In order to distinguish congenital from acquired heart disease, it may be borne in mind that the latter is rarely seen in infancy, especially early infancy. The congenital type shows early and general blueness, marked dyspnea, defective development with bulbous fingers and toes. There is likewise no appearance or history of rheumatism or acute endocarditis. The commonest bruit is the loud murmur at the base. Treatment. — A general hygienic oversight is the most that can be accomplished. The infants must be kept warm and carefully fed. If the blueness and dyspnea become extreme, oxygen may give tem- porary relief. Small doses of digitalis may be occasionally given as an aid to the circulation. Acute Endocarditis, Endocarditis is an inflammation of the endocardium which espe- cially affects the lining membrane of the valves and the parts con- tiguous to them. Etiology. — The commonest cause is acute rheumatism, and, in some cases, it may be the first and even the only manifestation of this common disease. Usually, however, it is preceded by several attacks of the mild form of rheumatism seen in early life. It is also not in- frequently seen in connection with chorea. The latter disease may alone be responsible for endocarditis or it may be associated with rheumatism, the two conditions either preceding or following the heart attack. Roger considers that rheumatism, chorea and endo- carditis are frequently manifestations of the same underlying patho- logical condition. Any infectious disease may attack the endocardium, especially scarlet fever, cerebrospinal fever, diphtheria, and typhoid fever. In some cases influenza may act as a cause. Any of the septic conditions are also liable to provoke inflammation in the endocardium. Pathology. — In fetal life the right side of the heart is attacked, but this rarely occurs after birth when the left side is almost exclusively affected. The valves are most frequently the seat of the inflammation, 25 II 386 DISEASES OF CHILDREN. the mitral valve being oftenest affected and next the aortic, and occa- sionally the pulmonary valves. The affected valve is thickened from a proliferation of connective-tissue cells and may be covered by small deposits of fibrin, especially around the margins. Small thrombi and vegetations may also be present, which are liable to separate and be carried into the general circulation. In this manner secondary infections are liable to take place in various vital organs. Leakage of the valve may be caused by contractions of the chordae tendinae or ulceration with perforation of the valve. Streptococci or the staphylo- coccus pyogenes are the bacteria that most frequently infect and inflame the endocardium and rarely pneumococci, either from the presence of the bacteria or their toxins in the blood stream. The tonsils have been supposed to be the primary seat of many of the bacteria that thus affect the heart, and cases have been reported of endocarditis following tonsillitis. There is usually some inflammation of the myo- cardium coexisting with endocarditis which causes a softening of the heart muscle and consequent dilatation. This may account for some of the valvular insufficiency seen during and after the attack. Symptomatology. — The symptoms are often very obscure, being masked by the original infectious disease that is the cause of the heart lesion. On this account the heart must be frequently and care- fully examined during attacks of rheumatism, scarlet fever, diphtheria, and in any septic condition. A soft, systolic murmur is usually heard, most noticeable at the apex and transmitted toward the axillary region. There may be slight dyspnea and evidences of some dilatation, espe- cially if the child cannot be kept quiet. An irregular fever with in- creased respiration and pulse rate may also be noted. Young children rarely complain of pain or discomfort in the cardiac region but older children may describe a feeling of constriction, slight pain, or palpitation. Septic Endocarditis. — The symptoms of this form of endocarditis, otherwise known as malignant or ulcerative endocarditis, are much more urgent and marked. There are chills with high, irregular fever and sweats. There is likewise great prostration, with delirium and even coma. There are no characteristic symptoms referable to the heart beside a murmur and possibly more marked dyspnea than in the ordinary attacks. Ulcerations take place on the valves, and septic em- boli are liable to be detached and carried to the lungs, kidneys, brain, or other vital organs. A typical sign consists of purpuric spots or petechia which soon appear on the neck, chest, abdomen, or extremi- ties. This form of endocarditis may occur in any septic condition, when various bacteria may be found in the blood and thus the cause DISEASES OF THE HEART. 387 of the heart lesion demonstrated. Fortunately, septic or malignant endocarditis is very rare in early life and it is a fatal disease. Diagnosis. — A soft, systolic murmur at the apex th-at develops during an illness, with irregularity of the heart's action and some dilatation is suspicious of endocarditis. The murmur is transmitted toward the axilla and is usually accompanied by fever and increased rapidity of the pulse. A purring thrill may also be present and an increased pulsation over the area of the heart's action. Hemic or myocardial murmurs are inconstant, are noted especially at the base or over the pulmonic area and are not transmitted. These murmurs are usually systolic, but there is no evidnece of dilatation or marked cardiac disturbance and there is absence of fever and other signs of acute illness. Pericarditis is recognized by the friction sound, or dullness on percussion, or absence of distinct apex beat when effusion is present. Prognosis. — The prognosis is good as regards life, except in the septic or ulcerative form. The outlook is not so good with reference to the future ciippling of the heart from thickening or retraction of the valves. Cases have been reported, however, in which no permanent lesion has followed endocarditis, especially when the disease has been early recognized and the child kept quiet. Most of the cases, espe- cially those of rheumatic origin, are followed by some permanent lesion. Treatment. — Rest in bed in a recumbent position is very impor- tant during the acute stage. Any exertion that results in dilatation of the softened heart muscle will cause valvular insufficiency. An ice-bag may be placed over the heart in cases of severe palpitation. Tumultuous heart action may also be controlled by aconite or by small, non-narcotic doses of opium. The latter drug will also tend to allay restlessness and thus render it easier to keep the child quiet. Grains -fa to fa of morphin sulphate may thus do good service. If the heart's action is weak, with evidences of dilatation, strychnia or digitalis will be indicated. Where rheumatism is present, it may be treated by sodium salicylate, aspirin, or alkalies. The bowels must be kept open, and a light, fluid diet given. In cases having a weak or dilated heart with irregular pulse, it may be necessary to keep the child quiet in bed for some weeks or until a distinct improvement is noted. In septic endocarditis blood cultures should be made twice a week in the effort of finding the organism. (This requires expert and specialized laboratory technic.) When the organism is found a homologous vaccine can be made and used according to Wright's method. Recent reports (Thompson, etc.) have been extremely en- couraging in this heretofore fatal disease. 3SS DISEASES OF CHILDREN. Myocarditis. Myocarditis is an inflammation of the heart muscle followed by softening and degeneration. Etiology. — The toxins produced by the bacteria of the various infectious diseases may cause an inflammation of the heart muscle. Diphtheria and scarlet fever are the diseases most often responsible for thus attacking the heart. Pathology. — In some cases there is a cloudy swelling and a granu- lar and hyalin degeneration of the muscle fibers, and in others there will be a fatty degeneration. If the latter is extensive, a cut section will show a yellowish appearance of the heart muscle. There may also be a small, round-celled infiltration between the muscular fibers. Symptomatology. — The milder forms of the disease may show no symptoms referable to the heart. In severer attacks there will be dyspnea, faint feelings, and a rapid, irregular pulse. It is difficult to locate the position of the apex beat, and there will be an increased area of cardiac dullness due to dilatation. The grave cases show general pallor with cyanosis of the lips and finger-tips, and a sudden collapse from heart failure may be the terminal condition. The symptoms are liable to be masked, as in endocarditis, by the primary infectious disease. Vomiting, occurring in connection with a weak, irregular pulse in diphtheria, is usually of serious import. A pulse becoming slow in an infectious disease, especially diphtheria, after having been rapid is of grave significance. We have seen the pulse drop from 150 to 50 and 40, and, in one case it reached 25 in diphtheria with a com- plicating myocarditis. Death nearly always ensues in cases having a very slow pulse. In chronic and severe valvular disease, a lack of tone in the heart muscle due to a slow and progressive myocarditis will be shown by failure of compensation with resulting dyspnea, congestion and enlargement of the viscera, and dropsies. Diagnosis. — The diagnosis rests upon a weak and irregular action of the heart, a feeble first sound, and accentuation of the pulmonic second sound and difficulty in locating the apex beat. In addi- tion to these local signs there will be faintness, pallor, and general prostration. Treatment. — The heart must be supported by absolute rest in the recumbent position. Sudden dilatation and weakness may be com- bated by hypodermatic injections of small doses of morphin and atro- pin. Sulphate of strychnin is useful in sustaining the heart's action. Prolonged rest and avoidance of exertion must be insisted upon during convalescence. CHAPTER XXVIII. CHRONIC VALVULAR DISEASE. Physicians are often called upon to treat cases with valvular dis- eases of the heart when it is impossible to find out the beginning of the trouble. The patient may be unable to give a history either of rheumatism or endocarditis, but seeks advice for dyspnea, swelling of the extremities, or other symptoms of failing circulation. We believe that a large proportion of the cases of valvular disease in the adult have started during childhood. The first beginning of the trouble, which is the period for hopeful treatment, is not recognized. The nature of the rheumatism that attacks children is often obscure, and several attacks of wandering or so-called " growing pains" may be overlooked. While the heart may be the first structure attacked by rheumatism, this is not the common order of events. In most of our histories of valvular disease in children, the cardiac affection seemed to come on after several attacks of rheumatism. Great care should be exercised in making an early diagnosis, and vigorous meas- ures be taken to combat these first manifestations of rheumatism, fearful that, although the heart may escape the first mild attacks, it may suddenly and unexpectedly become affected by an equally light manifestation of the disease. When endocarditis ensues, as previously noted, the symptoms are often very obscure. Palpitation, slight pain, and breathlessness, with a dry cough, may not be particularly noticed by parents. In all suspicious cases we would strongly emphasize the importance of a careful examination of the heart on the part of the physician, a stethoscope being used. Just at this juncture rest is indicated above all things. If this is not procured, the delicate, softened heart muscle quickly undergoes dilatation, followed by permanent damage to the valve. Dilatation takes place very readily in the young subject. If it is true that endocarditis need not always nor necessarily eventuate in permanent valvular disease, and this seems to be generally believed, we may certainly aid such a result by doing all in our power to avoid dilatation. By recognizing the endocarditis at the beginning and keeping the child as quiet as possible, we may thus seek to avoid dilatation and consequent crippling of the valves. Even after the 389 390 DISEASES OF CHILDREN. immediate symptoms of endocarditis have passed, children are too often allowed to take part in all kinds of vigorous exercises as if nothing amiss had happened. In many cases children suffering from chronic valvular disease show few symptoms of circulatory disturbance. This is explained by a more or less perfect compensation which generally and completely ensues from hypertrophy, and there may thus be no positive sign until years later that serious damage has been effected. The periph- eral arteries are also healthy and elastic at this time, which fact, as pre- viously noted, greatly facilitates the work of the heart. As the patients grow older, and vascular degenerations begin, and the limit of com- pensatory hypertrophy is reached, marked dyspnea and other symp- toms of a failing circulation will be noted. We have seen children after a severe, neglected case of endocarditis, or after several attacks, suffer in this way, but in a large number of cases the principal evidence of valvular disease will be shown by general underdevelopment, mal- nutrition, and anemia. The extent .of the heart lesion cannot be estimated by the rela- tive loudness or softness of the murmur. We must estimate the amount of crippling caused by valvular defect by two factors in our examination of the heart: first, the position of the apex beat, and second a marked accentuation of the pulmonic second sound. If there is no hypertrophy of any part of the heart muscle, it is not probable that any real valvular defect is present. While in early life the pulmonic second sound is relatively louder than in later years, if it is very markedly accentuated, there is evidently an interference to the pas- sage of the blood through the lungs due to some valvular lesion. In early years, the mitral valve alone is most frequently the seat of chronic disease; next a combination of mitral and aortic lesions is found, and very rarely the aortic valve alone is affected. This is ex- plained by the fact that the mitral valve is most often attacked by rheumatism, while atheroma, gout, and old age are the commonest causes of aortic disease. Location of the Valves. — The mitral valve is situated at a point where the upper border of the left fourth costal cartilage joins the left border of the sternum. The aortic valves are placed behind the ster- num at the junction of its left margin with the lower edge of the third left costal cartilage. The pulmonary valves are located at the junction of the left border of the sternum and the third left costal cartilage. The tricuspid valves are found behind the middle of the sternum on the level of the line connecting the fourth costosternal cartilages. The valves of the left heart are situated deeper than, and behind those CHRONIC VALVULAR DISEASE. 391 of the right heart. Organic defects in the valves give rise to adven- titious sounds known as organic cardiac murmurs, produced by the passage of the blood over or through the valves affected. These mur- murs are not heard with maximum intensity directly over the valve affected, but near it, and are transmitted in the direction of the blood current. The following are the locations of the loudest sounds in the valves when diseased: mitral murmurs loudest at the apex; aortic murmurs loudest at second right intercostal space; tricuspid murmurs loudest at the ensiform cartilage. Mitral Regurgitation. Any insufficiency or leak in the mitral valves will be followed by regurgitation of blood during the systole. There will then ensue, first, a dilatation and hypertrophy of the left auricle; next, hypertrophy of the left ventricle required by the extra work thrown upon it in propel- ling the blood through the aortic valves, and, finally, an hypertrophy of the right ventricle which has difficulty in forcing the blood through the lungs to be emptied in the left auricle. A physical examination will show general evidence of enlargement. A visible impulse of the heart's action can usually be detected and the apex beat is felt below and to the left, or outside its usual location. On percussion, the area of dullness will be increased to the left and below, from enlargement of the left auricle and ventricle. On auscul- tation a systolic murmur is heard, having a blowing and rarely a musical character. The murmur is transmitted from the apex across the axilla to the inferior angle of the left scapula. The murmur is sometimes heard in children at the latter location behind, plainer than at the apex at front. An accentuation of the pulmonic second sound 18 usually marked. Mitral Obstruction. A presystolic or auriculoventricular sound is produced by some interference with the normal and easy passage of blood through the auriculoventricular septum or valve. The murmur is rough and blubbering in quality, beginning at the end of diastole and ending ab- ruptly with systole. One of the most characteristic points about this murmur is its abrupt termination. This quick stop of the abnormal bruit is very different from the gradual ending of mitral regurgitation. The obstruction in the valve leads to hypertrophy of the left auricle and finally to enlargement of the right ventricle which has more work to do in flushing the blood through the lungs. The left ventricle is not 392 DISEASES OF CHILDREN. hvpertrophied, and accordingly the apex beat will appear in about its normal location. Any enlargement will be noted by an increased area of dullness to the right of the sternum. A purring thrill is usually felt by placing the hand over the heart. On auscultation a blubber- ing murmur is heard only in the region of the apex and is not trans- mitted. It is likewise somewhat variable and may be hardly audible during repose and yet very evident when the patient is required to make some exertion. The pulmonic second sound is always accentuated. Chapin has reported a series of forty cases in which children giving evidence of mitral obstruction w T ere kept under observation for different intervals of time from a few weeks to several years. The commonest symptoms noted were varying degrees of pain referred to the region of the heart and dyspnea on exertion. Thirty-one of the cases gave evidence of simple mitral obstruction, while in nine cases there were combined murmurs. Most of the cases were preceded by a rheumatic manifestation that was mild even for children, and he concludes that while mitral stenosis is not independent of rheumatism it is apt to be associated with the less pronounced forms of it. In growing children, especially girls, who are pale, nervous, anemic, and troubled with digestive disturbance, an irregular action of the heart may produce a rough sound simulating mitral obstruction, which disappears under improved conditions. Aortic Obstruction. This lesion is infrequent in childhood. It is accompanied by a systolic murmur heard at the base at the second right interspace and transmitted upward. The aortic second sound is somewhat weakened, but there is no accentuation of the pulmonic second sound. There is hypertrophy of the left ventricle and the apex beat is accordingly pushed downward and outward. The latter will distinguish this sound from functional or hemic murmurs with which it is apt to be confused. Aortic Regurgitation. This lesion is likewise not very frequently seen in early life. The murmur is diastolic, taking the place of the aortic second sound. It is rather harsh in character and is transmitted downward over the sternum, being heard with greatest intensity at about the fourth cartilage or sometimes at the lower extremity of the sternum. There is great hypertrophy of the left ventricle, and accordingly much dis- placement of the apex beat downward and outward, and the heart CHRONIC VALVULAR DISEASE. 393 usually acts with considerable force. The so-called "water-hammer pulse" is typical, consisting of a full, arterial wave followed by a sudden fall in the pressure. Tricuspid Regurgitation. This lesion is very rare and apt to be overlooked. It may be caused by disease of the valve itself or secondary to a dilated right ventricle. There is a very soft systolic murmur heard over the ensiform cartilage. It is distinguished from aortic regurgitation by being systolic instead of diastolic, and also by more marked cyanosis, by pulmonary edema, and jugular pulsation. Prognosis in Valvular Disease. — The immediate prognosis in children, even when the lesion is fairly severe and extensive, is usually good for reasons already noted. There is nearly always, however, a more or less defective nutrition. There are cases in which slight lesions appear to undergo complete recovery, especially when a healthy general growth can be accomplished. Repeated attacks of rheumatism, with the danger of renewed endocarditis, are a grave menace to the heart by upsetting compensation and increasing existing lesions or forming others. The ultimate prognosis is not good in most cases of marked valvular disease, as it is only a question of time when the compensation will fail in later life. Treatment. — Many cases require no treatment directed to the heart, but the general nutrition and growth require careful oversight. Nourishing, digestible food, with the occasional administration of remedies to build up tissues, such as iron and cod-liver oil, are fre- quently all that are required. These cases should not be restricted too much in exercise and amusement. All the milder games may be allowed, only avoiding the more violent and competitive sports. Any acute infectious disease and the slightest manifestation of rheumatism must mean extra rest, and anxious care on the part of the physician. Any evidence of failing compensation will likewise require rest and the administration of heart tonics, especially strychnin and digitalis. In cases of great dyspnea and restlessness small doses of codein by the mouth or minute non-narcotic doses of morphin given hypoder- matically will often afford relief. Functional Cardiac Disorders. The heart in growing children, especially those with a neurotic tendency, is very prone to functional disorder. Digestive disturbances and the anemias are the commonest exciting causes. 394 DISEASES OF CHILDREN. Palpitation of the heart. — This is seen in connection with dyspepsia from the use of improper food or from the abuse of tea, coffee, or con- diments. In older children the strain from overstudy or from mastur- bation, especially at the time of adolescence, is a common cause. The heart ma}' be unusually slow or rapid in action, but oftener the latter. Hemic Murmurs. — These murmurs are not often heard in infants and very young children, but are fairly frequent in older children. They are invariably systolic and are usually heard at the base. A diastolic murmur is always organic. The hemic murmurs are heard more distinctly over the pulmonary than over the aortic interspace, are inconstant, and are not transmitted in the direction of the blood current. ' They are usually accompanied by a venous hum in the jugular and subclavian veins. The most reliable differentiation between hemic and organic murmurs consists in the enlargement of the heart from compensatory hypertrophy seen in the latter. Mur- murs, apparently of hemic origin, are sometimes noted in acute febrile affections. Dynamic murmurs, due to a faulty action of the heart muscle, are sometimes detected after violent exercise and in choreic or hysterical children. A cardiorespiratory murmur may be produced by the impulse of the heart against some of the pulmonary vesicles at the end of a deep inspiration. It is always systolic and is not heard at the end of expiration. Treatment. — The management of functional heart troubles is principally dietetic and hygienic. The digestion must be carefully regulated and only nourishing and easily assimilable food be allowed. It may be necessary to remove the children from school so that they can be free from nervous strain and have more opportunity to get plenty of fresh air and sunlight. All the known sources of nervousness must be removed and opportunity given for abundance of sleep. Iron and cod-liver oil are the best remedies. Small doses of Fowler's solution may also be employed. CHAPTER XXIX. DISEASES OF THE PERICARDIUM. Pericarditis. This is an inflammation of the pericardium secondary to rheu- matism or some infectious disease. Etiology. — The most frequent cause is acute articular rheu- matism. It may also occur in connection with the exanthemata, especially scarlet fever, in various septic processes, in tuberculosis and pneumonia. Direct injury is rarely a cause, and it may spread by continuity from pleurisy. The following bacteria may act as exciting causes — streptococci, staphylococci, the tubercle bacillus, the colon bacillus and the pneumococcus. Pathology. — We may recognize three varieties — the fibrinous, serofibrinous and purulent, according to the inflammatory exudate. In the first or adhesive form, the pericardium is covered by an exuda- tion of fibroplastic matter which may lead to adhesions between the visceral and parietal surfaces. In the serofibrinous form, the peri- cardial sac contains a serous fluid, together with a fibrinous exudation, which produces adhesions on absorption of the fluid. The sero- fibrinous exudation may occasionally become purulent, and rarely blood is exuded into the sac. Miliary tubercles may infiltrate both the visceral and parietal surfaces in the tuberculous form. Permanent adhesions will be produced by the fibrinous exudation being replaced by new connective tissue. More or less myocarditis is present in connection with pericarditis, the same as in endocarditis. Symptomatology. — The symptoms are of such a negative character that the disease is often overlooked. As it is usually a secondary condition, the original disease is apt to mask the symptoms that are present and occupy all the attention of the physician. Palpitation of the heart, dyspnea, more or less pain in the epigastric region, rapid, irregular pulse, and increased respirations are usually present. In severe cases cyanosis may be marked. Where pus is present in the effusion, the temperature assumes a more remittent curve. Physical Signs. — As the rational signs are obscure, the physical I signs assume great importance in making a diagnosis. In the fibrous form, a superficial friction sound, synchronous with the beat of the 395 396 DISEASES OF CHILDREN. heart may be detected. It may be heard on systole alone, or with both systole and diastole. It is usually more distinct at the base, but it may also be heard toward the apex, especially at the onset of the disease, and is not transmitted. At first, the sound may have a crepitant quality, but later assumes a coarser, rubbing, or rasping character. A friction fremitus may be felt over the region in which the friction rub is localized by auscultation. In the serous form there may be some bulging at the precordial region, depending upon the amount of the effusion. From one to two fluidounces must be present in the pericardial sac in order to pro- duce marked signs. The apex beat is not distinct, being pushed up- ward and to the left. Where there is extensive effusion, the apex beat may be lost. There will be an increased area of precordial dullness over the distended sac. It may extend on the left outside the mam- mary line from the seventh rib up to the first rib, and from a little to the right of the sternum down to the liver. As in plueral effusions, there will be a slight resistance to the finger on percussing. On aus- cultation the heart sounds are muffled or feebly heard, and the apex is located with difficulty, if at all. As the fluid is absorbed the friction rub will again be noted and the valvular sounds become more distinct. Diagnosis. — This must be made by a careful examination of the heart in reference to the physical signs just noted. In endocarditis the apex can be located and the soft, blowing murmur is transmitted. Acute dilatation of the heart and hypertrophy will show an enlarge- ment and increased area of dullness, but there will be no friction rub nor signs of effusion, and the previous history will help to throw light on the case. A left pleural effusion, with or without pericardial effusion, may raise a difficult point in diagnosis. The flatness from the pleural effusion will not extend over the heart and sternum if there is no pericardial effusion, but, if both are present, the extensive dullness and feeble or absent heart sounds will afford a probable diagnosis. Prognosis. — The immediate outlook is good except in the septic and purulent forms of the disease. The heart may, however, be per- manently crippled in the case of extensive adhesions. Treatment. — The child must be kept perfectly quiet in the recum- bent position as in all other forms of acute heart trouble, and milk or other bland food given. Tumultuous action may be controlled by an ice-bag over the heart. Small doses of morphin or codein may be employed to quiet and strengthen the heart's action, to control pain, and relieve restlessness. If the heart is weak and unsteady, strychnia, digitalis, or alcohol may be employed. Where effusion is extensive DISEASES OF THE PERICARDIUM. 397 enough to seriously embarrass the action of the heart, aspiration has been tried, but with doubtful results. We have seen a case of sudden death due to a slight puncture of the heart muscle where this operation was employed. Rheumatism if present, or the original causative disease, must be treated in connection with the measures aimed at the pericarditis. SECTION IX. DISEASES OF THE BLOOD AND DUCTLESS GLANDS. CHAPTER XXX. DISEASES OF THE BLOOD. Glossary. Corpuscular Elements. Erythrocytes red cells. Leukocytes white cells. Poikilocytosis variations in shape of red cells. Normoblast nucleated red cell of normal size. Microblast nucleated red cell of small size. Megaloblast nucleated red cell of large size. Leukocytosis (or hyperleukocytosis) : increase in total number of white cells (more than 12,000) usually implies a polynucleosis. Leukopenia: decrease in total number of white cells (below 6.000). Polynucleosis : relative and absolute increase of the polynuclears. Lymphocytosis: relative and absolute increase in lymphocytes. Eosinophilic: relative and absolute increase in eosinophiles. Blood. Blood consists of a clear yellowish fluid, the plasma, in which float the cellular elements or corpuscles, the red cells giving to blood its characteristic color; the white cells or leukocytes act as phagocytes, and the blood plates are the product of degenerating leukocytes. Normal blood contains the following number of cells and blood- plates to the cubic millimeter. Erythrocytes 4.500,000 to 5.000,000 Leukocytes 7,500 Plates 150,000 to 300,000 The color of blood is due to the presence of hemoglobin, an organic compound of iron. When of normal intensity, this color is given as 100 per cent. The color-index of a specimen of blood is obtained by dividing the per cent, of hemoglobin by the per cent, of red blood-cells. Normally, the color-index is 'ZlZllll = l - The specific gravity of blood is highest in the new-born and during the first week or two falls to its lowest point. It remains low during the first two years of life, averaging 1.050 to 1.055, then gradually 398 DISEASES OF THE BLOOD. 399 increases as puberty is reached. In adults the specific gravity is about 1.059. The specific gravity varies directly with the amount of hemoglobin present. Red blood-cells (erythrocytes) are most numerous per cubic millimeter in the first twenty-four hours of life, Hayem estimating the number to be 5,900,000. This number gradually falls during the days in which the infant loses weight. About the seventh day the average number per cubic millimeter is 4,500,000. This is the average number of cells throughout childhood. Hayem is also the authority for the statement that early ligation of the funis reduces the number of red blood-corpuscles about 500,000 per cubic millimeter. Trifling causes in infancy and childhood result in marked changes in the red blood-corpuscles in number, size, and shape; hence poikilo- cytosis and anemia are common. The red blood-cell is a biconcave disk, non-nucleated, varying greatly in diameter, 3.3 micromillimeters to 10.3 micromillimeters having opaque yellowish rims and nearly transparent centers. In adults they show a marked tendency to cohere by their flat surfaces forming long rows (rouleaux), though in infancy this property is much less marked. Nucleated red cells are not normally found in infants. In prematures they may be found for three or four days. There are three varieties of nucleated red cells: (1) Normoblast which re- sembles a normal red cell in all particulars except that it is nucleated ; (2) Megaloblast — a large cell 10 micromillimeters to 20 micro- millimeters in diameter — seen only in severe anemias; (3) Microcyte which is smaller than the ordinary red cell; this form is rare. White blood-corpuscles (or leukocytes) vary in size from the size of a red cell to two or three times that size. In the fresh state the larger ones present ameboid movements if kept at body tempera- ture. In stained specimens the following forms may be recognized. (1) Polynuclears (or polymorphonuclear neutrophilic leukocytes); these constitute about two-thirds of all the white corpuscles in normal adult blood. In infancy, they occur in about 18 to 40 per cent. Stained by Wright's method, the nucleus takes on a deep navy-blue color. The nucleus is very irregular in shape, no two being alike. The protoplasm stains pink. The average size of these leukocytes is 13.5 micromillimeters. (2) Lymphocytes, stained by Wright's method, show a small oval nucleus about the size of a red cell and stain deep blue; around the nucleus is a narrow rim of protoplasm which stains a light blue. At birth, the lymphocytes comprise about 40 to 60 per cent, of the 400 DISEASES OF CHILDREN. total number of leukocytes; lymphocytes vary in size from that of a red cell to two or three times this size, and so are named large or small. In the large variety, the nucleus may be placed eccentrically or in- dented, and the protoplasmic rim may be much wider than in the small ones. The average size of large lymphocytes is 13 micromillimeters; of small ones 10 micromillimeters. (3) Eosinophiles also have polymorphous nuclei of much looser structure and larger granules than the polynuclears. With Wright's method the nucleus stains a light blue or lilac and the granules a brilliant pink, the protoplasm staining a pale blue. The average size of eosinophiles is 12 micromillimeters. (4) Mast cells are about twice the size of a red cell, i.e., 15 micro- millimeters. The nucleus is usually polymorphous. Large granules (staining dark blue or almost black) lie over and around the nucleus and along the margins of the cell. (5) Myelocytes occur only in pathological conditions. These are bone-marrow cells, and are the forerunners of the polynuclear cell. It is a large cell, the average diameter being 15.75 micromillimeters; it differs from the large lymphocytes in having granules; it differs from the polynuclears only in the shape of its nucleus which is oval and not broken up and which is in close contact with the cell wall for a large portion of its extent, i.e., if egg-shaped it is placed eccentrically. According to Hayem, the number of leukocytes per cubic milli- meter during the first forty-eight hours of life averages 18,000; falls to 7,000 for the third and fourth days; and averages 9,000 to 11,000 after the fifth day. The counts of Schiff, Orunsky and Rieder run con- siderably higher than this. The following table (by Wile) gives the relative percentage of polynuclears and lymphocytes in the blood during the first ten years: Age in years 1 2 3 4 5 6 7 8 9 10 Polynuclear neutrophils Lymphocytes 35% 53% 38% 51% 42% 47% 47% 41% 52% 39% 52% 37% 53% 35% 54% 33% 55% 31% 60% 30% DISEASES OF THE BLOOD. 401 Leukocytosis (or hyperleukocytosis), i.e., an increase in the number of white blood-corpuscles per cubic millimeter, is present in the following pathological conditions: Pneumonia, diphtheria, per- tussis, scarlet fever, erysipelas, rheumatism, acute rickets, septic and cerebrospinal meningitis, and in pus cases, such as appendicitis, peritonitis, empyema, osteomyelitis, and acute abscess. In the above conditions the increase of cells is in the polynuclears and is known as polynucleosis. Leukocytosis is also physiological; e.g., in the new-born, after exercise, after a cold bath, and after a full meal; in this latter condition the count may be increased 33 J per cent. Leukopenia is a state of diminished leukocyte count, and occurs in typhoid, measles, influenza, malaria, tuberculous inflammations and gastroenteritis. Lymphocytosis is an increase in the number of lymphocytes, and occurs in syphilis (congenital), scurvy and splenic disease. Eosinophilia, an increase in the number of eosinophiles, occurs in leukemia, chronic skin disease, and in patients infected with intes- tinal parasites, particularly trichina. Blood-plates (or plaques) are best seen in fresh-blood prepara- tions. They are- very small, round or oval bodies, about 2 to 3.5 micromillimeters in diameter. In a few seconds they lose their rounded form and become spinous, and ultimately very thin filaments of fibrin are seen starting from their angular projections. Their functions are not known. Anemia. A decrease in the amount of hemoglobin produces a state known as anemia. The decrease may be in the total amount of blood, in the total number of corpuscles, or in the coloring matter of the red cells. Alterations in the number of leukocytes do occur in anemic states, yet these changes cannot be regarded as factors in the process. Simple or Secondary Anemia. These anemias are more often secondary to some of the severe, acute, or constitutional diseases, as gastroenteritis, syphilis, rickets, tuberculosis, nephritis, pneumonia, etc. Bad hygienic conditions and unsuitable food are often responsible and occasionally fatal. The nurslings of diseased mothers are especially liable to anemia. Loss of blood from any cause is serious in early life, and the resulting anemia occasionally persists. The parasites and the toxemias produce anemias of this type. 26 402 DISEASES OF CHILDREN. Pathology. — The red blood-corpuscles are diminished in number, sometimes decreased to a million and a half or less. The hemoglobin is lowered to 30 per cent., but we have not too rarely had an estimation of 10 to 15 per cent. Irregular forms are seen in the severe types. Leukocytosis in our experience is more often observed than absent in early life. Symptomatology. — Languor, anorexia, pale or blanched mucous membranes and sallowness of the skin is usually present. Con- stipation is the rule. The gastrointestinal tract is early disordered. Later the child tires easily and becomes dyspneic on exertion. The extremities are cold. The pulse is soft. The heart action is rapid and hemic murmurs are heard over the base and in the neck. The sleep is broken, and the temperament changes. While there is usually a steady loss of w r eight, augmentation may follow in aggravated cases of edema. The spleen and liver may be found to be enlarged or enlarge after some- weeks of illness. These children are prone to intercurrent affections and easily succumb to a pneumonia or gastroenteric infection. Differential Diagnosis. — Lymphatic leukemia must be dis- tinguished if there is splenic hypertrophy present. The more intense blood picture with its varied forms establishes the diagnosis together with the slower and more protracted course resisting ordinary treatment. In the pseudoleukemia of infants (von Jaksch) w r e have a marked leukocytosis with splenic and hepatic enlargement coupled with a hypertrophy of the lymph nodes. Prognosis. — The etiological factor and the intensity of the leukocytosis present must be taken into consideration in framing the prognosis. A low red blood-cell count, reduction of the hemoglobin to below 30 per cent., coupled with a high color-index, are unfavorable features; otherwise the prognosis is good. Chlorosis. This is an anemia characterized pathologically by a lowering of the hemoglobin without a marked decrease in the number of red cells and clinically by a greenish-yellow color of the skin. Etiology. — Girls at the age of puberty, especially those who w DISEASES OF CHILDREN. 03 a o d 03 CO 3 .2 !§ '5 ® Generally greatly re- duced, about 2 mil- lion. a s: ' ■/. C ~ CD X 03 Megalocytes fre- quent, color usually not diminished. Poikilocytosis always extremely pro- nounced. Generally 2 0-4 0%, relatively higher in excess of corpuscles XI G CD 3 cr CD h &H G CD w CD a CO 03 js "o3 02 o £ < Nearly always pres- ent and more nu- merous than nor- moblasts. - o ad "^3 ■at o 2 rt S -2 .2 c3 > G o .2 03 > 3 -O -i^T G - CD n CD S-. Cm CO "co O ■+J r>~i CD o S O u ^.2 "3^ Ph Diminished proportionately to or greater than the corpuscles. CD co CD a '•+3 CD £ o 02 £ o G ^? CD G CD O >> co 03 — z - X < x < < .2~3 GT3 la — o X G t- CD T3 to B '■- a > More numerous in all degrees than in any other dis- ease. 6 u at 3 - pq < Pseudoleukemia (von Jaksch) Splenic anemia G T3.2 §1 a Unequal in size .... All degrees of {poiki- locytosis. Marked diminution, as low as 30%. Numerous, and show karyokine- sis. Sometimes found, especially if se- vere. .22 p O O Usually diminished, rarely under 2 mil- lion. Diminished in size. Microcytes frequent. Paler in color. £ o CO 02 '% 6 O CD rd o •o » Ph Relatively greater di- minution than num- ber of corpuscles. 5 cr > S < ■> Present in severe cases generally in small numbers. Absent or extremely rare. II •° 93 ~ — t- z C z. T r C N X . M — I 4) § 2 T3 O o CD X z X z 5 z E ■~ ) l ~ c s- c c C DC DC a — z z z CO ■~- ■f. St a D DISEASES OF THE BLOOD. 407 o3 a CD d co O '5 Fh CD 43 co '3 'S g, P i # d ,£? '© % . ►^ CD >> co Jd 03 gs p T3 CD 43 CO '2 1 xl d co P A very large percent- age frequently pre- sent. X CD 1? 'd CD co d -»3 o Iz; CD bfi 03 >> d 03 | "co d 1 Leukemia, Lymphatic — fl Fh — 3^3 <«42 T3 d 13 £ O " M £ £3 m CD 4h Oh 2 u o a^ S u «i « -p 1 _d >> CO d . §s d ° a +3 d CD CO 42 03 13 CO p T3 CD bD Fh 'd CD j>> 43 o3 CD Fh o 3 03 Leukemia Splenomeduliary Enormously in- creased. d '-3 'a; • >T3 43 _g CO 'd | x "cD '■+3 "3 - Fh 22 03 2^ 2 w CD - do-S t>^ d *Fh r 5 CD CD CD ^ "^ > T3 CD s? "d CD 03 CD ' Fh a pc H Pseudoleukemia (von Jaksch) Splenic anemia c +^ o o . S-a. cp © co O 8»© Fh 1—1 O H CI t— 1 d co CD 03 o o m 73 co co CD Fh O t d co P ■a 1 >> 13 d _o 'co o3 O o o i d cb °> Fh 4h © cy -O +3 CD CD d bfl 03^^ 43 H-? d o S 43 -^> CN O 43 CO co CD • Fh CO Fh C o 'co .S d I— i co '58 o Fh Q 13 s Fh o d d CD a > a. _> '•£ a p. a c E "■g S c CD, 03 CD Fh o # d cb - CO 11 §•■3 ►. co »^s CD 3 43 co P s o> Fh -t-3 X 03 (H O -+= • d ^ CO w CD bC Fh 03 CD co 1 co Fh 00 o +3 2 >» c 'a CD 42 s d of % a o 4* d CD a: a +: > c C C > a F- K C c E > c ■J DC a > c C a > : 43 £ z d . o3 co T3 d d a b < a a F- c c X e a 4^ a DC c C \0S DISEASES OF CHILDREN. Treatment of the Anemias. The general management of these cases is of greater importance than the administration of drugs. The causes which have produced the anemia may or may not be clear, but the majority of cases are in all events benefited by a regulation of their daily life. If the causa- tive agent, as parasites, is found, treatment should be directed to- ward its removal. Sunshine and fresh air coupled with an easily assimilated diet as rich in proteids and organic iron as possible, should be considered as necessities for all the anemias. Aerotheraphy may be limited by the circumstances as in the case of the poor city child, but five hours a day in the open air can always be obtained even in the winter months by using the child's room, the roof, or the parks. The children are more benefited when removed to the country. If the child has been attending school, this should be discontinued and the amount of exercise curtailed. Rest in bed is necessary for the severe cases, but this should not preclude sun baths and fresh-air treatment. If possible the child should be cared for and entertained by one person so as to avoid undue excitement or fatigue. A bottle-fed infant should gain in weight and strength if the formula is suitable to its requirements. If assimilation is at fault a wet-nurse may be required, or such changes and additions should be made to the food as will at least temporarily promote the digestive capacity. (See article on Infant Feeding.) Older children should have an individual diet list prepared for them which will contain especially such articles as fresh raw milk, eggs, vegetables, rare meats, and fresh fruits. (See Diet Lists, p. 174.) Spinach, yolk of egg, and the legumes contain organic iron in largest quantities, and it is desirable that the deficiency in iron should be made up from the natural foods rather than iron preparations. Drugs. — In chlorosis the iron preparations are of distinct value, especially when given with a nutritious diet and baths. Many of the anemias are benefited by the scale preparations, especially the citrate of iron and ammonia and the bitter wine of iron. Several trials may be required to find the preparation of iron best suited to the individual case. The various peptonates often do well, as they are easily tolerated by the stomach, but other cases will apparently do better on the old tincture of the chlorid of iron, well diluted and given through a tube. In older children, Blaud's pill will often do good service. Fowler's solution should be given in addition to the leuke- mias and in pernicious anemia, beginning with one drop three times DISEASES OF THE BLOOD. 409 a day well diluted and gradually increasing to the physiological result, care being taken not to produce symptoms of arsenical neuritis. Cod- liver oil is a valuable addition if it is well borne and does not produce an aversion to the ordinary diet. We have used the X-rays in selected cases of splenic leukemia, but the results which at first seemed promising do not warrant its general use. Purpura. In this condition subcutaneous hemorrhages, petechial or ecchy- motic in type, appear spontaneously and form one of the symptoms of a disease. Different names have been applied varying with the location and extent of the hemorrhages. It is known as purpura simplex when the hemorrhages occur into the skin only, and purpura hemorrhagica when bleeding takes place into the mucous membranes or internal organs. Etiology. — Any infectious process at any time during its course may be accompanied with purpura. It especially occurs in children with scarlet fever, variola, measles, cerebrospinal meningitis, and with septic processes in any organ. Pathology. — Hemorrhagic exudates may be found varying with the type of the disease either in the skin, mucous membranes, or internal organs, or in all of these situations. The spleen is enlarged in those types occurring with marked infection. The study of the blood has thus far thrown no light on the pathology of the disease. Further study of the adrenal bodies, which sometimes show large hemorrhages, may explain the etiology of the disease and prove whether it is an infectious process, a pathological change in the arteries themselves, or whether it is due to vasomotor changes that allow the hemorrhage to take place. Purpura Simplex. — The purpura may appear suddenly in a child that is apparently well, but as a rule it is preceded by prodromal symptoms resembling those of intestinal disturbance. There may be lassitude, loss of appetite, even nausea or vomiting. The stools may be slimy from improper digestion, and a low grade of fever is present in older children, but little or no variation is noted in infancy. The tibial surfaces are usually first involved, the hemorrhagic areas varying greatly in extent in different subjects. The color soon changes from a purplish-red to a dark, mottled, bluish-black. There is no pruritus nor pain on pressure over these areas. Indefinite muscle or joint pains are complained of, but localized with difficulty. In cachectic or marasmus infants it is not uncommon to see these 410 DISEASES OF CHILDREN. hemorrhagic areas appear over the abdomen or extremities. In any Long-standing or exhausting disease in the early months of life, purpura may appear and must be regarded as of serious import. In older children, however, purpura simplex tends to recovery, although relapses sometimes occur when the outlook seems most bright. Purpura Hemorrhagica. — In contrast to the simple form, this is a much more serious condition with a rather severe train of symptoms. After a few days of indisposition, with nausea and vomiting, fever Fig. 108. — Purpura hemorrhagica. appears ranging from 100° to 104° F., with prostration out of propor- tion to the symptoms. At the same time that the hemorrhages appear in the skin, there may be bleeding from the nose or mouth. Hemor- rhages in the alimentary tract may occur and are noted by finding blood in the vomitus or in the stools. The fact must not be forgotten, however, that the blood may be swallowed and later appear in the vomitus or stools. Blood in the urine usually occurs in the beginning, but ceases when the child is put at rest. Localized areas of edema may be present and, as a rule, correspond to, although greater than, the hemorrhagic areas. Pain referred to the gastric region, headache, and anorexia are quite common symptoms which persist in spite of treatment. Sleep is broken, and delirium, especially at night, may DISEASES OF THE BLOOD. 411 occur. Coma resembling that of the typhoidal state occurs in the severe cases and may persist until a fatal issue takes place. Henoch's Purpura. — This symptom-complex, occurring as a rule in childhood, was first described by Henoch. The symptoms refer- able to the skin consist of a purpura of varying degree, often accom- panied by an exudative erythema and urticaria or a localized edema. Besides the above manifestations, there are lesions in one or more joints which resemble rheumatic fever. Colicky pains, with vomiting Fig. 109. — Henoch's purpura. and diarrhea, are nearly always present, but as a rule are not of long duration. As in purpura hemorrhagica, there may be hematuria or hematemesis. Albumin is generally found in the urine. Recur- rences are frequent and succeeding attacks may show wide varia- tions in the symptoms. Schonleins Purpura. {Purpura Rheumatica.) — This form is char- acterized by a polyarthritis with the symptoms of rheumatic fever and purpuric hemorrhages. Circumscribed edema may be present. A variable amount of temperature occurs with the arthritis. Albumin is generally found in the urine. Purpura Fulminans. — A very rare but fatal form of purpura is designated as a fulminant type. The onset is sudden, occurring with 412 DISEASES OF CHILDREN. high fever, convulsions or chills, vomiting, and marked prostration. The purpuric eruption rapidly spreads over the whole body. The urine is scant and contains albumin. It most frequently occurs in children under five years of age, and what was formerly known as malignant or black scarlet fever and measles probably belong to this type. Hemorrhages into the adrenals have been recorded. Diagnosis. — The diagnosis of purpura is usually easily made from the hemorrhagic nature of the lesions which do not disappear upon pressure. It is to be distinguished from infantile scurvy in which there are present swollen, spongy, bleeding gums, and articular pain combined with a long history of cooked food. Prognosis. — In certain forms, as the simple and rheumatic, the prognosis is favorable, although it may persist for several weeks. Hemorrhagic purpura and Henoch's purpura have sometimes been attended with fatal results. The fulminant type is always dangerous to life. Treatment. — This must necessarily be directed to the under- lying cause when this is known. Rest in bed with a carefully regu- lated diet, including raw fruit juices, is indicated. The fluid extract of ergot internally or 5 minims of a y-oVo adrenalin solution hypoder- matically may be given if the hemorrhages are profuse. In convales- cence the tincture of the chlorid of iron is important. Hemophilia. Hemophilia is an hereditary blood disorder characterized by a tendency to inordinate bleeding from the vessels following a trauma. or spontaneously from the capillaries into the tissues. It is almost invariably transmitted through the mother, who herself may not -have been a bleeder. The male offspring (the first born often escaping) is affected in the proportion of eleven to one of the female. The male may again transmit the disease through his daughter. No characteristic blood changes or histological peculiarity of the vessels has been found. Coagulation is always retarded. The hemorrhages occur most frequently from the nose, mouth, genital organs, and lungs. Some trauma to these parts may be the first notice of the diathesis or the fact that slight, almost imperceptible blows produce subcuticular hemorrhages. Following a fall there may be internal hemorrhage or bleeding into a joint that may produce dis- ability or subsequent anchylosis. Death has occurred from uncontroll- able hemorrhage following circumcision or the extraction of a tooth. DISEASES OF THE BLOOD. 413 Treatment. — Marriages in the families of bleeders should be con- trolled or at least due warning of consequences given. Subcuticular hemorrhages are sometimes controlled by absolute rest with ice applications and compression. Adrenalin 1-1,000 or 1-500 adrin solution may be directly applied. Stypticin in doses of gr. J oifers some hope of control. The gelatin solutions for subcu- taneous use are to be deprecated, as they may be carriers of tetanus infection. Warm or rather tropical climates are the safest for the hemophiliac. CHAPTER XXXI. DISEASES OF THE DUCTLESS GLANDS. The Thymus. This small, ductless gland, of epithelial origin, consists of two lobes coming in contact in the median line. It is located during its greatest development partly in the lower part of the neck and partly on the anterior mediastinum, extending from the lower edge of the thyroid above to the fourth costochondral articulation below. It is thus in relation with the trachea above and the great vessels and pericardium below. It is largest during the first two years of life and then atro- phies, but occasionally it persists longer and may last until puberty. In the course of atrophy it disappears from the neck and remains behind the manubrium. Various authorities disagree as to its normal weight. From 14 to 20 grams are said to be the average weight during infancy, but Boviard finds it much smaller than usually stated. From 100 observations made on the normal size of the thymus in early life, he found it averaged not over 3 grams, in weight. The histo- logical structure of the thymus is similar to that of lymph-glands, and it probably functionates as a blood-forming organ. Enlargement of the Thymus. Hypertrophy of the thymus may produce grave effects apparently from pressure. Two possible explanations may be offered — first, that the enlarged thymus pushes on the trachea and thus embarrasses breathing; second, that dyspnea may be caused by pressure on the phrenics or pneumogastrics. It is, however, difficult to prove the lat- ter. Laryngismus stridulous and various forms of dyspnea, some- times called "thymic asthma," have been referred to the enlarged thymus. The symptoms may eventuate in sudden death. The diagnosis of enlarged thymus by physical signs is rarely made positively during life. It may occasionally be palpated by deep pressure over the top of the sternum and there may be dullness on percussion behind the upper part of the manubrium extending down from both lateral borders of the sternum. The area of dullness on the sides of the sternum may be unsymmetrical. 414 DISEASES OF THE DUCTLESS GLANDS. 415 Fig. 110. •Marked enlargement of the thymus gland with its relations; from an infant, 7 months old. 416 DISEAJ5ES OF CHILDKKN. Status Lymphaticus. By this condition is understood a lowered vitality seen in con- nection with enlarged thymus and a general hyperplasia of the lym- phoid tissue of the body. Sudden death from cardiac paralysis and asphyxia may ensue under anesthesia or from any intercurrent disease or irritation. Enlargement may be noted of the superficial and deep lymph nodes of the neck, of the follicles at the root of the tongue, of the tonsils, of the adenoid tissue at the vault of the pharynx, and, on autopsy, of the lymphoid structures of the stomach and bowels. There may be some enlargement of the spleen with hypertrophy of the Malpighian bodies. There may likewise be a proliferation of the lymphoid tissue of the bone-marrow. Drs. Musser and Ullom report the pathological findings to be practically constant in eighteen cases of status lymphaticus collated from the literature of the subject, consisting of an enlarged thymus, spleen, lymph glands, Peyer's patches, tonsils and pharyngeal tissue. While these conditions were not reported in every case, the enlarged thymus, spleen, and some of the lymph-glands were constantly found. Cloudy swelling of the liver and kidney were also fairly constant lesions. German path- ologists, especially Virchow, have noted a lack of development of the heart and arteries. Thus the heart may be small and the aorta narrow and thin-walled. With this may be associated a lack of development of the sexual organs sometimes reaching the condition of infantilism. Varying grades of rickets, with resulting mild or severe bony defor- mities, are seen in a large number of cases of status lymphaticus. These children may show a fair amount of fatty tissue, but are usually anemic. Chlorosis or hemophilia may also exist. It is very probable that the disastrous results so often seen in status lymphaticus are due to an autointoxication from a sort of lymphotoxemia having its source in the lymphatic tissues of the body. The importance of recognizing the condition is very great not only in respect to anesthesia, but for guarding the prognosis in any intercurrent mild or severe disease and as an explanation of certain cases of sudden death without any known cause. The diagnosis often cannot positively be made, but children or young adults with bony evidences of rickets, with much enlarged tonsils and adenoids, with generally hypertrophied lymph-glands, with the male genital organs or breasts undeveloped in the older subjects, together with an absence of pubic hair, should be considered as possible subjects of status lymphaticus. In young subjects, attacks of laryngospasm, in conjunction with DISEASES OF THE DUCTLESS GLANDS. 417 a number of these stigmata will greatly strengthen the diagnosis. .Congenital underdevelopment of the heart and arteries is usually accompanied by smallness of the surface arteries and a smallpulse. The treatment consists in careful hygienic oversight, especially as regards food, fresh air, and warm clothing. Cod-liver oil and the syrup of the iodid of iron may be given. The hypertrophied tonsils and adenoids must be early removed, but without the administration of an anesthetic. Diseases of the Spleen. The spleen is not uncommonly found to be enlarged in infants and children. Its elastic, distensible structure makes it peculiarly susceptible to enlargement, especially from congestion, infectious, blood, or constitutional disorders. Its upper border lies on a line with the ninth rib, its lower border reaching to the eleventh rib. It is a safe rule to say the spleen is not enlarged if it cannot be palpated below the ribs. The position for palpation should be that described on page 44, Fig. 11. Inflammation of the Spleen. This occurs, as a rule, from a neighboring process or from trauma. Perisplenitis may occur in syphilis, tuberculosis, peritonitis, and injuries. Older children may refer their pain accurately to the splenic region. In some cases a friction rub is distinctly felt. With the stethoscope a coarse friction sound, not unlike that in pleurisy, can be heard. Chronic Passive- Congestion of the Spleen. This is seen in connection with enlargement of the liver, tuber- culosis, and in cardiac affections. Other Enlargements of the Spleen. — Sarcoma, although rare, has been observed as a primary condition. The tuberculous and syphilitic enlargements are nodular and irregular. Primary spleno- megaly is accompanied by enlargement of the liver and anemia. Hydatid cysts and abscesses have been reported, but are extremely rare. Disorders of the Adrenals. Reports of sudden deaths from hemorrhages into the adrenals have increased the importance of these structures in early life. In 27 I 1 8 DISEASES OF CHILDREN. infants they are relatively larger, and destruction of their function, whatever it may be, is attended with serious results. Hemorrhage into the Adrenal. — The symptoms come on suddenly not unlike an acute infection. There may be vomiting and diarrhea with acute abdominal pain and, in some instances, a pur- puric rash. The pulse is weak, the pallor is marked, and coma or convulsions may usher in the rapidly fatal endings. Addison's Disease. This is extremely rare in early life and is accompanied by the same symptoms; that is, slow progressive cachexia and bronzing of the skin as in adults. In nearly all cases tuberculosis of the structure is found on postmortem examination. The course is slow, sometimes extending over years, and the prog- nosis invariably bad. Treatment. — Restriction of muscular exercise and the general treatment suitable for the tuberculous is indicated; the feeding of adrenal products, as the desiccated extract or glycerinated extract, may be employed or adrenalin in solution may be given. Hodgkin's Disease. (Adenie; Lymphadenoma; Pseudoleukemia.) This disease very rarely occurs in children. The main features are painless, progressive glandular enlargement, usually beginning in the cervical region, and without the blood changes of leukemia; en- largement of the spleen and liver and a pronounced anemia; either tuberculosis or syphilis may be associated, but in all probability neither of these conditions bears any relation to Hodgkin's disease. Symptomatology. — The enlargements generally first appear in the neck. The glands slowly but steadily enlarge. They are not pain- ful to the touch. The axillary and inguinal regions are later involved. When the general health begins to be affected it will be found that both the superficial and deep glands are affected. From their posi- tion the nodes may produce various pressure symptoms, such as dysp- nea or dysphagia. In the later stages pronounced cachexia develops with an irregular or remittent type of fever. The glands never tend to suppuration, although they may fuse and form large tumors. Differential Diagnosis. — It is distinguished from chronic adenitis by the history, the localization, and absence of cachexia. Tuberculin or the various tuberculin tests would be required to distinguish it in DISEASES OF THE DUCTLESS GLANDS. 419 the absence of suppuration. Excision of a lymph node for histological examination is the safest course for absolute diagnosis. Treatment. — Thus far this has been quite unsatisfactory. Unless the diagnosis is made when only a few glands are involved surgical removal is not advisable. The Roentgen rays have given some good results, but this should only be used by those accustomed to the work. Arsenic may be given in large doses in the form of Fowler's solution. Out-door life at the seashore is to be preferred. Acute Adenitis. This is an acute inflammation of the lymph-glands producing hypertrophy of their structure. Clinically the lymphatic glands are of great importance, their function being to guard the circulatory system since they are obliged to take up, destroy, neutralize, or at least hold in abeyance the num- berless bacteria which block their channels, and it is only when over- whelmed and overpowered by these germs that they themselves be- come affected. Recent investigations along these lines have sufficiently proved that inflammation of the lymphatic glands is due to absorption, from a more or less distant focus, of bacteria or their toxins. Accepting the crude classification of inflamed glands into acute and chronic we find that the glands most frequently affected are the cervical, mesenteric, axillary, inguinal, bronchial, and mediastinal. The majority of children with enlarged glands have cervical adenitis. This is accounted for by the delicate epithelium of the skin of the face and neck and the mucous membrane of the mouth and the pharynx. These being largely exposed to irritations, to bacteria, and to traumatism, we find the glands easily overpowered. It is always necessary to seek the cause or focus of the trouble and, if possible, to remove it. Remembering that the superficial glands drain the side of the head and neck, face and external ear, and that the deeper glands drain the mouth, tonsils, palate, pharynx, and larynx, we have a clue to the initial trouble. It is not to be forgotten that the primary focus may have cleared up or may have been apparently cured and forgotten, but still the glands remain enlarged. A careful history of the eruptive and infectious diseases must be obtained; any irritations of the scalp, diseases of the ear, eyes, nose, throat, gums, or teeth must be taken into consideration. The importance of working backward from the 420 DISEASES OF CHILDREN. effed to the cause in these cases must be kept in mind. Either the superficial or deep nodes may be affected. Under two years of age the externa] glands are affected in the majority of cases, and they also have a greater tendency to undergo suppuration. When the latter is about to take place the gland becomes painful and tender and the over- lying skin is reddened. Restlessness and some degree of temperature is observed. Asa rule, this takes place during the second week or it may be held in check by cold applications and result later. A spon- taneous discharge of pus does not occur until the entire gland has been disintegrated. Occasionally there seems to be no apparent cause except anemia and debility for the glandular hypertrophy, but here we have a valuable clue to the treatment. The glands may at first show no acute inflammatory changes; they grow steadily and surely, and do not easily break down. Because of the slow growth and painless tumor, and with no local cause observable, we are justified in presuming the glands to be tuberculous. The tuber- culin test (page 54) should be made. Such a condition by no means signifies that the child has pulmonary tuberculosis, although having once given entrance to these germs the possibility of an extension is present. The cervical glands may infect the thoracic chain and thus infect the lungs. Chronic Adenitis. This may occur as a result of frequent attacks of acute adenitis or from persistent local lesions in the neighboring structures. It is also observed in children who are the subjects of status lymphaticus. The glands must be differentiated from tuberculous lymph nodes or those seen in Hodgkin's disease. Thoracic adenitis is in greater part of the chronic type and very often the glands are tuberculous. Loomis has examined and found the tubercle bacillus in apparently normal glands. We may safely say that in a large proportion of tuberculous cases in children it would appear that the primary infection was in these structures and that, contrary to Parrot's law, clinical experience shows that the glands may be involved without local lesions in the lungs. In a large number of autopsies in children, we have found the mediastinal and bronchial lymph-glands enlarged, sometimes pressing on the great vessels or against the bronchial tubes. In one case per- foration of the cheesy bronchial gland into the adjacent lung was the cause of death. We cannot describe any definite symptoms invariably produced by these pathological glands, but occasionally we do get a DISEASES OF THE DUCTLESS GLANDS. 421 persistent irritative cough caused by pressure on a bronchus or on the recurrent laryngeal nerve, or localized feeble breathing with sibilant rales due to compression of a bronchus. Percussion is unreliable, for the dullness may be due to the thymus. Recurrent attacks of bron- chitis may. however, often be traced to hypertrophied lymph nodes in the thorax. The enlarged mesenteric and retroperitoneal glands of the abdominal cavity may alone give sufficient evidence of the old- fashioned tabes mesenterica. The point of entrance of the offending germs in these cases is through the mucous membrane of the intestinal canal. If we find a general enlargement of the glands all over the body — a condition which Legrouz called microadenopathy, we have a valuable hint in doubtful cases of general tuberculous infection. On the other hand, the absence of hypertrophied lymph-glands and the enlargement of the liver and spleen is an important negative sign in chronic diffuse tuberculosis, provided we can rule out syphilis by the history of skin rashes, fissures, and the therapeutic test; for here also we may have enlargement of the superficial glands. The glands, therefore, may assist in establishing a correct diagnosis; they may point out by their anatomical distribution the source of their own infection, or they may themselves be productive of pathological con- ditions in adjacent viscera. Treatment. (Acute.) — As has been above pointed out the removal of the local focus of irritation is most important. If seen early the application of the ice bag or cold compresses may cause a subsidence of the jDrocess. The application of a 5 to 10 per cent, ointment of ichthyol is also effective. If suppuration has begun the local appli- cation of heat will hasten the process. Incision and drainage are then indicated. (Chronic.) — Any underlying cause as a chronic eczema, adenoids and hypertrophied tonsils or a sinus must be removed before treat- ment can be effective. The syrup of the iodid of iron must be given for a long period. The X-ray treatment has given some good results. Exophthalmic Goiter. (Grave's Disease; Basedow's Disease.) This condition, which is rare in early life, is due to an increase in the growth and activity of the thyroid gland. Our cases have occurred at or about the time of puberty, especially in girls of the neurotic type. Hyperemic goiters occurring at the time of puberty 422 diseases of children. must be distinguished from true Basedow's disease. Tachycardia is present in both conditions, but the exophthalmos, tremors and pur- poseless movements are not present. This variety often disappears suddenly when menstruation is well established. Symptomatology. — With the gradual enlargement of the lobes of the thyroid there may be noted symptoms resembling chorea. Nausea and vomiting at the sight of food may be the first symptom to call attention to the true condition. The child is apt to be irritable, easily excited and depressed if left without companionship. Physical examination will show a well-marked tachycardia, usually with a soft systolic murmur at the base. The eye later has a peculiar fixed, staring look, and is covered by the upper lid with difficulty. Graefe's sign, or the difficulty of ra sing the upper eyelids when the child is asked to look upward, is usually observed. Profuse diarrhea which is controlled with difficulty is rather frequent in early life. The sleep is disturbed, and several times during the day the face may become flushed and perspiration appears on the body. Course and Prognosis. — Rarely the course is very rapid and ends fatally in a few weeks. In the majority of cases the prognosis is slow, with steady emaciation and periods of remission. The younger the patient the better the prognosis. Treatment. — Rest in bed, both physical and mental, with a light milk and vegetable diet is required until the symptoms subside. The extremely rapid pulse may require cardiac sedatives. Ice-cold applications or alcohol compresses may answer. If not sufficient in effect, the tincture of strophanthus or digitalis may be required. The serum of Rogers and Beebe, of the Cornell laboratory, has proven of value in selected cases. The amount injected varies with the degree of toxicity and the duration of the disease. Galvanization with a mild current of three milliamperes may be used with advantage in con- junction with any form of treatment. Thyroidectin, a product derived from the blood of thyroidectomized sheep, is sometimes of distinct value; it may be tried and continued if the pulse and nervous symptoms subside. Achondroplasia. Achondroplasia (fetal chondrodystrophy) is a rare affection in which there is a marked disproportion between the head and trunk and extremities. This is due to an abnormal process of endochondral ossification at the junction of the epiphysis and diaphysis. The principal change is a defective formation of rows of cartilage cells DISEASES OF THE DUCTLESS GLANDS. 423 in the columnar zone. There often occurs an overgrowth of perios- teum in this region, this tissue wedging its way in between the epiphysis and diaphysis from the periphery toward the axis of the bone. These processes both prevent growth in length of the bone. Achondroplasia is a congenital condition, and the features are evident at birth; usually the parents are undersized or dwarfed. The extremities are mostly affected, leaving the head and trunk nearly normal; the length of the arms and the legs is greatly diminished, the hands often reaching only to the trochanters, while normally they should reach to the knees. There is a redundancy of tissues around the thighs, making thick folds in the skin. Muscular tone is low and the joints are lax, consequently all these children are late in walking. The head is relatively large, the bridge of the nose is usually depressed, the tip of the nose is bulbous, the eyes are far apart and in the infant the tongue may be thick, this being due to a real hyperplasia. As a rule, the fontanels are late in closing; teething also is delayed. The bones are short and thick with enlarged epiphyses; curvature in the shaft of the long bones which often occurs is not due to softening but to periosteal intrusion which offers resis- tance to growth in length of the dia- physes. Frequently a marked lumbar lordosis is present, the saerum being tilted upward and backward. Beading of the ribs, as in rickets, may be present. The hands are small and square, the fingers being short and nearly equal in length and blunted at the ends. The " trident deformity" (divergence of middle and index-fingers from ring and little fingers) is often noted. The mentality in these children is not affected to any marked degree, although they are inclined to be backward. Prognosis as to life is good, but such children are always under- sized. Organic extracts from the thyroid and pituitary glands are used in the treatment, although the results have not been satisfactory Fig. 111. — Achondroplasia {Bradford and Lovett). 124 DISEASES OF CHILDREN. and are not to be compared iii any sense to those obtained with cretins. For the differential diagnosis see the article on Cretinism, p. 426. Infantilism. This is a condition characterized by a retardation of bodily de- velopment out of all proportion to the chronological age. These children are always small in stature, underweight, unde- veloped sexually, and retain the falsetto voice of childhood. Their mentality, however, is usually fair and they are capable of making good progress when placed in school. Two types have been distinguished. In the Brissaud type the children are somewhat cretinoid in appearance, the face being flat and chubby, the body plump, the hair sparse and fine on the head, and there is an absence of pubic hair. In this type, ossification and epiphyseal growth maybe delayed. The juvenile state of the body and mind is long retained. The second, or Lorain type, is distinguished by the rather slender body and finer features, although the genitals and voice remain long undeveloped. The mentality is apparently unimpaired in this latter type. Herter has recently pointed out that in cases of infantilism an intestinal digestive disorder may be the etiological factor. He believes the Bacillus infantilis to have a direct relation to the disease. The intestinal bacteria are replaced by gram-positive bacilli. The maldevelopment is attributed to the loss of fat in the stools and the intolerance to carbohydrates. The cretinoid type reacts favorably for a short time to the use of thyroid extract. The Lorain type is not affected by this drug, and we are inclined to favor Herter's suggestion to treat the disease as a nutritional disturbance. Gelatin is recommended as of value. Th° diagnosis, however, would need to be made very early in order to obtain good results. Cretinism. (Myxedema.) Myxedema is a disorder of metabolism, resulting from an alteration oi- absence of the thyroid body or its functions. Cretinism. — Two varieties are recognized: The endemic and sporadic (infantile myxedema). It is with sporadic cretinism that we are concerned in this country. The symptoms are the result of the complete absence of the thyroid gland. Etiology. — Hereditary factors, such as syphilis, rickets, and tuber- DISEASES OF THE DUCTLESS GLANDS. 425 culosis in the parents, seem to favor the development of cretinism. The disease rarely occurs in the tropical climates, and we have not as yet seen a colored cretin. Symptomatology. — Sometimes at the sixth month, or soon there- after, the mental dullness of the child is noted. It shows very little, if Fig. 112. -Hand of a cretin, showing the uideveloped carpal bones and blunt nn£ers. any, interest in its parents or surroundings. Even its toys are unnoticed. Upon inspection, the face is found to have a stupid, vacant expression, the eyes are dull, the eye-lids often simulating the Mongolian type and are wide apart; the hair is sparse and coarse, the nose flattened, and the bridge sunken, the head appears large and is set upon a short thick neck. From the thick lips a tongue apparently too large for the mouth protrudes, and saliva drools from the mouth. The general 426 DISEASES OF CHILDREN. stature is quite characteristic. The child is markedly stunted, the abdomen appears protuberant, due to the anteroposterior curvature of the spine. The child appears well nourished or even obese. An umbilical hernia is quite generally present. The arms and legs appear short and stumpy. The hands are spade-like and the fingers blunted; X-ray examination shows characteristic changes in the carpal bones. On palpation pads of subcutaneous fat may be felt over the upper part of the chest. The skin is found to be harsh and dry. The subcutan- eous fat does not pit on pressure. The fontanel may be imperfectly closed. If held erect, the peculiar stature and prominent abdomen are intensified. The head will often show a disproportion from the normal, as will the length of the child to its years of life (see Diagram p. 31). A cretin of eight or ten years may simulate in height a child of two or three years. The temperature is usually slightly subnormal. In older children a history will be elicited of marked mental deficiency. The child does not learn to speak, often showing irritable or vicious tem- per, with uncleanly habits as to stooling or urination. The teeth are very apt to become carious soon after eruption, and stomatitis is fre- quently observed. Untreated cases form a good proportion of the so-called dwarfs scattered throughout the country. The blood examination shows nothing characteristic; usually, how- ever, there is a diminution of the red blood-cells and hemoglobin. The above description applies to the typical cretin; however, we quite frequently meet cases exhibiting a mental deficiency plus some of the physical characteristics outlined above, but in a milder form. In the early months of life the condition often goes unrecognized because the physician has not carefully enough observed and watched the infant. These may be classed as cretinoids. If the examiner will keep this type in mind, he will be more likely to diagnosticate cases in infancy. Differential Diagnosis. — Mongolian idiocy, achondroplasia, in- fantilism, rickets, and chronic nephritis must be differentiated from sporadic cretinism. The Mongolian idiot is small in stature and mentally deficient, but the distinct slanting type of eyes with the more shapely bodies and their willingness to go about, quite readily distinguish them from the cretins. Achondroplasia. — The large heads, the very short arms and legs, which are in marked disproportion to the normal body length, added to their fairly well developed intellect, quite readily stamp the diagnosis. Infantilism. — The symmetry of body and normal mental develop- DISEASES OF THE DUCTLESS GLANDS. 427 es a 0) B° § 8 5 ^ I ^ 128 DISEASES OF CHILDREN. men! are strong distinguishing characteristics. However, the infantile voice and lack of genital development with the child-like skin, may occasionally lead to a mistaken diagnosis of cretinism. Rickets. — This condition should not be confounded, as in rickets the mentality is normal and the bony changes are quite characteristic, even when the child is dwarfed by its deformities. Pig. 1 Hi.— Radiograph of arm from Fig. 117.— Cretin with acromegaly. Fig. 117,, showing carpals. Age 7 years, untreated. In chronic nephritis the pitting of the skin and the examination of the urine should clear up a suspicious case. The therapeutic test should be applied whenever there is any doubt. Prognosis. — The importance of early diagnosis has been dwelt upon, as the prognosis is so much better the earlier the treatment is DISEASES OF THE DUCTLESS GLANDS. 429 instituted. Up to the age of puberty comparatively remarkable changes result from treatment. Young adults receive only very meager benefit from the treatment. Untreated cases usually suc- cumb to some intercurrent infection and their mentality remains quite stationary. Fig. 118. — Cretin, before treatment. (Dr. Long's case.) Fig. 119. — Same case after one year of treatment. Treatment. — Desiccated thyroid extract, if fed to cretins, soon produces wonderful changes in their physical and mental state. Thyroid extract, in large doses, it should be remembered, has a depressing influence on the heart and circulation and should be carefully given if there is any cardiac lesion. It should be given in 430 DISK ASKS OF CHILDREN'. increasing doses to infants, beginning with one grain three times a day. and increased slowly to five grains three times a day. Older children may finally take twenty to thirty grains in a day if necessary and if no depressing effect is produced. (A case under our observation had so far improved as to locate the box of tablets hidden in the clock. He ate sixty grains in all. He became somewhat cyanotic, but quickly revived under the influence of stimulation.) The treatment must be continued in fairly large doses, until a decided change has been reached and further improvement does not take place. Then smaller doses, that is, about ten grains a week, may be necessary throughout life to prevent a relapse into the former condition. The recession of the tongue, loss of adipose, and lack of drooling are the first signs of successful thyroid therapy. SECTION X. GENERAL DISEASES OF NUTRITION. CHAPTER XXXII. NUTRITIONAL DISORDERS. Rachitis. (Rickets.) Rachitis is a general disorder of nutrition, complex in character which affects the growing organism, and is characterized chiefly by changes in the bones, ligaments and muscles in conjunction with ner- vous symptoms. Etiology. — Although a number of theories have been advanced to explain the causation of rickets, none have displaced the generally accepted idea that rickets is a result of faulty nutrition. It is distinctly a disease of infancy and childhood, and generally a preventable one. It seldom occurs before the sixth month of life (although congenital rickets is not unknown), and is rarely seen after the third year. In this country it is more commonly seen among the children of foreigners, especially the Italians and negroes. While it is undoubt- edly more common in Europe than with us, still the number of cases seems to be increasing in our large cities where the hygienic conditions are poor. It is most frequently seen among the children of parents who, themselves, have suffered from nutritional disorders or who have been the subjects of alcoholism or tuberculosis. The enfeebled off- spring of such parents are particularly liable to rickets when they live in badly ventilated, sunless quarters and are improperly fed. The food may cause perversion of nutrition because it is deficient in certain elements, as the proprietary foods, or because in quantity and charac- ter it overtaxes the digestive functions. It is rarely seen in breast-fed children unless the milk is deficient because of prolonged lactation, pregnancy, or disease. The proprietary foods and condensed milk, if constantly used without the addition of fats, are particulary liable to cause rickets. Under these conditions it may also occur among the better classes. Pathology. — The greatest changes are found in the bones. Clinical analysis shows that the bony structures in rickets are made up of two- thirds organic matter instead of one-third, as found in normal bones of this age. A cross section of a long bone at its junction with the 431 432 DISEASES OF CHILDREN. epiphysis shows an enlargement and an increase in the cartilaginous structure which is engorged and vascular. The periosteum is easily removed and the medullary portion is soft and traversed with trabecule. The long bones may he soft and brittle in an early case, but in cases of long standing they become unusually firm and hard. In the bones of the skull similar periosteal changes occur which produce abnormal ossification and calcification. Many of the ligaments are imperfectly developed or abnormally stretched. The spleen is en- larged in about 10 per cent, of all cases. The liver and the spleen may be forced down- ward by thoracic deformities. Symptomatology. — The first evidences of rickets may escape attention unless the examiner considers the possibility after obtaining the history. Among the early signs are fret fulness, disturbed sleep and excessive perspiration about the head, in an anemic child. It is not easily comforted, and cries when moved as a result of muscle tenderness. In cases of longer standing, physical examination will show back- wardness in development. The infant may be unable to hold up its head, to sit up, or stand as a normal child at the same age. The muscles are. in gen- eral, soft and flabby, the ab- domen is distended and tym- panitic, and evidences of im- perfect digestion are found in the fetid stools and in the con- stipation alternating with an occasional diarrhea. In spite of this the appetite is generally good, more food being taken than is digested. In more advanced cases the spleen is palpable, and the anemia becomes more marked. The subjective symptoms above recorded become more intensified, and changes in the bony skeleton occur which Fig. 120. — Extreme rachitis, showing marked bony deformities. NUTRITIONAL DISORDERS 433 can be felt on palpation. Among these the beading of the ribs at the costochondral junctions forming the so-called rachitic rosary is the most characteristic. In infants parchment-like areas in the occipital bones, known as craniotabes, is a finding which helps to establish the diagnosis. At the junction of the epiphysis and diathesis nodular bony en- largements are felt, particularly at the wrists, ankles, and knees. The forehead is marbled with enlarged veins and in shape is squared in Fig. 121 . — Rachitis, mild form with bow-legs. Fig. 122. — Rachitis, showirg pigeon-chest deformity. front and flattened on top. The fontanels are late in closing, even the line of the sutures being palpable. Bosses may be felt in the center of the parietal bones and near the base of the temporal bones. At this stage there is generally an evening rise of temperature and an accelerated pulse rate. The body weight may remain stationary or the increase may be very irregular. Dentition is a very irregular process. The first teeth are frequently delayed, sometimes erupting 28 i:;i DISEASES OF CHILDREN. only during the second year, and then with much discomfort. They easily decay, sometimes eroding almost to the gum. Nervous Phenomena often develop in the rachitic infant. Among these the most characteristic is laryngismus stridulus. This glottic spasm may occur several times a day and sometimes results in carpo- pedal spasms. In others nystagmus, tetany, or inspiratory crowing develops from the nervous instability. Convulsions are not uncom- mon and recur from apparently slight causes. Deformities occur later in the disease as a result of the softened condition of the bones and the relaxation of the ligaments. Be- sides the deformity of the head, the thorax shows marked changes. The ra- chitic rosary becomes more marked, due to a sinking in of the ribs in the axillary line and a flaring out of the ribs below. The thorax may be more or less funnel-shaped and ap- pear very narrow at the clavicles, due to the abnor- mal flaring below. The sternum may be drawn in- ward or pressed forward, causing the pigeon-breast de- formity. The anteroposte rior diameter of the chest may be increased while the transverse diameter is lessened. Not infrequently a well-developed groove or sulcus is formed running from the ensiform on either side to the scapular line. This is known as Harrison's groove, and results from the pull of the diaphragm, intrathoracic pressure and the ab- dominal distention. These thoracic deformities necessarily affect the organs and structures within. The lungs are impeded in their action, favoring the production of bronchitis, pneumonia, and pulmonary collapse-. The heart action and circulation may be impaired with a resulting cyanosis. Pneumonic affections are peculiarly resistant to treatment, and their chronicity may be responsible for lymph-node enlargements at the root of the lung. The bones of the extremities now show other changes besides the epiphyseal enlargements at the wrists and lower end of the tibia. Fig. 123. — Knock-knees in a rachitic child. NUTRITIONAL DISORDERS. 435 which occur very early in the disease. The humerus may be curved outward while the legs are deformed from the weight put upon them in efforts to stand or walk. Bow-legs, knock-knees, and deformities of the foot are thus produced. The peculiar sitting posture of these children sometimes induces curvature of the femur. The spine, owing to the relaxed condition of the ligaments, bony changes, and deficient muscular power, loses its normal curves, eventually becoming bowed from the cervical region to the pelvis. Lateral curvatures or scoliosis result from postural positions assumed while being carried in its mother's arms. The pelvis may suffer with the remainder of the skeleton, becoming flattened or shortened in its anteroposterior diameters. The blood shows no characteristic changes. Simple anemia is always present. The hemoglobin may be reduced to 40 or 50 per cent. A moderate leukocytosis is occasionally obtained. Diagnosis. — There is no difficulty in making the diagnosis in well advanced cases. In the early stages, pseudoparalysis, sweating of the head, anemia, irregular dentition, and a distended abdomen in a child exhibiting abnormal nervous symptoms are often sufficient to suggest the diagnosis. Infantile paralysis may be distinguished by the electrical reaction or by obtaining mobility in the prone position by irritating the plantar surface of the foot. In hydrocephalus there is a true enlargement, in place of an apparent enlargement, of the circumference of the head, with a bulging fontanel (see Fig. 143). Syphilitic affections are monoarticular, while many joints are simultaneously affected in rickets. In Pott's disease the spinal deformity is angular and rigid, causing pain when attempts at motion or pressure are made. Course and Prognosis. — The disease itself, while chronic, has a tendency to recovery when changes are made in the dietary and surroundings of the patient. -But even if a cure results, many of the bony deformities remain. While it is seldom a fatal disease it in- fluences the mortality in early life because of the lowered resistance which it engenders. These children more readily succumb to respira- tor};, intestinal, and infectious diseases. Under suitable treatment the disease may be arrested after two or three months, and further bony changes prevented. Nervous symptoms, such as laryngismus stridulus, are very promptly controlled when the proper treatment is instituted. Treatment. Prophylactic. — The education of mothers and of school girls by settlement workers in matters pertaining to the feeding 436 DISEASES OF CHILDREN. and hvgieno of infants will do much to reduce the number of cases. Frequent regulation and supervision of artificially-fed babies by their physicians would prevent overfeeding with too strong formulae which so often occurs among the more intelligent classes. Examination of the breast milk in children who are not sufficiently developing may show a marked deficiency in the proteins or fats. Milk of this character may cause the development of rickets. Mixed feeding and improvement in the secretion should be attempted by proper food. Dietetic Treatment. — Dietetic instruction for the mother, an out- door life, and cleanliness are the necessary requirements for a cure. The food in the case of an infant must contain a sufficient amount of proteins. If the feeding has been on condensed milk and high dilu- tion or the proprietary foods, properly modified cow's milk will in a short time produce a marked improvement. The modifications recommended for difficult cases of infant feeding should be studied in this relation, as the change must be so made that it w T ill be com- patible with the defective assimilation which is usually present. Older children should have a diet list especially prepared for them which may contain fresh raw milk, yolk of eggs, butter, legumin- ous gruels, and vegetables suitable to their age. Hygienic Treatment. — Provision should be made so that the child may live as much as possible in the open air. In bright sunny weather at least five hours a day should be spent out of doors. A roof or a room with a sunny exposure and with open windows may be utilized for this purpose. Daily baths to which a pound of sea salt is added are given, unless contraindicated by muscular tender- ness. Mild forms of massage, breathing exercises, and gymnastic treatment given in the second year of life are productive of good results. Medication. — With the exception of cod-liver oil or olive oil, which is of value in older children, drug treatment is of little avail. Iron and arsenic may be given for the anemia after progress has been made in proper food assimilation. If phosphorus is administered, the oil or the elixir may be used, although this drug and the lime salts have not proven of any benefit in our experience. Deformities of the long bones may be prevented by not allowing the child to assume wrong positions and not encouraging them to stand or walk until the softness of the bones is overcome. The rachitic spine is corrected by keeping the child in the horizontal posi- tion in bed or on a frame. Surgical measures to correct bow legs and knock knees are necessary in the advanced cases. NUTRITIONAL DISORDERS. 437 Congenital Rachitis. (Antenatal Rachitis.) Rarely we see infants born with well-marked evidences of rickets. The rachitic fetus develops the affection in its intrauterine existence, probably during the placental period of nutrition (see Fig. 25) in consequence of disease or starvation in the pregnant mother. The infant is born with changes in the bony skeleton which, although not well-marked, resemble those in a lesser degree found later in rachitic infants. Craniotabes, enlarged epiphyses, and beaded ribs may be seen and palpated. Scorbutus. (Infantile Scurvy; Barlow's Disease.) Scorbutus is a constitutional disease due to a prolonged faulty diet and characterized by pain and swelling in the extremities, and hemorrhages into the skin and mucous membranes. Etiology. — Proprietary infant foods, the continued use of steril- ized and pasteurized milk, food almost exclusively of one kind, as condensed milk or cereals alone, are the factors which produce the necessary predisposition to intestinal putrefaction and toxemia, and which may result in scurvy after some weeks or months. Although it occurs in children under two years of age, the latter half of the first year shows the greatest number of cases. Malnutrition from food not adequate to maintain development is also a causative factor of impor- tance. The chemical changes brought about in the food by boiling or evaporation in dry heat for the purposes of preservation are essentially the underlying cause of the disease. The cases occur more frequently among the well-to-do than among the dispensary cases, as the latter cannot afford proprietary foods, and much sooner give a mixed diet. Pathology. — Subperiosteal hemorrhages occur in the long bones, especially in the tibia and femur. The epiphyses show similar changes, usually in proportion to the involvement of the periosteum of the shaft. In some cases the periosteum itself, close to the bone, is infiltrated and thickened. The ribs in marked cases show these changes especially on their margins. The spleen may be found en- larged and hemorrhages occur in the pericardium, pleura, liver, and into the muscles. Symptomatology. Mild Cases. — Attention is usually first at- tracted to the infant because it cries when handled. The tenderness is especially marked about the lower extremities. The child is ex- 438 DISEASES OF CHILDREN. tremely fretful and usually anemic. It is not uncommon to obtain a history of some fancied injury which may be misleading. The infant will hold the limbs motionless, usually in a position of flexion, and cries or screams when any attempt to disturb them is made. In some only one extremity may at first be tender. No fever and no swelling may be present at this stage in the early or mild types. Such a train of symptoms when present in conjunction with a history of prolonged feeding with, artificial foods which lack the essential quality of freshness should be suggestive and the therapeutic test applied. If swellings are noted over the epiphyses in one or both extremi- ties, with swelling and engorgement of the gums, the diagnosis is quite certain. Aggravated Cases. — In these unrecognized or neglected cases, hematuria may be the first symptom for which the child is brought to the physician, or it may have been treated for rheumatism because of the swelling and pain at the ankles. Careful examination will show spongy gums, bluish in color, which may bleed on pressure. If teeth are present the gums override them, and ulcerations may be seen. Anemia is a constant symptom. The appetite is lost, the child cries constantly when handled and blood may appear in the stools. In exceptional cases blood is effused into the joints and the epiphyses may separate. Ecchymotic areas appear under the skin especially over the swellings on the lower extremities, but may also appear over the ribs. Concomitant rachitic changes may also be noted due to the nutritional faults. About the orbit, conjunctival hemorrhages may be seen or even protrusion of the eye-ball. The face is usually swollen, or even edematous. Albumin and casts are sometimes found in the urine. A collective investigation by the American Pediatric Society gave the following symptoms in their order of frequency: Pain and tenderness of the extremities, sponginess or puffiness of the gums, disability, anemia, cutaneous hemorrhages, hemorrhage from the rectum and hematuria. Diagnosis. — Infantile scurvy is rarely mistaken by those who are accustomed to obtain a good history and who make a systematic examination. Traumatism, acute articular rheumatism, and osteo- myelitis are differentiated by the swelling, which is mainly over the shaft of the bone, the absence of temperature, swollen gums, ecchy- moses in the skin, pseudoparalysis, and blood in the urine and stools. A radiograph will in questionable cases complete the diagnosis. Course and Prognosis. — The prognosis is very good when the NUTRITIONAL DISORDERS. 439 disease is recognized in its early stages and prompt treatment insti- tuted. The development of rickets or extreme malnutrition may delay the cure in aggravated cases. The great majority, even the neglected cases, recover under antiscorbutic treatment. Beneficial results are noted after a few days, the mild types showing remarkable changes within a fortnight. Treatment. Prophylactic. — The disease can be prevented by the use of some orange juice and untreated cow's milk in the dietary. Overanxious mothers should be warned against repasteurization of their infant's milk supply. Dietetic Treatment. — The food should be abruptly changed; fresh raw milk, properly modified is allowed. Orange juice, one ounce daily in divided doses, and expressed beef juice about one ounce during the day, in addition, are readily taken. Older children should be given mashed potatoes and minced vegetables, such as carrots or spinach. The limbs are encased in cotton wool and supported on a pillow until the tenderness disappears. Unnecessary handling should be avoided. Removal to the outer air should be made with the in- fant in its crib or on a pillow. The anemia needs no drug treatment as it disappears under the dietetic management outlined above. Marasmus. {Infantile Atrophy; Athrepsia.) Marasmus is a very common functional disorder in infancy, characterized by extreme emaciation resulting from inability to assimilate food. Etiology. — This is still obscure. It is usually seen in the first year of life. The greatest number of cases appear in institutions and in dispensary practice. Undoubtedly food poor in quality and given in great quantities, coupled with unsanitary surroundings, have- a distinct etiologic bearing on the development of marasmus. If the digestive secretions have not been sufficiently developed by proper food or if they have been overproduced for some time in efforts to digest abnormal food constituents, then the disorder may insidiously appear with symptoms of acid intoxication. It is rarely seen among breast-fed infants unless there is a marked perversion of the supply. Pathology. — The gross lesions found in even a well-marked case of marasmus are surprisingly few. Microscopically, nothing character- istic can be described. The body is devoid of adipose tissue. The muscles are soft, pale, and thin. The overlying skin is dry and 440 DISEASES OF CHILDREN. wrinkled. Hemorrhagic areas are frequently seen beneath the skin and sometimes in the mucosa of the gut. The lungs are frequently involved, showing either hypostatic pneumonia, bronchopneumonia, or atelectatic areas. We have found these often in combination. The liver is somewhat enlarged and fatty. The spleen may be soft, but is not enlarged. The kidneys show degenerative changes or at least a cloudy swelling. The heart is small, with pale muscle fibers. The mucous membrane of the intestinal tract is ex- tremely thin and pale. The stomach is usually dilated, and its lining is covered with ropy mucus. The agminate and solitary follicles stand out more prominently and give the " shaven beard" appearance. The villi are not easily found, or in some cases are entirely absent. The lymph nodes are enlarged. In some cases con- nective-tissue changes take place in the intestinal mucosa in isolated patches. Symptomatology. — The train of symptoms begins in- sidiously. The mother usually brings the infant because she has noted emaciation in spite of the fact that the food has been the same or even increased in amount. The loss of weight, if recorded, is found to be steady but constant. The muscles become soft and flabby. The skin is loose and wrinkled. The facial appearance changes, due co the loss of fat, with a wrinkled forehead and sunken cheeks. The fat pads over the buccinators in young infants remain, however, almost to the end. The abdomen and thighs show the emaciation quite early. The skin feels harsh and dry and has lost its elasticity. The muscle tone especially over the abdomen is lacking. The emaciation progressing further, gives an "old man" expression to the face. This Fig. 124. — Marasmus. NUTRITIONAL DISORDERS. 441 outward wasting that takes place corresponds with changes in the heart muscle. The pulse becomes weak, and anemia of a simple kind is present. A striking feature is the insatiable appetite. The infants will take an enormous quantity of food and still cry as if unsatisfied. The stomach dilates and vomiting may ocnur. The abdomen is distended with gas, and the liver may be palpated well down in the abdomen. The stools vary considerably. As a rule, they are mixed in» color, with a greenish-yellow cast predominating. They contain much unchanged food, and the bulk is decidedly increased. The odor is musty and foul and almost characteristic. Diarrhoea may follow after several days of constipated movements. Erythemata in the napkin region develop and persist. The temperature is rarely much above normal, although subnormal readings are not uncommon. The thirst in some cases is extreme; the infants have a red, dry, and glazed tongue. A finger or the hand is sucked continually, which the mother attributes to hunger. The cry is a low moan or whine, and is not repressed when attempts at comforting the baby are made. In fact, it often cries more when disturbed. As the disease progresses the emaciation becomes extreme; the child resembling a living skeleton. The fontanel and eye-balls are sunken. Excoriations and bed-sores develop easily. Stomatitis is not infrequent. Otitis may develop. The breathing becomes shallow and feeble. Pneumonia, usually of the hypostatic variety, or convulsions frequently bring on the fatal termination. If the disease is arrested, the improvement is noted first in the stationary weight and improved condition of the stools. Later slight gains are made, however, with frequent discourag'ng remissions. Finally the gain is steady, but slow. Course and Prognosis. — The course is long and tedious, and even when improvement begins months are needed to regain a normal appearance and development. Unless the conditions are eminently favorable, the prognosis is extremely poor, the infant usually dying of some intercurrent disease. Treatment. — Since the disorder is the result of defective assimi- lation, and artificial feeding being at best the introduction of a foreign food, a good wet nurse (see p. 109) should be secured whenever this is at all feasible. Maternal milk even for one or two months has been sufficient in our experience to turn the balance from inevitable disaster to beginning success. A change of surroundings, especially in the case of the poor infant, is the next consideration. A life in a country district with plenty of fresh air and sunshine is of the greatest im- 442 DISEASES OF CHILDREN. port a nee. Those infants should not be placed or taken for treatment in hospitals or asylums. Treatment in homes, preferably in the country, which are under the direct supervision of a physician, is much more satisfactory. The Speedwell Society, at Morristown, N. J., is a good example of the best method of dealing with these cases. If the child is being breast fed it may be found after examination that the char- acter of the secretion may be improved, and meanwhile mixed feedings can be tried. If in spite of this no gain in weight is made, a radical change of the milk must be made. If artificial feeding must be resorted to, the problem is a very difficult one and will demand a knowledge of the principles of infant feeding, so that the food may be adapted to the needs of the case at hand. A detailed history of the previous feeding is essential, and it is not unusual to find that these cases have gone through the gamut of almost every conceivable food in an effort to find something that will agree with the baby. Begin the dietetic management by clearing out the intestinal tract with calomel or castor oil. If there has been vomiting, lavage is indicated once a day for two or three days. A daily irrigation of the bowels with saline solution for the first week is rarely amiss (see pages 72 and 74). Feedings should be small in quantity, and contain at first protein and fat slightly above the caloric value necessary to maintain life. The gruel diluent should be converted by a diastatic ferment, and, if necessary, the milk may be peptonized. It is a good rule not to pre- scribe, no matter what the age, greater percentages than 2 per cent, fat, 6 per cent, sugar, and 1 per cent, protein. Not infrequently the marasmic infant does not do w T ell on any ordinary milk modifications, because the infant has been neglected too long or fed upon foods wmich do not react to the rennin in the stomach. Legume gruels, one to two ounces of the flour to the quart, with the addition of one teaspoonful of pineapple juice to each four ounces of feeding is given until the stools change in character. Whey alternating with the le- gume gruel (see section on Infant Feeding) is then cautiously tried, and as soon as it is tolerated, the yolk of one egg rubbed up with a quarter of a teaspoonful of sugar is fed daily from a spoon. Cream may now be added gradually to the whey and this mixture may en- tirely replace the gruel. If gain in weight is made and development progresses, milk and gruel mixtures containing 1.5 per cent, of protein with the addition of sodium citrate, one grain to the ounce, may be given so that the rennin action may be controlled. As the digestive secretions improve the infant is able to adapt itself NUTRITIONAL DISORDERS. 443 better to the fcrm of focd prescribed and in this resembles again the normal baby. Progress will only be made by careful attention to every detail and a study of the stools before making any advances in the strength of the food. The fats may be kept low with advantage; the protein being raised if the dejecta appear to warrant it until a satisfactory gain in weight is being made. Medication is only indicated to support the strength until the dietetic measures are sufficiently advanced to support life. For this purpose strychnin is valuable. Alcohol in any form, if given for any length of time, does more harm than good. Bismuth is occasionally necessary to allay intestinal irritation. Baths are decidedly helpful adjuncts in the management. Brine baths are especially valuable. They are given warm and followed by a brisk alcohol rub daily. Asthenic cases may at first need sub- cuticular injections of normal saline solution, or the use of sea water as advocated by Simon may be tried. Diabetes Mellitus. This is a condition of persistent glycosuria rarely seen in child- hood, and differing from the same affection in adult life by rapid wasting and a speedy fatal ending. Etiology. — While rarely, if ever, seen in young infants, the disease may occur in children, oftenest between the ages of five and ten years. Heredity is supposed to act as a predisposing cause, and a diet con- taining excessive amounts of starch and sugar may have a causative influence. The real cause and pathology of diabetes mellitus are as obscure and uncertain in the child as in the adult. Symptomatology. — Among the earliest symptoms noted is an ex- cessive thirst. A child who has been previously well-nourished, besides drinking great quantities of' water, is seen to be listless or irritable, easily tired and with a large and capricious appetite. Failure of nutri- tion and strength soon follow, and in a short time, possibly within a few weeks, the wasting becomes very appreciable. The urine is passed frequently and in large amounts. Several quarts may be voided in the twenty-four hours. The specific gravity is high, as in older subjects, and large quantities of sugar and occasionally diacetic acid and acetone may be found. Nocturnal incontinence is usually present. Irritation of the genital organs is sometimes caused by the passage of the sugar. The skin and mucous membranes are apt to be dry, and the former may show patches of eczema and occasionally boils. Itching of the 444 DISEASES OF CHILDREN. skin may be marked and annoying. The wasting and loss of strength proceed with great rapidity and death is apt to ensue from exhaustion. In some cases the fatal ending is due to an intercurrent pneumonia and in others to diabetic coma. The disease generally runs its course within a few months and usually under six months. The younger the child the more rapid is apt to be the course of the disease. Prognosis. — We have never seen a case recover in a young child. In any given case of glycosuria, the only hope is that the condition is temporary and due to an excessive ingestion of starches and sugars, the so-called alimentary glycosuria. There will then be an absence of wasting and the other symptoms previously noted. Treatment. — The diet must consist, as far as possible, of milk, meats, fats, eggs, and green vegetables. Von Noorden recommends oatmeal that has been long and thoroughly cooked, which then ap- pears to be well-borne by diabetics in spite of its starch, and he thinks it has a curative tendency. The weakness may be combated with alcohol and strychnin. Small doses of morphin and codein may also be tried. SECTION XI. DISEASES OF THE UROPOIETIC SYSTEM. CHAPTER XXXIII. DISORDERS OF THE URINE AND KIDNEYS. The Urine in Infancy. The somewhat vague and conflicting reports concerning the early secretion of urine are due to the difficulty of collecting it. The follow- ing methods have heretofore been relied on: Placing a small sponge or piece of absorbent cotton over the parts, which is intended to be saturated with the urine, and then squeezed out; in females, fitting a cup or wide-mouthed bottle or pus basin under the vulva to be held in place by the diaper; in males, placing a bottle or condom over the penis and holding it in position by straps of adhesive plaster. When these methods fail, as often happens, the only resort left has been the cathe- ter, a soft-rubber catheter, about 6 size, being best to employ. In females, where the greatest difficulty is usually encountered, the employment of a catheter is not always easy, and several preliminary passages into the vagina often occur in the hands of the inexperienced. To obviate these difficulties and to make easy and safe the routine collection of the infant's urine for examination, a special urinal has been devised. It consists of an oval opening ending in a funnel that fits into the collecting vessel. For efficiency of application, two sizes have been found necessary. No. 1. (Small size). For infants under one year. No. 2. (Large size). For infants over one year. Place the large opening around FlG - 12 5-Chapin's infant urinal, the vulva in the female and over the parts in the male with the funnel pointed downward. Put tapes through the openings in the arms and fix by tying around the abdomen and both groins. To fix more firmly in place, put strips of plaster over the arms. Place the end of the funnel in the collecting bottle which is kept in place by the diaper. If the infant is very restless, put a cork in the end of the funnel and dispense with the bottle. It was hoped that this apparatus would enable one to collect the full amount passed in twenty-four hours, but this has not proven 445 44(i DISEASES OF CHILDREN. feasible without constant watching, as the movements of the baby make a small leakage unavoidable. Character of the Urine. That the kidneys functionate before birth is showm by the blad- der usually containing urine just after birth, and from traces of this excretion in the liquor amnii. The kidneys at this time are of rela- tively large size and more distinctly lobulated than in later life. There is a great discrepancy among the various writers as to the amount of urine passed during the early days of life. All agree that the infant passes a relatively greater amount of urine than the adult. Parrot and Robin state that the new-born passes four or five times Fig. 126. — Chapin's infant urinal applied, more urine, per kilogram of its weight, than the fully-grown sub- ject. They also found that the urine at this time has always about the same composition, whether passed in the morning or evening. The quantity and product of each urination varies but little as the in- fant has no urine of sleep, digestion, etc., since he takes an identical food and at nearly the same intervals of time. These authors found that the morning voiding varied from 10 to 30 c.c. Small amounts may be voided every hour through the day and several times at night. There seems to be a concensus of opinion among various observers that during the first few days the young infant excretes about from one to three ounces of urine, and after this the quantity rapidly in- creases. At the end of the first week there mav be from three to DISORDERS OF THE URINE AND KIDNEYS. 447 :welve ounces; at six months, twelve to sixteen ounces; at one and two years, from sixteen to twenty ounces; from two to five years, twenty to thirty ounces, and after that, approximating the adult. It must be confessed that these figures are general and tentative and seem to be a fair estimate after considering many conflicting figures of the various writers. The amount will vary in proportion to the quantity of fluid given as well as the action of the bowels and skin. The specific gravity is low, rarely rising above 1010 during the first six months. A few days after birth and until the end of the first month the specific gravity is very low, only averaging from 1003 to 1004, as urea and inorganic salts are not found in large quantity at this time. It then increases in density, but it is not apt to rise much above 1010 until after the tenth year, when it may reach as high as 1020. The first urine is clear colored, although it is sometimes reddish from an excess of uric acid and urates. In the latter case it may be scanty and passed by drops which discolor the diaper. The uric acid crystals may even form cencretions in the pelvis of the kidney. In- fants seem to form uric acid with great facility, but the proportion of uric acid to urea diminishes later, though comparatively large all through childhood. In proportion to the body weight there is rela- tively less urea excreted by the infant than by the child, although the latter excretes more than the adult. This may be accounted for by the active metabolism occurring in early life. The reaction is usually neutral or faintly acid. In the cases men- tioned where large amounts of uric acid are formed and eliminated dur- ing- the few days after birth, the reaction will be markedly acid. The reaction may be at times slightly alkaline without being considered abnormal. The question as to the presence of what may be considered patho- logical ingredients at this time and their significance is interesting, but one upon which various writers are not in accord; some state that traces of albumin and hyalin casts are occasionally found during the first clays of life and with little significance. According to Martin Ruge, both hyalin and granular casts may be found in the urine of the newly-born. Parrot and Robin, on the contrary, never found albu- min in the urine of healthy new-born infants, nor mucus or hyalin cylinders as in normal urine of the adult. Slight glycosuria has occa- sionally been reported during the early months, especially when sugar has been too freely given in the food. All through infancy traces of indican will be found in connection with gastrointestinal irritation. During the early years of life slight renal hyperemia appears to 448 DISEASES OF CHILDREN. be very easily induced and to be coincident to almost any marked bodily disturbance. The rapid metabolism occurring at this time of life and the vulnerability of the kidneys will occur to everyone. A careful examination of the urine in various conditions is presented in the following series of cases from the babies' wards of the New York Post-Graduate Hospital. The first series includes eighty-six cases in which some disturbance of the gastrointestinal tract was present. Xo attempt was made to classify these cases, and they include simple indigestion, fermentative diarrheas, intestinal inflammation and ma- rasmus. In a large number the condition was not severe, and such cases were purposely included in the list. Albumin was present in seventy-five cases in this series of eight-six. Its presence was noted as follows: trace, twenty-nine; faint trace, thirty-one; heavy trace, fifteen. Casts were present in thirty-seven cases, noted as hyalin, granular, epithelial, and mucous. There were sixteen deaths in the series, and of these fourteen had albumin present and ten both al- bumin and casts. In thirty-two cases an examination for indican was made and found present in twenty-two of the cases. The amount was estimated as follows: trace, four; faint trace, one; heavy trace, seventeen. A series of fifty-seven cases of pulmonary diseases, such as severe bronchitis, pleurisy, and pneumonia, gave the following results: forty-nine had albumin in the urine, thus noted; trace, thirteen; faint trace, thirty; heavy trace, six. Thirty-two cases had casts present, either hyalin, granular, epithelial, or mucous. Of the seventeen deaths in this series, fifteen had albumin present and ten both albumin and casts. An examination for indican in twenty-three specimens showed its presence in sixteen cases. Trace, two; faint trace, two; heavy trace, twelve. In forty-five cases of general illness, other than pulmonary and gastrointestinal, albumin was present in thrty-one cases. Trace, nine; faint trace, eleven; heavy trace, eleven. In eleven cases of cerebrospinal meningitis, nine showed heavy traces of albumin and casts. In a number of cases of cerebrospinal meningitis, with coma, a special effort was made to collect the twenty-four hours' amount. A baby of nineteen months passed 18 ounces, one of two years passed 16 ounces, one of three years passed 16 ounces, and one of four years passed 20 ounces. All of these specimens had traces of albumin and 3, and the urea varied from 1.7 to 2.7 per cent. It is evident that any disturbance of the bodily functions during DISORDERS OF THE URINE AND KIDNEYS. 449 infancy will often be accompanied by the presence of albumin and casts in the urine. What significance does this condition present ? Can actual renal disease be considered to exist when traces of- albumin and a few casts are found, or is there simply an irritation of the renal tubules accompanying a slight congestion and having no special significance ? To the writer's mind a study of the cases here reported favor the latter view. Koplik, in a study of twenty-five consecutive cases of gastroenteritis, found that all but four showed a more or less severe involvement of the kidney. In all of these cases there was albuminuria, and the majority of them showed the presence of casts. This author further says that in view of the peculiar physical signs, and the rapid improvement of an almost complete suppression, without leaving behind any appreciable lesion of the kidney as evidenced by albumin or casts in the urine, it is seen we are not dealing with a nephritis in the ordinary, but in a special sense. As in these cases there is usually a great loss of fluid from the system, the toxins circulating in the different organs are thus placed in contact with the delicate cell structures in concentrated form. As soon as the water taken from the system is partially supplied, these poisons are washed from the organs, and the latter have an opportunity to resume their functions and are restored to normal. The moral is not to employ irritating antiseptics in the treatment of intestinal diseases and to give a full and free supply of water. It would seem that we are justified in concluding that the urine of infants may contain traces of albumin and even casts without any very grave results. Even when actual congestion or parenchymatous inflammation exists for quite a long time, it may be remembered that in early age the kidney possesses a wide power of regeneration. The exceedingly fine tests now often employed in examining for albumin must be noted as one explanation of its frequent discovery. As small amounts of nucleoproteid are always present in urine, prob- ably derived from the disintegration of the epithelial cells from some part of the urinary tract, such as the ureter or bladder, fine traces of albumin may come from such a source. Formation of the Kidney. First are noted two minute oval structures appearing about the seventh week of fetal life. As these masses develop into the kidneys, they assume a marked lobulated form, and this structural peculiarity persists until shortly after birth when this distinctively lobulated structure disappears. The kidneys are relatively larger in the new- 29 150 DISEASES OF CHILDREN. born than in older subjects and are placed a little lower down in the abdomen. The suprarenal capsules nearly cover the kidneys at first and are relatively large all through childhood. Malformations have been rarely noted, such as a fusion of both kidneys into an irregular, horseshoe mass. Congenital cystic kidneys have been occasionally reported due to stenosis of the pelvis, ureters, bladder or urethra, fol- lowed by a dilatation of the capsules of the Malpighian bodies and of the tubules. As a result, the kidneys may be greatly enlarged, con- sisting of a mass of cysts. A few cases of single kidney, supernumer- ary ureters, and other rare anomalies have been reported in the literature of the subject. Anuria. This term applies to a cessation of the urinary secretion. In the newly-born note should always be taken of the first passage of urine. Its non-appearance may be due to some congenital malformation in any part of the urinary tract. Delay in voiding at this time is most commonly caused by uric acid infarction in the kidneys. The highly acid urine may then pass in drops which dry upon the diaper and the nurse will report that no urine is being passed. Sometimes a reddish- brown, brick-dust discoloration is left upon the diaper, and the in- experienced will think that the infant has been passing bloody urine. There may be anuria for twenty-four hours from this cause without the infant showing any constitutional disturbance. Examination will usually show that the bladder is empty. There are occasionally cases in young infants where no urine is passed from twelve to twenty- four hours, as far as can be seen, and, as long as there is no apparent bodily disturbance, it need not cause undue alarm. In older children anuria may be caused by various drugs, such a phosphorus or arsenic; by nervous disturbances, as from fright, hysteria, etc. ; there may like- wise be complete suppression in the course of acute nephritis. Treatment. — Before deciding that a case is one of true anuria, the bladder must be examined to be sure that we are not dealing with ordinary retention. To be absolutely sure of this, it may sometimes be necessary to pass a catheter. A soft-rubber catheter, about 6 size, is best employed in the young infant. When there is actually a stoppage of the urinary excretion, the kidneys may be stimulated into action by slowly injecting into the bowel large quantities of warm normal salt solution. Hot fomentations over the kidneys may like- wise be tried. The best diuretic is pure water given frequently and freely. When the urine is scanty and very acid, the young infant DISORDERS OF THE URINE AND KIDNEYS. 451 may be given from one to three grains of citrate or acetate of potash every two or three hours in a tablespoonful of water. One or two drops of sweet spirits of niter may be combined with the alkali or given alone to favor diuretic action. Polyuria. A temporary increase in the amount of urine excreted may be caused by the administration of large quantities of fluid, such as milk or water, by irritation of the base of the brain, by hysteria, by the cirrhotic form of nephritis, or by diuretics. As a rule, the condition is due rather to functional than organic disturbance. Diabetes Insipidus. When polyuria assumes a chronic form and there is a daily ex- cretion of large quantities of pale-colored urine having a very low specific gravity, the condition is known as diabetes insipidus. The real pathology of this disease is not understood, but the prevailing opinion is that it owes its inception to some sort of neurosis. The causes are obscure, but cases have been reported where heredity seemed to be a factor and others seem to be coincident to injuries of the brain induced by falls or blows, and to the various forms of menin- gitis. The disease begins early in life, the maj ority of the cases reported being under ten years. An evacuation of very large quantities of watery-looking urine is characteristic of the disease, even as much as ten quarts may be passed daily. The specific gravity is very low, varying from 1001 to 1005, and the urine contains neither albumin nor grape sugar. Urination is frequent and may reach a condition of incontinence. There is great thirst and the patients drink very large amounts of water to make up for the constant loss. The loss of fluid sometimes induces a condition of dryness of the skin and mucous membranes with diminished glandular secretion. Palpitation of the heart, neuralgia, and headache may occasionally be present, and vaso- motor disturbances, such as flushing of the face. When the disease has lasted a long time the general nutrition is apt to suffer and the bodily resistance is lowered. In many cases, however, the appetite is good and the general health does not seem to be affected. While occasionally a case may recover spontaneously, the disease is usually chronic, lasting many years, and death finally ensues from some inter- current disease. The diagnosis is made by noting the continual passing of very large quantities of pale urine with low specific gravity, 152 DISEASES OF CHILDREN. hut without grape sugar, albumin or casts of any kind. Excessive thirst is likewise always present. Treatment. — The best results will be attained by hygienic meas- ures. The diet must be carefully regulated, only easily digested articles being allowed. The ingestion of fluids may be moderately restricted. Warm clothing with a free, out-of-door life and a pleasurable amount of exercise are valuable hygienic agencies. Drugs have little effect upon the course of the disease. The following have been recommended: atropin or belladonna, antipyrin, the various bromids, ergot, and arsenic. Renal Calculi. Uric acid infarctions often are found in newly-born infants. They consist usually of uric acid or urates deposited in the straight tubes. The calices and pelvis of the kidneys may at the same time contain small masses of uric acid or the urates of ammonium and sodium. These concretions should disappear by the end of the first or second w T eek. They are caused by the abundant excretion of uric acid during the first days with an insufficient supply of water to hold the salts in solution. As noted in another section, the urine may be passed in drops leaving a dark red stain upon the napkin, or there may even be temporary anuria in this condition. A true renal lesion is not apt to follow. A free administration of water will generally induce a solution and washing out of these deposits. Small calculi sometimes persist in the pelvis of the kidney or they may be formed later by the deposition of uric acid or the urates. When the calculi are not dissolved they may be washed down into the ureter and pro- duce the symptoms of true renal colic. There is then acute pain in the region of the kidney radiating downward, with possibly even retraction of the testicle on the affected side. Small amounts of urine are frequently passed which may be tinged with blood. In older children there may be vomiting and marked evidences of prostration. When the calculi reach the bladder the pain quickly ceases. Pro- longed acts of screaming on the part of infants, otherwise unaccounted for, are doubtless often due to the passage of small crystals of uric acid through the ureter. The only way to be positive, however, is to examine the urine when voided for the presence of these crystals. Occasionally, but rarely, a good-sized calculus may become impacted in the urethra. Examination may be made for this condition in cases of anuria, and evidences of local discomfort will be a guide for the search. The irritation of pelvic calculi may sometimes induce a DISORDERS OF THE URINE AND KIDNEYS. 453 mild form of pyelitis. Where a large calculus becomes firmly wedged in the ureter it may produce a complete stoppage which will eventuate in hydronephrosis. Treatment. — Young infants should be given water as a routine measure, from a teaspoonful at first to half an ounce later, several times daily, in order to keep the uric acid and urates in solution and flush out the kidneys and urinary tract. When the urine becomes scanty and high-colored the water may be given even oftener, and one or two grains of citrate or acetate of potash added every three hours will form a good alkaline water. Older children must have their diet carefully regulated and fluids freely given. The indications for surgical interference are the same as in adults. Hematuria. The red blood-corpuscles may be present in the urine either from certain general disturbances of the body or from local causes in the genitourinary tract. As an example of the first may be cited infec- tious diseases, such as variola, scarlet fever, or severe paludism; various blood diseases of obscure origin, such as hemophilia and purpura; scorbutus and large doses of irritating drugs, such as chlorate of potassium. Among local causes may be mentioned acute nephritis, new growths in the kidney or bladder, and calculi in the kidney, ureter, bladder, or urethra. Some help may be had in discovering the source of the bleeding by noting the condition of the urine as passed. If the blood is thoroughly mixed with the urine at this time, the source is apt to be in the kidney. Where the bladder is the seat of the hemor- rhage, the blood is usually passed at the end of urination, while if the urethra is affected, the first urine passed contains the blood. Small amounts of blood in urine may give it a slightly reddish or smoky appearance, while large quantities may appear as clots. In any uncertain case the microscope must be depended on for the diagnosis. Treatment. — This must be directed to the cause, but small doses of the fluid extract of ergot may be frequently given if the bleeding continues. Hemoglobinuria. Hemoglobin may be present in the urine with very few or no blood-cells. It is occasionally seen in the same infectious diseases that may produce hematuria; also from irritating drugs that are eliminated by the urinary organs as carbolic acid and chlorate of 454 DISEASES OF CHILDREN. potassium. It is also rarely seen in an epidemic form, occurring in the newly-born, known as WinckeFs disease. The diagnosis is made by the microscope which shows the blood pigment granules, but not the red cells themselves. Functional Albuminuria. {Cyclic or Physiologic Albuminuria.) An occasional albuminuria, without casts or other evidences of kidney disease, may be noted in children. It is more apt to occur shortly before or during adolescence. The cyclic form is apt to exhibit itself in the urine passed during the day, while the patient is on his feet, but disappears during the night and early morning. This is explained by posture, as there is no albumin present when the patient is lying down, but appears after the erect posture is maintained. Cold bathing, overexercise, too large ingestion of protein food, and various forms of indigestion and malassimilation have all been advanced to explain transient albuminuria. There are usually no symptoms, and the patient may even show T all the signs of apparently perfect heath. There is frequently the same uncertainty and obscurity in this con- dition in childhood as in later life. The cases should be kept under observation and if albumin persists very long, even in small amounts, there is probably some lesion in the kidneys. The condition of the heart and the tension of the pulse must be watched, as beginning hypertrophy and constant high tension point to kidney trouble. While being observed, the diet should be carefully regulated, overfatigue prevented, and attention given to general hygiene rather than to measures directed to the kidneys. Indicanuria. Indican in minute traces may be found in normal urine, but the condition may be considered abnormal when a marked reaction is given to the test. It is usually seen in the various forms of intestinal indigestion and fermentation. The putrefaction of proteins under the action of various bacteria results in a substance known as indol from which the indican is derived. The condition is sometimes also noted in tuberculosis, empyema and various diseases accompanied by suppuration. The treatment is dietetic and directed against the various forms of intestinal disturbance that are accompanied by undue food decomposition within the intestine. The color scheme and test for indican are given in the section on Special Tests (p. 53). DISORDERS OF THE URINE AND KIDNEYS. 455 Acetonuria and Diacetonuria. Minute traces of acetone and diacetic acid may be found in normal urine. They may be increased in fevers and in any condition accompanied by undue protein decomposition. They have been found in cases of diabetes followed by coma. Congestion of the Kidney. As the kidneys functionate very actively in early life, various grades of hyperemia may be easily induced. The various infectious conditions, marked digestive disturbances, high fevers from any cause, irritating drugs, and exposure to cold may be accompanied by traces of albumin and tube casts in the urine. This does not necessarily mean that there is the beginning of an acute nephritis, as the condition may pass away with the subsidence of the cause of the irri- tation. If the latter persists too long, however, actual nephritis may ensue. In a previous section, evidence was shown that almost any marked bodily disturbance, especially in infancy, will often be accompanied by the presence of albumin and casts in the urine. This may be simply an evidence of irritation of the tubules accompany- ing a slight congestion. The urine may be scanty, but if there is nothing beyond congestion, even if extreme and followed b} r almost complete suppression, there will be a rapid improvement without leav- ing behind any appreciable lesion of the kidney. A congested kidney is apt to be somewhat enlarged as there is more blood in the vessels than normal, and if the condition has lasted for several days the cortex may be very red and have the gross appearance of cloudy swelling. The treatment includes keeping the bowels free and giving plenty of pure water. The latter is especially important in condi- tions accompanied by a great loss of fluid when the toxins circulating in the d fferent organs in concentrated form irritate the delicate cell structures of the kidney as of the other vital organs, and hence need dilution and washing out from the system. The skin must be kept warm and moist and hot fomentations over the kidneys sometimes appear to do good. A milk diet is best. Chronic Congestion. (Passive Hyperemia of the Kidney.) Chronic lesions of the heart or lungs or any pressure effect that interferes with the general circulation, and thus with the kidney circulation, may result in chronic congestion. It occurs principally 156 DISEASES OF CHILDREN. in older children. A long-continued impeded circulation through the kidney will be followed by enlargement of the organ caused by a dis- tention of the vessels with blood. On section, a dark-red color is noted. The urine is passed in small amounts, with high specific gravity, and usually showing albumin and tube casts. The treatment must be directed to the skin and bowels, with the use of various diuretics, all of which are noted in our consideration of the treatment of nephritis. The principal treatment must naturally be aimed at the original condition that results in keeping up the con- gestion. Nephritis. In attempting to classify the various forms of nephritis from the standpoint of morbid anatomy, the student at the bedside will be much confused. It is often impossible to diagnosticate the anatomical varieties of nephritis by either a study of the clinical symptoms or of the urine. The physician frequently cannot tell wmether he is dealing with acute congestion, acute degeneration, or acute glomerulonephritis of a mild type. From the standpoint of treatment, it is not very important to attempt to sharply differentiate these various disturb- ances. Nephritis will be here considered only as acute or chronic, although the synonyms will show r the lesions that may preponderate in each condition as far as the epithelial, interstitial or vascular tissues of the kidney are concerned. Acute Nephritis. (Acute Parenchymatous Nephritis; Acute Exudative Nephritis; Acute Desquamative Nephritis; Acute Tubular Nephritis; Acute Glomerulonephritis; Acute Diffuse Nephritis; Acute Brighfs Disease.) Definition. — An acute inflammation involving any or all (diffuse) of the histological structures of the kidney. Etiology. — Acute nephritis commonly occurs as a secondary con- dition in the course of the specific infectious diseases. Scarlet fever and diphtheria most frequently induce nephritis, but variola, varicella, measles, meningitis, typhoid fever, and influenza may also be noted as not infrequent causes. Any severe disease, such as pneumonia or acute enteritis, may irritate the kidney to the point of inflammation in striving to eliminate noxious products. Thus the colon bacillus may be the irritating agent. Cases that are considered primary are DISORDERS OF THE URINE AND KIDNEYS. 457 doubtless usually due to some infection that is obscure as to its point of entrance. The kidney lesions may be started by the toxins gen- erated by infectious bacteria or may be caused by the direct action of the organisms themselves, in which case the disease assumes a severe type. Exposure to cold and wet may cause nephritis, possibly by checking the action of the skin and thereby throwing extra work upon the kidneys, or possibly by lowering the vitality so that various bacteria will grow sufficiently to infect the body, as in tonsillitis. The continued ingestion of drugs irritating to the kidney, especially chlorate of posash or the carbolic acid series, may induce nephritis. Pathology. — The kidneys are usually congested, soft and some- what enlarged, the cortex being swollen and presenting the appear- ance of cloudy swelling. The pyramids generally appear congested. In other cases the kidney shows little apparent change to the naked eye. Under the microscope, changes may be noted in the epithelial, interstitial or vascular tissues. The various names have been given to the nephritis according to the tissue that is preponderatingly affected by the inflammation. When the glomerular lesions are most marked, it may be called glomerulonephritis; if the glandular, epithelial cells in the tubules are mostly affected, we have parenchymatous nephritis; if the stroma is principally affected, it is named interstitial nephritis. When all the anatomical structures of the kidney are markedly in- volved, it is called diffuse nephritis. The renal cells of the tubules, as seen under the microscope, show cloudy swelling, degeneration and sometimes desquamation. The tubules may be filled with casts. In the glomerular type, the cells covering the capillary tufts undergo swelling and proliferation. The cells making up the capsules of the Malpighian bodies may likewise undergo proliferation. There may be an infiltration of the stroma, with leukocytes and plasma cells and a production of new connective-tissue cells. The blood-vessels of the affected part are engorged, and there may be a proliferation of the cells of the capillaries. Symptomatology. — In early life, nephritis most frequently occurs as a secondary condition in the infectious diseases, especially in scarlet fever. It may come during the height of the primary disease or when the latter is subsiding. In scarlet fever it is more apt to ensue during the period of desquamation in the third and fourth week. The urine becomes scanty with a reddish-brown, smoky discoloration from the presence of red blood-cells or hemoglobin. Albuminuria is present, usually in marked degree; it may be so extreme as to change the urine into a solid on boiling. The urea is only partly excreted by the crippled kidneys, and hence accumulates in the blood. The amount »:>s DISEASES OF CHILDREN. of urea daily found in the urine is thus below normal. The specific gravity may be diminished, but when the urine is loaded with albumin it usually is as high or higher than in normal urine. Epithelial, granular and hyalin casts are usually found in abundance. Renal epithelial cells, red blood-corpuscles and leukocytes are also present. The temperature in nephritis is not apt to be very high, perhaps averaging from 101° to 102° F. ; if it goes much higher — such as 104° to 105° F. — it shows a severe type of the disease. The ner- vous symptoms vary with the severity of the attack. In mild cases there may be only apathy or restlessness and slight head- ache; in severer cases there is worse headache, dimness of sight, stupor, coma, or convulsions. A high tension pulse usually precedes the symptoms of ure- mia. The graver nervous symp- toms usually come in connection with scanty or suppressed urine and they disappear as the secre- tion becomes more abundant, with a lessening of the amount of blood, albumin and casts, and a freer elimination of urea. The cerebral symptoms may be caused by a general edema of the brain or by a compression of that organ by an effusion of serum within the ventricles., The principal gastroenteric symptom is vomiting, without much or any nausea, and occasionally diarrhea is seen in the uremic state. More or less dropsy, due to a transudation of serum caused by the altered con- dition of the blood, is one of the commonest symptoms of the disease. It usually begins as a slight anasarca of the feet and ankles from whence it may extend up the legs to the scrotum and finally to the trunk. An effusion of serum in and around the internal organs with grave results may take place in the following usual order of frequency — edema of the lungs, effusion into the pleural and peritoneal cavities, into the pericardial sac, into the brain and finally into the loose con- nective tissue of the larynx producing that alarming and fatal con- Fig. 127.— Puffiness of the face and edema of the extremities in a case of acute nephritis. DISORDERS OF THE URINE AND KIDNEYS. 459 dition, edema of the glottis. The anasarca is apt to precede these internal effusions but this is not invariably the case. It is evident that dropsy as a symptom may induce little or no discomfort to the patient or seriously threaten his life according to the part of the body affected. The types of nephritis seen in different infectious diseases show some difference as far as the symptom dropsy is concerned. Thus in scarlet fever there is early seen a puffiness under the eyes and a swelling of the limbs, while in diphtheria it is rare to see any anasarca, even with a severe nephritis. The nephritis rarely seen in infants and young children, inde- pendently of the acute exanthemata, is sometimes called the primary form. This means only that the exact source of the agent that infects the kidneys is unknown. It may come from the tonsils or gastro- enteric tract. Doubtless the colon bacillus is frequently responsible. The few cases reported in infancy have usually shown an abrupt onset, high fever, vomiting, and sometimes diarrhea and a high mortality. In older children, the onset and course are less severe and the prog- nosis better. Dropsy is reported as uncommon in both varieties in so-called primary nephritis. The average duration of acute nephritis is from one to three weeks. The improvement in symptoms, and clearing up of the urine is gradual. Nephritis is usually accompanied and followed by marked pallor and anemia. While there is always diminution in the amount of urine, complete suppression is comparatively rare. The latter may exist for many consecutive hours and yet be followed by recovery. An examination of the bladder must always be made to be sure that retention is not interpreted to mean suppression. Complications. — The most frequent complications are referable to the heart and lungs — in the former, endocarditis and pericarditis; in the latter, pneumonia and pleurisy. In rare instances meningitis may supervene. Diagnosis. — The recognition of the disease must rest principally on careful examinations of the urine. It may be suspected when moderate fever and pallor exist without apparent cause. Prognosis. — The younger the child, the worse the prognosis. After three or four years of age the prospect of recovery is good, espe- cially if a fair amount of urine is passed and there are no marked evi- dences of uremia. If, however, there is a large number of casts pres- ent with a tendency to suppression, the outlook is graver. The mere amount of albumin passed is not of so much prognostic value. While a majority of the cases undergo complete recovery, there is always the possibility of chronic nephritis supervening. This must 4(H) DISEASES OF CHILDREN. be borne in mind in giving the ultimate prognosis and the urine should be examined at intervals for a long time so that such a condition may be early recognized. Children may have a subacute or chronic nephri- tis with very few symptoms, and hence the condition may be overlooked during a long period of apparent health, or until an acute exacerbation brings on a serious or fatal result. Treatment. — Children suffering from infectious diseases, especially scarlet fever, should be handled carefully as far as the organs of elimi- nation are concerned — particularly the bowels and the skin. In this way the kidneys will be saved some of the irritation induced by the effort to eliminate the toxins produced by the original disease. Rest in bed, keeping the skin warm, and the use of mild saline laxatives, with milk and farinaceous foods will usually be sufficient for this pur- pose. When nephritis supervenes, in spite of such care, more active measures must be employed. These resolve themselves into a freer use of cathartics, diuretics and diaphoretics, with a fluid, unstimulating diet. The action of cathartics is usually more certain than other agencies. Calomel in doses of one or two grains is a good cathartic and diuretic as well. Citrate of magnesia, a few ounces at a dose, and compound jalap powder, ten grains to a child of five years, given every few hours, will prove helpful in relieving the kidneys through the bowels. Unstimulating diuretics, such as the citrate and acetate of potash, from two to five grains every two or three hours, are valu- able remedies. A teaspoonful of cream of tartar to a glass of water, drunk freely from time to time, is a pleasant diuretic. Sweet spirit of niter, from 5 to 20 drops, according to age, well diluted, occasionally does well. Plain water, given freely, is one of the most constant and valuable diuretics we possess. It should always be frequently given in cases of illness of all kinds in children to insure a free action of the kidneys. The alkaline effervescing waters, such as vichy, will some- times be taken in preference to plain water. Most of the diuretic remedies have diaphoretic effect when the skin is kept warm, while if the surface is cool the latter is lost and the result will be exclusively diuretic. In urgent cases, the muriate of pilocarpin will often have a most beneficial effect in producing free sweating and hence in reliev- ing the engorged kidneys. To a child of three years, gr. ^ or even ^V of a grain may be given every five or six hours until results are obtained. It may be given hypodermatically if a quick effect is de- sired, but, as it is depressing, stimulants must be given at the same time. The infusion of digitalis has a diuretic as well as stimulating effect, but it sometimes tends to upset the stomach. The hot pack affords one of the most convenient and efficient DISORDERS OF THE URINE AND KIDXEYS. 461 methods of acting on the skin. A blanket is soaked in hot water (110° to 115° F.) wrung out and packed around the patient's body. Hot- water bottles are put in position and the whole is surrounded by a dry blanket. The skin is soon bathed in a profuse perspiration, aud this may be repeated several times in the clay if necessary. Hot saline injections (105° F.) given with a fountain syringe and soft catheter, or a double current tube, have a very beneficial effect in favoring kidney action. One or two quarts may be thus employed several times a day. If there is a pulse of high tension and nervous symptoms pointing to eclampsia, nitroglycerin, and small doses of morphin may do good. At five years, grains g-J^ to -^q of nitroglycerin may be given every two or three hours. During convalescence, some preparation of iron should be given for the anemia that always ensues. The diet all through the disease must consist principally of milk given freely. Some of the variations of milk often do better than whole milk. Thus skim milk, buttermilk, milk and vichy, kumyss, junket, and whey may be tried. The various farinaceous foods mixed with milk are also desir- able as nourishment. Chronic Nephritis. (Chronic Diffuse Nephritis; Chronic Parenchymatous Nephritis; Large White Kidney; Amyloid or Waxy Kidney; Chronic Interstitial Nephritis.) Definition. — A chronic inflammation involving any or all of the histological structures of the kidney, but usually either prevailingly parenchymatous or interstitial, especially the former. Etiology. — It usually occurs as a sequel to one of the acute infec- tions, but with especial frequency after scarlet fever. The interstitial variety is usually seen in older children in connection with hereditary syphilis. Valvular disease of the heart, alcoholism, and chronic tuberculosis may also be noted as causes. Prolonged suppuration, especially of bones or joints, is usually responsible for the waxy form. Pathology. — In the parenchymatous form, sometimes known as the large, white kidney, the organ is generally enlarged, with a yellow- ish-white appearance on section. The renal epithelial cells present a swollen, granular, or fatty appearance. The tubules may be con- tracted or dilated, and are usually filled with casts. There is com- pression of the tufts in the glomeruli from proliferation of the cells 462 DISEASES OF CHILDREN. of the capsule and increase of connective tissue. The waxy kidney is usually much enlarged and presents the mahogany-brown dis- coloration with iodin. This form of degeneration is marked in the capillaries of the tufts and in the smaller arteries of the kidney. In the interstitial form, the kidney is small, with adherent capsule and nodular surface. The new connective tissue is distributed through the kidney in an irregular manner, producing a twisting or atrophy or dilatation of the tubules, the latter sometimes forming cysts. The glomeruli may likewise be enlarged or atrophied into little fibrous specks. There is thinning of the cortex after the chronic inter- stitial change has become marked. Symptomatology. — The symptoms and course of chronic nephritis in the child do not differ in any essential way from the clinical mani- festations seen in the adult, especially as the disease is usually found in later childhood. In mild cases, there may be only general weari- ness, occasional vomiting and digestive disturbances, headache, and anemia. In severer cases, dropsy is a very constant symptom. The edema may be limited to the lower extremities and the vulva or scrotum, or there may likewise be effusion into the interior cavities, more often into the peritoneal cavity and occasionally into the pleura and pericardium. The dropsy is variable, sometimes being excessive and then suddenly clearing up for a time. Albumin is pretty constantly present in the urine, with hyalin, granular, and fatty casts. These abnormal ingredients vary in amount with the increase or decrease in the severity of the disease. The daily quantity of urine passed likewise varies from much below normal to about the proper amount. The progress of the disease is usually slow and very irregular, perhaps continuing for a number of years with occasional exacerbations when the symptoms become urgent, followed by periods of remission when the patient is comfortable. Eventually, death takes place from uremia or some intercurrent disease. In the chronic interstitial form, edema is rare, but there is the usual high tension pulse and enlarge- ment of the left ventricle. As in adults, the nervous disturbances preponderate, such as headache, neuralgia, spasmodic dyspnea, poor vision, and dyspeptic troubles. The urine is passed in large amounts, having a low specific gravity and frequently without albumin. Casts are not nearly so abundant as in the other and more common form of chronic nephritis. Complications. — Edema of the lungs and pneumonia may be considered the most frequent complications. One may also look for pleurisy or endo- or pericarditis. Diagnosis. — The most objective symptoms leading to a recognition DISORDERS OF THE URINE AND KIDNEYS. 463 of this condition are a marked lessening in the quantity of urine passed and some form of dropsy. Poor nutrition, pallor, headache, high arterial tension and an enlarged heart should lead to careful exami- nations of the urine upon which the diagnosis must ultimately rest. Prognosis. — Complete recovery is rare. The symptoms, however, may rest in abeyance for long intervals of time. The disease may last for three or four years and the patient eventually succumb to some inter- current trouble. The immediate prognosis becomes bad in the pres- ence of very scanty urine and extensive dropsy. Treatment. — The management of the case must be largely hygienic and dietetic. The skin must be kept warm by flannels and, if possibe, the patient sent to a warm, dry climate. Sudden changes, with marked lowering of the temperature, are liable to be dangerous. If dropsy is present the cathartics, diuretics, and diaphoretics used in acute neph- ritis may be employed. The same is true of uremic symptoms. General tonics, and especially iron, may be constantly given. While a fluid diet, principally milk, is the mainstay, it is sometimes necessary to allow a more generous diet, especially when anemia is extreme. The farinaceous foods can always be given, and it is sometimes an ad- vantage to give meat in moderation. If weakness is great, one must not persist on a too low protein diet. Pyelitis. Definition. — An inflammation of the lining membrane of the pelvis of the kidney, often associated with nephritis or cystitis. Etiology. — Congenital malformations of the kidney or ureter may cause pyelitis, also tuberculosis of the kidney and renal calculi. There may be an infectious form of pyelitis in connection with such infec- tious diseases as typhoid fever, scarlet fever, or diphtheria. Cases have been reported as caused by the common colon bacillus. There may be an extension of inflammation from neighboring structures, such as the kidney or bladder. Finally, general pyemia may be re- sponsible for the disease. Pathology. — The pyelitis accompanying a general infection usu- ally attacks both kidneys, while a purely local irritation involves only one side. The inflammation involves the mucous membrane of the pelvis and is of an acute inflammatory nature with congestion and infiltration of the cells and occasionally punctate hemorrhages. Pus is formed and passes out with the urine. It may quickly collect in such an amount as to distend the pelvis and calices of the kidney, 4()4 DISEASES OF CHILDREN. thus leading to pyonephrosis. A pyelitis that persists is accompanied by more or less nephritis. Symptomatology. — These are somewhat irregular in character. Pain may be a prominent symptom, especially noted during urination. In other cases there is no evidence of local discomfort and not much besides pyuria to indicate the disease. A moderate, continuous fever may be present or, perhaps more often, the temperature assumes an intermittent character and may be accompanied by chills and sweat- ing. In all cases of unexplained fever in early life with cachexia, this disease may be suspected and the urine carefully examined. The urine is turbid, with an acid reaction, and contains blood- and pus-cells and epithelial cells desquamated from the pelvis of the kidney. Albumin is present, sometimes from the pus and at other times as an evidence of accompanying nephritis, when epithelial, granular, or hyalin casts are also found. The urine is usually swarming with bacteria. If the pyelitis is of tuberculous origin, tubercle bacilli will be present in the urine. Occasionally large quantities of pus will be discharged into the urine from an abscess rupturing into the pelvis of the kidney. If the disease becomes chronic, pyuria may be the only constant symptom to be noted. There is also apt to be evidences of failure of health and emaciation in these cases. An examination of the blood in pyelitis usually reveals a leukocytosis. Diagnosis. — This rests finally on an examination of the urine, which, when acid and containing pus and pelvic epithelium, will make the diagnosis positive. Cystitis is rare in children, but examination for urethritis in the male and vulvovaginitis in the female must be made when pus is found in the urine. The acid reaction; however, in- dicates pyelitis. Pain in the region of the kidneys, irregular fever with chills and scanty urine point to pyelitis, but pyuria is the only constant and positive symptom. Prognosis. — The prognosis is good when the kidney proper has not become much involved in the inflammation. Where there is extensive nephritis from calculi or pyonephrosis ensues, the prog- nosis is bad. Treatment. — A free administration of water to which citrate or acetate of potash has been added will serve to flush out the kidney and che?k the acidity of the urine. Two to five grains of these alkalies may be given every three hours. Urotropin, in doses of one to two grains, three times a day, to a three-year old child, is an efficient urinary antiseptic. If calculi are present and can be located, sur- gical treatment may give relief. The same may be true of pyo- nephrosis. DISORDERS OF THE URINE AND KIDNEYS. 465 Perinephritis. Definition. — An inflammation of the loose connective tissue around the kidney. Etiology. — The inflammation may be primary and due to trauma or possibly to cold and exposure; and secondary to suppurating foci within the kidney, such as may be produced by calculi. Symptomatology. — There may be two methods of invasion — one sudden, with chills, fever, and pain in the region of the kidney; the other more gradual, with rigidity of the hip and spine and flexion of the femur. Pain is present and motion is accompanied by pain which may be referred to the knee, thigh, groin, or back. There is usually marked pain on making extension of the thigh, which is considered diagnostic. There is a constant temperature which is not very high at first. As the disease progresses, the spine becomes curved with the concavity toward the affected side, and the thigh is constantly flexed. Suppuration may take place and the abscess may burrow between the lumbar muscles behind or the abdominal muscles in front and be recognized as a tumor in these locations. The disease may last from a few weeks to a few months, and recovery usually quickly ensues after evacuation of the pus. Diagnosis. — The disease most apt to cause confusion is hip-joint disease. This is slow in onset, with a gradual atrophy and limitation of motion affecting all the movements of the joint and not coming to abscess much under a year. In perinephritis, the onset is much more sudden with deformity and abscess ensuing within a few weeks or months. There is no tenderness in the joint and flexion of the thigh, with pain on extension, is the principal deformity. Pott's disease, with psoas abscess, may be differentiated by an examination of the vertebrae for caries. Prognosis. — Good. The cases will recover unless the abscess ruptures into the peritoneal cavity. Treatment. — The patient must be kept quiet in the horizontal position. Sedatives may be given for the pain and both hot and cold local applications tried. An early recognition and opening of an abscess will usually be followed by a rapid recovery. Tumors of the Kidney. Very rarely there may be tuberculous growths in the kidney, usually in connection with a tuberculous infiltration of other portions of the genito-urinary tract. The vast majority of cases in which a 30 466 DISEASES OF CHILDREN. malignant growth attacks the kidney in the child are of a sarcoma- tous nature. The sarcomata are primary growths in these cases and may be followed by secondary growths in other organs, such as the lungs or liver. The growth may start in the pelvis of the kidney or in the adrenals or cortex. The increase in size is rapid and may produce pressure effects on the various abdominal viscera, with ascites and rarely general peritonitis. Generally only one kidney is involved. Symptomatology. — The tumor is usually the first symptom to be noted. It steadily grows until a very great size is reached. The growth may usually be first noted in the side of the abdomen, but soon pushes forward to the middle, and in a few months may fill the whole cavity. Hematuria is sometimes present, and there is a rapid failure of strength and vitality. There will be pressure symptoms according to the size and direction of the growth. The patients rarely live beyond a year, and frequently not so long unless an operation is sue cessful. Diagnosis. — The diagnosis is made by the rapid growth of a solid abdominal tumor in an infant or a young child. Practically all tumors of this nature at this time and in this position are sarcomata. Treatment. — The tumor must be removed as soon as recognized. While the mortality is high, a certain number of recoveries have been reported. Hydronephrosis. Hydronephrosis is a dilatation of the pelvis and calices of the kidney, often associated with necrosis of the kidney parenchyma, due to some obstruction to the outflow of the urine. It is seen more frequently in early than late childhood and about half the cases are found to be congenital. The obstruction may be situated any where in the genitourinary tract from the external meatus to the calyx of the kidney. The fol- lowing causes may be noted: Imperforate prepuce or meatus; congeni- tal stricture of the urethra; congenital hypertrophy of the bladder wall inducing stenosis of the ureters; misplacement of the ureters; valve-like strictures in the course of the ureter or of the ostium pel- vicum, showing a reduplication of the mucosa and of the muscularis from inflammatory change or abnormalities of development; urinary calculi occurring after birth and, by their growth, occluding the uri- nary tract; pressure by abnormal growths in neighboring organs or mechanical pressure from a floating kidney; deformities of the skele- ton or any foreign body in connection with the genitourinary tract. DISORDERS OF THE URINE AND KIDNEYS. 467 Hydronephrosis may be unilateral or bilateral, in the latter case the obstruction usually exists in the bladder or urethra. The congen- ital form may be either unilateral or bilateral, but is usually unilateral. There will be extensive dilatation if the obstruction in the urinary tract occurs before the fourth month of intrauterine life, as the secre- Fig. 128. — Bilateral congenital hydronephrosis, caused by valve-like strictures in the ureters. From an infant 26 days old. tion of urine begins about this time. When the hydronephrosis is unilateral, the other kidney will functionate vicariously. In some cases the obstruction may be only temporary or partial, when the affected kidney will retain part of its function. Cases of hydronephrosis of both kidneys are fatal during infancy, and the condition is usually overlooked, the babies' dying of some 46S DISEASES OF CHILDREN. intercurrent affection. In older children, with the unilateral form, the disease may be suspected or recognized when the dilatation is sufficient to produce a tumor in the lumbar region. Nephrectomy may then afford a radical cure if the other kidney is sound. Where hydronephrosis is due to an impacted calculus in a ureter, the con- dition is apt to eventuate in pyelonephritis. Enuresis. {Incontinence of Urine.) The symptom-complex of incontinence of urine can best be studied by considering, first, the phenomena which accompany the voiding of urine under the action of the bladder reflexes, and, second, the ana- tomical and physiological peculiari- ties accompanying this function in early life. The bladder, the spinal centers innervating it, and the brain hold- ing an inhibition over the spinal centers, all have a part in this ac- tion. The following diagram, modi- fied from Gowers, will give a sug- gestive idea of these parts : In the bladder we have the sphincter (S), guarding the outlet by its tonic contraction, and the detrusor (D), or muscle of the bladder, usually distended, but which, by its contraction, empties the organ. Both sphincter and detrusor are innervated by the segments in the spinal cord corres- ponding to the third, fourth, and fifth sacral nerves. The motor tonic centers for the sphincter (MS) keep this muscle in contraction, while the centers for the detrusor (MD) hold it in a state of dilatation corresponding to a positive and negative, or plus and minus action, of the motor nerves MNS and MND. As the bladder becomes distended with urine, sensory impulses are transmitted by sensory nerves (SN) to the sensory centers of the cord (SC) which are con- nected with the motor reflex centers (MS and MD) by association fibers. Fig. 129. DISORDERS OF THE URINE AND KIDNEYS. 469 When the motor centers are sufficiently irritated they reverse their ac- tion, as a negative impulse ( — ) is sent down by the motor nerves MNS to the sphincter, which dilates, and a positive ( -f ) action is transmitted by the motor nerves MND to the detrusor which promptly contracts. The action of a physiological, automatic reflex is thus shown. This action, however, is held in check by the inhibition of the brain (B) that holds a restraining influence on the spinal reflexes by nerve fibers connecting with them (MT and ST). It is usually necessary to relax the inhibition of the brain before the automatic reflex can take place. Urination is, therefore, not so much a direct voluntary action as an indirect action of the brain in relaxing its hold on the spinal centers and thus allowing the automatic reflex full sway. In early life there are certain anatomical and physiological pecu- liarities that render the bladder and its reflexes very unstable. While the sphincter is weak, the detrusor is thick and powerful. In making autopsies on female infants the bladder, owing to the thickness of its wall, is sometimes mistaken for the uterus. A powerful detrusor acting against a feeble sphincter thus renders the action of the bladder in retaining the urine unstable. In early life the spinal reflexes are also very active. The motor areas of the cord are relatively more developed than the sensory part, and hence motor actions preponder- ate. What would cause a sensory disturbance in an adult is reflected into a motor arc in the child and hence produces a motor disturbance. This is exemplified in the beginning of severe illness, especially in acute infections, where the chill (sensory disturbance) of the adult is often replaced by a convulsion (motor disturbance) in the child. This activity of the motor reflexes exhibits many forms in early life, especially in infancy, when the action of the spinal cord is most active, and the brain being as yet undeveloped fails to hold a proper inhibition on these lower centers. The watery brain of the infant, with rela- tively little gray matter, cannot hold the active reflexes of the spinal centers in proper equilibrium. There are two forms of incontinence — active and passive: (a) Active incontinence is produced when sufficient urine is present in the bladder to cause enough irritation of the sensory nerves to induce a contraction of the detrusor and dilation of the sphincter through the spinal centers. There is no paralysis, but either a lack of proper brain control or overaction in the cord. In this form the urine usually passes rapidly and in full stream, (b) Passive incontinence is caused by weakness or paralysis of the sphincter, and the urine usually dribbles away without ability of control. With the constant underlying predisposition to incontinence in 470 DISEASES OF CHILDREN. early life, there are certain specific causes that may be mentioned in order to throw light on treatment: (1) Excessive acidity of the urine. Uric acid is readily formed in early life; in new-born infants crystals are often seen in the calices of the kidney. The urine may thus become so irritable as to be passed drop by drop, or with a reddish tinge that simulates the appearance of blood on the diaper. Other acids, such as the acid phosphate of sodium and lactic and hippuric acids may be present in excess in the urine. Very small quantities of overacid urine often provoke incontinence by irritating the bladder, and thus stimulating the nerve reflexes to act. (2) Excessive irritability of the muscular coat of the bladder even when the urine is mildly acid or neutral. As the detrusor has an exaggerated contractile power in these cases, the urine is passed in a full and rapid stream. Even ordinary stimulation often causes strong contrac- tion in the unstriped muscular fibers. This explains why atropin or belladonna acts almost as a specific when the muscle is thus at fault. (3) Weakness of the sphincter. This form occurs in feeble children who are in poor condition from severe illness or underfeeding, or where the innervation of the sphincter has been weakened by diseases of the spine or spinal nerves. The urine is not passed rapidly nor in full stream, but is more apt to dribble aw*ay. (4) Reflex irritation from disturbances outside the bladder. The genitals, anal ring or rec- tum may present conditions producing sufficient irritation to cause fre- quent contractions of the bladder under reflex action. • Phimosis, adhe- sions of prepuce to glans with retained smegma, stricture of the urethra, balanitis, vulvitis, ascarides, fissure of the anus and hard scybala in the rectum may be noted in this connection. (5) Neurotic causes. Children with unstable nervous equilibrium from chorea, epilepsy, and similar conditions are prone to incontinence of urine. Under psychical influence, especially in dreams, the child imagines a con- venient place for urination and the reflexes act. (6) Vesical calculus may be a rare cause of incontinence, and, when acting, will be both diurnal and nocturnal, with urine turbid from mucopus and frequent painful micturition. (7) Malformation of the bladder. Congenital deformities, such as extroversion of the bladder, rectovesical and vesicovaginal fistulse, and a few cases reported where ureters have emptied directly into the urethra, will be accompanied by constant dribbling of the urine. Treatment. — It is evident from an enumeration of the different causes that one kind of treatment wall not be adapted to all cases, and hence the physician must find, if possible, the principal reason for incontinence by an examination of the urine, together with a general DISORDERS OF THE URINE AND KIDNEYS. 471 and local physical examination of the patient. More than one cause will often be found present. Highly acid, scanty urine may be relieved by a free administration of water together with an alkali, such as the acetate or bicarbonate of potash, five grains of either thrice daily. Where overirritability of the detrusor is the principal cause, belladonna in full physiological dose, by its action on unstriped muscular fiber, will usually diminish functional activity and thus correct the condition. For a child of five years, grain ¥ ^ atropin sulphate or the tincture of belladonna, r\\. v, may be given late in the day, and the dose increased until there is dryness of the throat and flushing of the skin. If the incontinence is not relieved when the drug is pushed to its full effect, it will not be necessary to continue it very long. Where there is evidence of weakness of the sphincter, nux vomica or strychnin and ergot will act in strengthening its tonicity and stimulating the nerve centers. From 5 to 10 minims of fluid extract of ergot and 5 minims of the tincture of nux vomica may be given thrice daily, well diluted in water, to a child of five years. Unlike belladonna, these remedies may have to be continued for sev- eral weeks before the full benefit is obtained. Occasionally good results will be obtained by a few hypodermatic injections of ten drops of the fluid extract of ergot directly into the ischiorectal fossa. Sup- positories, containing half a grain of ergotin, may also do good in this class of cases. Incontinence of feces may have the same nervous causes and mechanism as incontinence of urine and may require the same treatment. The general hygienic treatment is always important. A simple, unstimulating diet, with a light early supper is desirable. Restriction in the amount of fluids, especially late in the day, may be tried. Postural treatment at night, with the buttocks elevated to save the neck of the bladder, has been advised, but is impracticable. General tonic treatment, such as the use of large doses of the syrup of the iodid of iron will relieve certain cases. Cold bathing, and plenty of fresh air will act as adjuvants. Sometimes a change from one bed to another will bring at least temporary relief. The children should be taken up late at night and early in the morning, and placed upon a commode to prevent the bladder from getting too full. Punishing these children is unavailing and usually makes the matter worse by upsetting the nervous system. The trouble is apt to be more frequent and intract- able in boys than in girls, and in rare cases may last for years. An intelligent study of the child's condition and a recognition of the principal cause in each case and an adaptation of the treatment to such specific cause will, however, usually bring relief. SECTION XII. DISEASES OF THE GENITAL ORGANS AND BLADDER. CHAPTER XXXIV. DISEASES OF THE GENITAL ORGANS. Phimosis and Paraphimosis. Phimosis exists when the prepuce is so narrowed or contracted that the foreskin cannot be freely drawn back over the glans. Hof mokl notes four causes of phimosis : (1) A prepuce congenitally too long and too narrow (hypertrophic form), (2) congenital narrowness restricted to the external opening of the prepuce, (3) long persistence of extensive epithelial agglutination between glans and prepuce, (4) congenital and abnormal shortness of the frenulum and its location too far toward the front. Symptomatology. — Urination is frequent and painful. When about to urinate the child is very restless, and while voiding will often cry out with pain. Older children attempt to restrain the act as long as possible. In some cases the prepuce balloons out with urine as it passes or it may escape drop by drop. If the foreskin is very tight, drops of urine remain and decomposition of this retained urine often produces an eczema at the meatus or even on the thighs and over the entire genital region. Such inflammatory processes may cause balan- itis. The habit of masturbating may be induced by the irritation. Following such a course, an infection may occur which may ascend through the urethra, sometimes, although rarely, causing urethritis and cystitis. Dilatation of the bladder and hydronephrosis may also result in neglected cases. The increase of intraabdominal pressure from straining may produce a hydrocele, a hernia, or prolapse of the rectum. Syncope and epileptiform convulsions were formerly erro- neously attributed to phimosis. If the foreskin be forcibly retracted over the glans, the pres- sure of the preputial ring in the coronary sulcus may cause strangula- tion. Such a condition is known as paraphimosis and soon causes violent pain. If this obstruction to the circulation is not relieved 472 DISEASES OF THE GENITAL ORGANS. 473 edema and inflammation will occur which later can produce ulceration and necrosis of the parts. Treatment. — The treatment of phimosis with adhesions consists in gently separating the agglutinated surfaces with a blunt probe and then retracting carefully the foreskin over the glans. If this is not easily accomplished the foreskin may be stretched by slowly separating the blades of a forceps until it is possible. Any smegma which is present is wiped away. If urine is retained in the foreskin causing decomposition, circumcision is indicated rather than stretching. To relieve a paraphimosis, replace the glans within the prepuce by using the first and second fingers of both hands from below and with the thumbs above, forcing the glans through the constriction. If this cannot be accomplished by manipulation, the strangulating ring must be incised and cold compresses applied to reduce the swelling and in- flammation. As a rule, circumcision is performed at a later date. Balanitis. This condition is usually due to an accumulation of smegma and retained urine, the decomposition of which causes an inflammation of the prepuce. Such accumulations occur most frequently where there is phimosis. Other causes of balanitis are masturbation, injury, and infection of the mucous membrane of these parts. There is redness and swelling of the free margin of the prepuce, the opening of which is often covered by small crusts. Several drops of seropus may appear if the opening of the prepuce is separated; it is usually impossible to retract the prepuce entirely. Treatment. — Distend the prepuce by injecting an antiseptic solu- tion, such as bichlorid of mercury, 1 to 5,000, or a weak permanganate of potash solution, three or four times a day. When this cannot be accomplished, apply the antiseptic dressing ice-cold. A solution of bichlorid of mercury 1 to 10,000 or liquor Burowi, one to four parts, is suitable. The wet dressings are applied until the swelling is reduced. Slitting up the prepuce to permit of thorough cleansing is sometimes necessary and then gives the quickest relief. All adhesions should be removed when this is done. Circumcision at this time should not be performed. Urethritis. Urethritis may be simple or specific. In the former, lack of cleanliness, injury or uric acid crystals are the usual causes. There is pain on urination and a slight discharge of pus. The inflammation is 474 DISEASES OF CHILDREN. usually confined to the anterior portions of the urethra. There are no sequelae as in the specific form. Infection causing specific urethritis takes place by direct con- tact and can be diagnosticated only by a bacteriological examination. Gonococci are generally found in great numbers in the discharge. Except for the constitutional symptoms, which are mild or entirely absent, specific urethritis gives the same clinical picture as in adults; that is, a thick purulent discharge and burning pam on urination. Complications are rare; those likely to arise are stricture, posterior urethritis, epididymitis, arthritis, and gonorrheal conjunctivitis. Treatment. — Urotropin in 5-grain doses three times a day with rest in bed is usually sufficient, but in some obstinate cases it is neces- sary to irrigate the urethra with argyrol in a 5 per cent, solution or potassium permanganate in h per cent, solution twice daily. The pelvis should be covered to avoid carrying the infection to the eyes and the attendants warned of such danger. Vulvovaginitis. (Urogenital Blennorrhea.) This condition is a frequent cause of dysuria in girls, and may occur under the influence of general malnutrition, as in marked anemic conditions, uncleanliness, masturbation, when parasites are present, or following an infectious disease. The usual cause, however, is an infection by Neisser's gonococcus. In this specific form infection takes place by either direct sexual contact or by handling, contact with the infected bed linen of parents, and less frequently from towels or discarded dressings. Epidemics of vaginitis frequently occur in hospitals and especially institutions for children. Differentiation of the simple and gonorrheal types is based on the bacteriological examination of the pus. Vulvovaginitis begins with redness and swelling of the parts and a discharge of pus, which is usually yellowish or white in the simple form and greenish in the gonorrheal. The pus is abundant, and on drying forms crusts causing the labia to adhere. Micturition is frequent and painful, due to contact of the urine with excoriations of the mucous membranes of the urethra and the labia. There is also pain on locomotion, due to the excoriated thighs. In severe cases pus may be seen oozing from the cervix. The vaginal mucous mem- brane bleeds easily, due to the excoriations present. Constitutional symptoms are infrequent, but buboes occasionally occur and may even DISEASES OF THE GENITAL ORGANS. 475 suppurate. In the gonorrheal form the usual adult complications may occur, such as arthritis of the large joints, conjunctivitis, and cystitis. Salpingitis and general peritonitis have occurred in our service. Treatment.— Treatment of all vaginitis cases requires isolation of the case and scrupulous cleanliness as regards the patient, the linen, and the dressings as well as the attendant's hands. In severe cases the patient should be in bed. In the simple form, after removing the cause, irrigate the parts two or three times daily with warm normal salt or boric acid solutions, bichlorid of mercury 1 in 10,000, silver nitrate solution 1 in 10,000, or formalin solution 1 in 5,000. Cover the thighs and vulva with unguentum zinci oxidi or stearatis. A sterile pad is applied over the parts.- In gonorrheal cases this treatment may be supplemented by the use of vaginal suppositories of argyrol 10 per cent, in oleum theobro- matis; insert one after each irrigation. In all cases general tonics are indicated. In simple cases under treatment the course of the disease is about two or three weeks. The gonorrheal form lasts much longer, often for months, and relapses are frequent. Vaccine Treatment. — The vaccine treatment may be tried in intractable cases or for a series of cases in an institution. A study of recent investigations shows that the injections of vaccine must be controlled by determination of the opsonic indices of each individual case, reinjection being made before the index falls below normal. A dose too large or two small gives little or no response, five million dead bacteria being the preferred initial dose. Under this treatment clinical evidences of gonorrhea disappear in ten to twenty-one days, and no gonococci can be found in the smears. In some cases a polyvalent vaccine seems more efficient than a univalent one. The best results are obtained when the vaccine used is obtained from the patient's own organisms, except where the case is of long duration or has been treated by antiseptics, as these lower the virulency of the organism; it is then better to make vaccine from a strain of known high virulence. Experiments have proved this step to be most efficient in spite of Torrey's conclusion that "the family gonococcus is heterogeneous." If an eye should become infected, the injections should be made at once without determining the index or waiting for the vaccine to be made. The frequency of injection depends on the index; nothing can be gained by more injections during the negative phase. If the initial 47(> DISEASES OF CHILDREN. dose be high the negative phase may last two weeks or longer. It is therefore better to wait a longer rather than a shorter time for the second injection. As a rule, the discharge increases for the first two or three days after the injection, and then diminishes very rapidly. Improvement is always marked after the first few days, and the patient may continue to gain during the negative phase; consequently clinical signs should not be made the guide for future injections. Index determinations alone must be depended upon. Masturbation. In infants and very young children, the presence of some organic source of irritation in or about the genitalia is assumed as the cause of masturbation. Of such irritations itching, vulvar eczemas, and pin worms which have escaped from the rectum and found their way into the vagina are the most frequent causes in girls. Attempts to relieve this irritation by scratching or rubbing the thighs together results in the persistence of the habit because of the sensations it produces. In boys, an elongated prepuce, friction from a phimosis, excoriations at the meatus from a highly acid urine may be the original cause. In girls, adhesions about the clitoris from smegma and uncleanliness are common causes. In older children the beginning of such a habit is more probably due to acquaintance with others with whom the practice is in vogue; in some cases, accidental discovery that genital irritation produces voluptous sensations occurs in certain sports, such as bicycle-riding or tree-climbing. It is an error to assume that this practice produces nervous, irritable children, with pallor, headache, and sickly appearance and dark rings under the eyes unless masturbation be indulged in to excess. In children of the neurotic type such symptoms are, however, greatly aggravated by the violent sexual excitement so produced. Treatment. — It is essential to remove the cause. By the use of suitable night gowns and bandages children can be prevented from masturbation at night. During the day constant supervision is imperative; this is more difficult with children of the school age. Dietetic changes and psychic treatment after suitable explanation are potent factors in eradicating the habit. Effort should be made to keep the child occupied all the time and frequent diversion of the mind toward active and healthy normal channels will prove most efficient measures. Cold affusions to the spine may be employed in intractable cases. DISEASES OF THE GENITAL ORGANS. 477 Hydrocele. When the peritoneal sac surrounding the testicle and epididymis is distended with fluid, the condition is known as hydrocele. It is not uncommon, and is usually congenital in origin. The following varieties may be differentiated: Hydrocele of the Tunica Vaginalis (with the funicular process obliterated). — This is one of the most common forms found in children. The tumor formed is oval and is firm and tense. It may occur on one or both sides. The tumor cannot be reduced. Fluctuation can usually be obtained, and the site of the testicle can be seen by illumina- tion of the scrotum. The cord is felt above the rounded upper portion of the swelling, and the testis is generally situated posteriorly, projecting into the cavity, and is therefore not readily detected by manipulation. Congenital hydrocele exists when the funicular process is patent. The signs above stated exist except that upon manipulation the fluid can be returned to the abdominal cavity. Infantile hydrocele occurs when the funicular process is closed at its upper extremity only. The fluid extends along the cord, and the tumor is therefore elongated; the other signs are the same as given above. Encysted hydrocele of the cord is one in which there is an additional point of obliteration of the intraabdominal portions of the funicular process above the internal abdominal ring; fluid distend- ing this portion of the canal forms a tumor resembling a cyst in addi- tion to the tumors in the scrotum. Treatment. — As a rule, no treatment is required. After several weeks the condition spontaneously disappears. If phimosis is present this should be corrected at once. In more resistant cases puncturing the sac and allowing the fluid to thoroughly drain off usually produces a cure. If relapses occur, instillating one or two drops of the tincture of iodin in ten drops of water will set up adhesions sufficient to ob- literate the sac. In some of the congenital forms, a truss may be applied in order to obliterate the funicular process, and then if a cure is not af- fected aspiration is performed. If the hydrocele is associated with a her- nia a suitable truss must be worn after the evacuation of the fluid. Undescended Testicle. {Cryptorchidism.) When not in the scrotum, the testis may be found (1) in the ab- dominal cavity attached to the abdominal wall or (2) just inside the 478 DISEASES OF CHILDREN. internal abdominal ring or (3) as is most common, in the inguinal canal or (4) just beyond it. The causes of such a malformation may be a short or abnormally attached gubernaculum, a contracted external ring, or an abnormally large epididymis. The diagnosis is made when the scrotum is found empty on the affected side, and a small movable tumor the size of a hazelnut is found in the inguinal region which gives the unpleasant testicular sensation on pressure. If no symptoms arise the best treatment is neglect; if, however, there is much pain or tenderness which sometimes occurs when the testicle is in the canal, surgical intervention is required. The surgeon may succeed in drawing the testicle down into the scrotum or he may be obliged to replace it in the abdomen. If the testicle lies within the abdomen and develops there, its function is not interfered with. When it is subjected to constant pres- sure within the inguinal canal, such compression may hinder develop- ment or lead to atrophy. Differential Diagnosis of Swellings in the Inguinal Region. Swellings in the inguinal region are either fluctuant or non-fluc- tuant. If fluctuation be present the tumor may be an abscess or a hydrocele. If an abscess be probable, there may be a hist or}' of vulvo- vaginitis, urethritis, scabies, or other irritant lesions about the genitals, and the patient will have some degree of increased temperature and a leukocytosis. Caries of the vertebra may produce a psoas abscess. If hydrocele be suspected, the history may show that the tumor has persisted since birth or that there has been an injury. The tempera- ture and the blood count will be normal, and the light test will be positive. On percussion of a hydrocele or an abscess the note is dull and not tympanitic as it may be in hernia. A hydrocele with patent funicular process may recede under moderate pressure, but no gurgling is felt as in the reduction of hernial contents. In tumors without fluctuation, hernia, undescended testicle, or enlarged inguinal glands may be suspected. If the condition be hernia, the percussion note is resonant; if reducible, the tumor disappears quickly and is accompanied by a gurgling sound; the external abdominal ring is patent and there is an impulse on crying or coughing; there is opacity when tested by trans- mitted light. If the tumor is an undescended testicle, the corresponding side DISEASES OF THE GENITAL ORGANS. 479 of the scrotum will be found empty; the tumor is dull on percussion, freely movable, and hard. On pressure, the characteristic testicular sensations can be elicited in older boys. If the swelling is due to the presence of enlarged inguinal glands there will probably be an existing cause found in the genital region, such as eczema, vulvovaginitis, scabies, etc. Such tumors are dull on percussion, and hard and freely movable unless suppurating. In these cases the testicle will be found in its normal place. Enlarged glands are usually multiple. Frequently hernia and hydrocele occur simultaneously, and in such cases the diagnosis is more difficult. CHAPTER XXXV. DISEASES OF THE BLADDER. Cystitis. In infants, two forms are distinguishable, one presenting general symptoms, including restlessness, anorexia, fever, pallor, and debility, but without urinary symptoms; the other with the above general pic- ture, but with symptoms showing urinary involvement, such as in- creased frequency of urination, pain or difficulty in voiding, abdominal colic, tenderness over the bladder, and redness about the meatus. A frequent cause of cystitis is infection by the bacillus coli, either alone or in mixed infection, and such infections are termed coli- cystitis. Many other organisms are also found as the causative factor but are of far less frequent occurrence. In colicystitis, the urine shows the following characters; it is turbid, acid in reaction, and contains albumin (usually less than y 1 ^ per cent.) pus-cells and bacteria, a pure culture of bacillus coli being frequently obtainable. The acid reaction of the urine in cases of cysti- tis signifies infection by the bacillus coli or the bacillus tuberculosis; the latter is very rare as a primary infection, but does occur with general tuberculosis or when the kidneys or genitals are involved in tubercu- lous lesions. When due to infection by the pyogenes, the reaction is alkaline. In cases of such origin, the symptomatology is much the same as in colicystitis, but the disease is more severe. In pyogenic infections, blood is often found in the urine. Pfaundler's thread reaction may be of service in doubtful cases (see p. 55). Treatment. — The remedy par excellence for cystitis is hexamethy- lenetetramin (urotropin) ; infants may be given two grains every four hours; older children 5 to 1\ grains every four hours. Salol in the same doses is also useful, but not quite as effective. Chronic cases may require irrigation of the bladder; in such cases boric acid solution 1 per cent, or silver nitrate solution 1 in 5.000 are the best solutions to use. In all cases give plenty of alkaline waters to drink, avoid salty foods and spices, and keep the patient in bed while the acute symptoms persist. 480 DISEASES OF THE BLADDER. 481 Vesical Spasm. Spasm of the sphincter muscle of the bladder often occurs in young children due to a variety of causes; for example, dysentery, anal fissure, parasites, inflammations in the neighboring parts, as Pott's disease, and lesions in the rectum, pelvis, or perineum. Occasionally in older children a brief spasm occurs due to certain drugs, such as tur- pentine, or to sudden exposure or local chilling, as a cold closet. The usual cause of spasm of the sphincter is the irritant effect of a highly acid or concentrated urine on the bladder walls. The most prominent symptom is frequent micturition, each act often yielding but a few drops of urine. Pain is severe and is accompanied by marked vesical and rectal tenesmus, but no blood is present in the urine. Treatment. — Treatment consists in the removal of the cause in conditions other than that due to the urine itself. When the spasm is clue to the urine, the treatment consists in copious draughts of alkaline water and the administration of potassium acetate or citrate in doses of two to five grains with the tincture of belladonna or the tincture of hyoscyamus one to four drops every two or three hours. Vesical Calculus. The severest dysuria of the chronic type may be produced by a vesical calculus. This condition rarely occurs in children, Avhile in infants it is still less frequent. A sudden stopping of the stream of urine is the most characteristic symptom, although diurnal inconti- nence is occasionally the evidence which may call to mind the possi- bility of the presence of a calculus. Pain on urination often occurs and is usually felt in the end of the penis or in the perineum. Rectal tenesmus with prolapse is frequently present, due to straining when cal- culi exist. On account of the genital irritation in this condition mas- turbation is often practised. Urinary changes differ from those in adults in that hematuria is rare, and pus and mucus are infrequent or occur in small quantities. A positive diagnosis is made when the stone is felt by bimanual rectal examination or by searching the bladder with a sound or wax-tipped catheter. The treatment is surgical. Removal through suprapubic incision is usually necessary. 31 SECTION XIII. DISEASES OF THE NERVOUS SYSTEM. CHAPTER XXXVI. GENERAL NERVOUS DISEASES. General Consideration. To the unstable equilibrium of the rapidly developing brain ; to its peculiar sensitiveness to peripheral irritation, to the important role played by the infectious diseases, the liability of the child to trau- matism, and finally to hereditary influences, singly or combined with any of the above, must be attributed the many neurotic disorders which are peculiar to early life. A full and detailed history will be of great assistance in arriving at a diagnosis in this class of cases. A careful and complete physical ex- amination should be made with the child entirely naked. Trained ob- servation for details coupled with logical reasoning will be required for success in many instances. Certain cases if once seen in life are rarely mistaken, as, for example, cretinism; on the other hand, an unusual case of multiple neuritis may require a complete knowledge of the methods of examination, and the diagnosis will have to be supported by a differential diagnosis, consciously or unconsciously made by the physician. The sensory disturbances are elicited with difficulty in early life, and the muscle tone must be interpreted also from the view-point of the history of previous feeding. The gait should be carefully observed, as some are quite charac- teristic of certain groups of cases, for example, the cross-legged pro- gression, or scissors position, indicates a spastic paraplegia. The spastic gait is seen in cerebral palsies, while the ataxic gait is assumed by children suffering with cerebellar disease, neuritis, or the more rare disease, hereditary ataxia. The swinging gait of poliomyelitis is distinguishable from the waddling, swaying gait seen in those with the various dystrophies. As the cooperation of the patient is not always obtainable and the mother's statements may be innocently misleading, tests should be made for blindness and hearing. A candle or bright-colored objects may be presented to the eyes as a test. 482 GENERAL NERVOUS DISEASES. 483 Vision may be tested with the cards described on page 573. The finger will be allowed to touch the eyeball in absolute blindness, but if the corneal reflex is present there will be prompt closure. An ophthalmoscopic examination is feasible after proper preparation with atropin. Mummying the child as for intubation may be necessary with intractable children. It should be recollected that inequality of the pupils and even nystagmus may be congenital. The hearing may be estimated by clapping the hands suddenly behind the child, by the use of a whistle, or the whispered voice. Where an intelligent response may be expected the tuning-fork can be used. Tickling or pinching the toes or fingers may be used as a test for actual paralysis. It should be remembered that both upper extremities are rarely paralyzed in children. That the patellar reflex may be obscured by fatty deposits, and that it should be relied upon only after obtaining the same result after repeated tests. Ankle clonus, however, is always indicative of an abnormal condition. The superficial reflexes are of little or no value in the early years. The Babinski reflex, extension of the big toe, is of no significance in the first year of life, being normal during this period. When the electrical examination is made in children, great care should be employed not to frighten the patient; allowing them to play with the electrodes at first is a good plan. Use the mildest cur- rents that will produce results, and compare the reaction to the oppo- site extremity. The behavior of the muscle in reacting is often suffi- cient to appreciate degenerative changes. Paralysis in General. Paralysis or the loss of motor power may be associated with sensory and reflex disturbances and with atrophy of muscle. The motor inability may be localized and result in a monoplegia, that is, a paralysis of one extremity,, diplegia in which both sides are in- volved, paraplegia in which the two lower limbs are paralyzed, and hemiplegia or a paralysis of one half of the body. Again paralyses are spoken of as central when they are due to lesions of the brain. Spinal, when they originate in the cord; periph- eral, when the result of nerve or muscle disease. General Characteristics of the Various Types— Cerebral Paralysis (Spastic Paraplegia). — This is commonly unilateral, the lesion being on the opposite side of the cortex; the face is partially involved. Spasticity, increased reflexes, slight electrical changes and no atrophy of muscle distinguish this type. 484 DISEASES OF CHILDREN. Spinal Paralysis. — Flaccidity with wasting of muscle indicates involvement of the peripheral motor neuron. There is no disturbance of sensation (except in myelitis). The reflexes are absent or dimin- ished, and the reaction of degeneration is present. Nerve Paralysis.— The toxic forms are apt to be bilateral in distri- bution, the reflexes are lost and so also is muscle excitability. The traumatic paralyses are due to pressure on the nerves, as a result of Fig. 130 — Volkman's ischemic paralysis, following fracture of the radius. fracture, dislocation, and pressure from without. They are local in distribution and if there is response to electrical stimuli, the nerve re- covers its function. Muscle Paralysis. — The motor inability is here due to the changes in the muscle fibers themselves. There is diminished electrical reac- tion and atrophy or pseudohypertrophy of muscle. Diseases of the joints, bones, and tendons may by atrophy and disease produce a paralytic condition, as in rheumatoid arthritis. Pseudoparalysis. — True paralysis may be simulated by muscle weakness, as in rachitis or chorea. Close observation and the electri- cal reaction easily distinguish the condition. Convulsions. (Eclampsia Infantum.) This symptom or symptom-complex results from a cerebral irrita- tion producing a temporary unconsciousness, attended by irregular muscular contractions. GENERAL NERVOUS DISEASES. 485 The symptom in the infant and young child often corresponds to the chill of the adult. It is quite commonly observed because of the relatively greater excitability of the brain and the undeveloped power of inhibitory control. We may divide the causative factors into two groups — the reflex or functional and the organic. Etiology. — The peripheral disturbances which may cause a con- vulsive seizure are many and various. The susceptible age is in the first two years of life. An apparently trivial cause, such as psychic or sensory impressions resulting from unusual excitement in a child with an inherited unstable equilibrium, may produce a typical seizure. Foreign bodies in the nose or ears, traumatism, intestinal parasites, preputial abnormalities, improper or indigestible articles of food, poisons, and the toxemias resulting from or preceding certain diseases, as rachitis, malaria, or tetany, are among the causes .producing con- vulsions. Rachitis deserves special mention as an underlying predis- posing cause because of the nervous instability it produces. The organic causes are meningeal hemorrhages at the time of birth, tumors of the brain, cerebral abscess, hydrocephalus, and the various forms of inflammation of the brain or its coverings. It should be recollected that regional as distinguished from general convulsions are indicative of organic lesions, and also that re- peated seizures over prolonged periods are characteristic of cortical disease. Description of the Symptom-complex. — The attack begins without warning. It may be preceded by slight twitching of the face and rolling of the eyes. There is then unconsciousness, the eyes are fixed and staring, tonic rigidity of the head, back, and extremities is shortly followed by clonic contractions of the facial muscles. These usually begin at the mouth, causing grimaces and distortions of ex- pression and some frothing. The teeth are firmly set. The color is dusky. In a general convulsion all the extremities show clonic con- tractions and purposeless activity. The pupils are usually dilated and do not react to stimuli. The respirations are labored, affecting the pulse and causing irregularity of the heart action and increasing the cyanosis. There may be involuntary passage of urine and feces. After a variable time the muscular twitchings cease and the child passes from a coma into a deep sleep. The attacks may be and usually are shortly repeated unless influenced by treatment. After a period of sleep the child arouses and takes a normal interest in its surroundings; it may then be considered free from the danger of another immediate attack. Prognosis. — This is usually good, but should be guarded until 486 DISEASES OF CHILDREN. a definite cause is established. It is always serious if the attacks occur in the new-born in advanced childhood, or if they are unduly prolonged and recur often. If convulsions usher in a disease they are not of as great prognostic importance as when they occur in the course of the disease. An exception to this statement must be made in cerebrospinal meningitis in which initial convulsions are of bad omen. Differential Diagnosis. — The essential characteristics are tempo- rary unconsciousness and irregular muscular contractions. In convulsions from organic causes, the regional involvement, often neuritis, and the resulting paralysis may be distinguishing features. Epileptic seizures occur usually after the second year of life, they are apt to recur after longer periods and without an immediate causative factor. The history of predisposition may be obtained. Treatment. — First overcome the attack or symptom. Some one in the family will in all probability have given a mustard bath before the arrival of the doctor. If the attack persists inhalations of a few drops of chloroform may be given and if there is any fever an ice-bag is placed to the head. Meanwhile a soap-suds enema is prepared and given on general principles. If there is an elevation of temperature, the enema may be given cool at 70° F. Examine the fecal discharge for a possible etiological factor as some foreign substance ingested or for intestinal parasites. Keep the room noiseless. Follow the enema by a rectal injection of the bromid of soda grains ten, and chloral hydrate grains three, for a five-year-old child, if the twitching still persists. When the child can swallow, calomel or castor oil is given to rid the intestinal canal of possible toxins. In the period of quiescence obtain a careful history, make a detailed examination and arriving at a diagnosis order such treatment as is suited to the underlying cause as, for example, a properly balanced diet with sufficient proteins and fats for rachitis. Chorea. (St. Vitus' Dance; Sydenham's Chorea; Chorea Minor.) Chorea is a neurotic affection, characterized by .purposeless move- ments of various parts of the body. Etiology. — Girls are more often affected than boys. It appears most frequently from the fifth to the twelfth years of life. Rheu- matism and tonsillitis are antecedent causes. It may develop as a result of fright, excessive school duties, intestinal autointoxications, GENERAL NERVOUS DISEASES. 487 or imitation of other choreic children. The offspring of neurotic parents are especially predisposed. Pathology. — The theory that rheumatism, chorea, and endocardi- tis are related in many instances is gaining ground, and is certainly clini- cally of value. The toxin of rheumatism may affect the heart or the cortex of the brain in the Rolandic area, and causing irritation produce the characteristic movements seen in chorea. Hypertrophied tonsils and valvular disease are not infrequently associated with chorea. The infectious theory is held by the majority of pathologists to-day and these same observers believe in the infec- tious character of rheumatism and endocarditis. Symptomatology. — The symptoms usually come on insidiously, and may not be noticed until quite marked. The child is chided for care- lessness or awkwardness in dropping articles or for unnecessarily fid- getting. Nervousness and irritability of temper are noticeable. Upon little or no provocation the child begins to cry. The muscles in various parts of the body later begin to twitch and contract, the face making ludicrous grimaces. These movements are entirely involun- tary, and if the examiner fixes the child's attention, these irregular movements are exaggerated. In the early stages the body move- ments may be slight and are best felt when the child's hands are placed within those of the examiner and the arms put on a slight tension. The tongue also when closely observed shows *the twitching movements quite early in the disease. During sleep the movements cease. Fol- lowing a severe fright or chastisement chorea may suddenly develop with well-marked symptoms. Aggravated cases or those under no control are often pitiably affected; the child cannot dress or feed itself; sleep is disturbed; speech is altered and may be so changed as to be unintelligible. Pseudoparalysis due to muscular weakness may occur but the extremity is never completely at rest for any length of time. On the other hand, a case recently under our observation in the Post-graduate Hospital had such marked jactations, that she had to be fastened in bed and fed by gavage until relief of symptoms was obtained by medication. Hemichorea, in which the movements are confined to one side, is sometimes seen, and in these cases sensation is somewhat impaired on the same side. There is no elevation of temperature, unless the case is compli- cated with rheumatism or endocarditis. It is not uncommon to find a mitral regurgitant murmur develop during the attack. Sometimes, in fact, it may precede it. Functional or anemic murmurs are heard in prolonged cases. 488 DISEASES OF CHILDREN. Course and Prognosis. — Chorea is in itself almost never fatal. Uncomplicated cases tend to recover in from one to several months. Ten weeks is the duration in the average case. Relapses are frequent. Diagnosis. — This is, as a rule, quite simple, resting upon the characteristic muscular movements and especially the abnormal movements of the tongue. Imitative choreic movements are dis- tinguished by their short duration, while in hysterical chorea the harmonious character of the movements and other hysterical phe- nomena serve to distinguish the neurosis. Sachs calls attention to the fact that choreic movements may be associated with infantile cerebral palsies and must be distinguished from true chorea. Spasticity and the increased reflexes should here put the examiner on the right track. Complications. — Acute or subacute rheumatism, and heart disease are the most frequent complications. Treatment. — The treatment differs for the mild and severe cases. Mild Cases. — Rest is the first and most important measure. With- out it all treatment is unsatisfactory. The child should be immedi- ately removed from school. By rest is here meant avoidance of all mental excitement or effort; physical rest is obtained by putting the child to bed in a well-ventilated room, and keeping it there until the coarser movements cease, then the child may be allowed up for a half- hour in the same room, and this allowance increased from time to time if good progress is" made. Toys which require no effort on the part of the child are allowed, while reading and singing to the patient by the attendant serves to shorten the enforced rest. Visitors and the other members of the family are to be excluded. The diet is to be carefully supervised. Milk alone for a few days and later cereals and vegetables, eggs and butter are allowed. Alcohol sponge baths or brine baths for their tonic effect may be given daily. Arsenic in the form of Fowler's solution is given as an adjuvant, but should not be depended upon to cure the patient without the rest treatment, as it is far from being a specific. Begin with three drops three times a day for a five-year-old child and increase gradually by one drop up to thirty drops daily. The arsenic should be administered after meals, well diluted in some alkaline water. It must be stopped if there is any nausea or puffiness of the eye-lids. In rheumatic cases novaspirin or the salicylate of soda may be given in conjunction with the above treatment. Severe Cases. — The rest cure is imperative. A padded bed is sometimes necessary. The movements should be quickly controlled by doses of the bromids with chloral per os or per rectum, and then the arsenic treatment may be begun. If the chloral and bromids are GENERAL NERVOUS DISEASES. 489 not sufficient to control the jactations, a hypodermatic dose of hyos- cin hydrobromate grains -^ for a five-year-old child will do so. This should not be used if there is any heart involvement. Veronal, grains 3, at night will promote sleep if there is insomnia. Feeding through a tube must occasionally be practised. It is best to order a certain fixed amount of nourishment to be taken or fed during the day. Convalescence. — School duties should be abandoned for some months. Life in the country, at the seaside, or in a suburban town is advisable. Baths, iron tonics, and nutritious diet, including the fats and meats, are now indicated, for profound anemias are often con- current with chorea and lead to relapses unless corrected. School life must not be resumed until such time as the possibility of a recur- rence is well past. Forms of Chorea. — Choreiform affections or movements are prac- tically synonymous with habit-spasms and tics. (See page 500.) Huntington's chorea or hereditary chorea is a rare disease of a chronic nature and occurs in later life. Chorea insaniens is a fatal form, which may be due to a bacter- emia. Chorea major is a hysterical chorea under which are included several groups described mainly by German writers, for example chorea electrica. Hysteria. True hysteria is a rare disease of early life, and is usually seen in children of the school age, especially in girls at puberty. Etiology. — Heredity is an important factor, for if one or both parents are neurotic there is likely to be little or no control over the offspring; they are indulged in every whim, and too much attention is paid to minor ailments, and the imitative disposition of the child is often the precursor of real trouble. Children in institutions and asylums who receive only little personal attention from their superiors are often the victims of hysteria. Morbid sensations and psychical phenomena, such as fear, are productive of attacks. Symptomatology. — The attacks do not present any great varia- tion from those seen in adults. The tendon reflexes are not so often found exaggerated and disturbances of sensation are not commonly observed. It would be impossile to describe a typical case of hysteria, as certain groups of symptoms are in evidence in one case and entirely absent in another. The symptoms are traceable to defects in the various body functions, symptoms, and organs. Sachs classifies the symptoms into three groups — psychic, motor, and sensory manifestations connected with vasomotor disturbances. 490 DISEASES OF CHILDREN. Under the first group are the weak-minded children with a per- verse will. Hysterical mania may manifest itself if the child's wish is opposed, following a sudden fright or even a fit of anger. Alternate laughing and crying with kicking or tearing of objects and clothes occur, while the disturbance is made worse by attempts to console or sympathize. Hysteroepilepsy, while undoubtedly extremely rare in children, is of greater importance than some of the other hysterical manifestations. These children have a vicious family history, in- cluding alcoholism, insanity, etc. The attacks must be studied and epilepsy excluded after repeated observations. In hystero-epilepsy there is no aura. The bladder and rectal functions are not disturbed, the attacks are of longer duration, there is no complete loss of con- sciousness, personal injury is rare, and the movements themselves are tonic, exaggerated, and often purposeful. A great variety of hysterical manifestations may be seen: those involving only the lower extremity or the head and neck alone. The esophageal spasm is not rare in girls at puberty (globus hystericus). Sometimes paralysis follows the jactations or occurs alone as a hysterical manifestation. Again, only certain functions may be paralyzed. Hysterical aphonia is not uncommon, especially in insti- tutions and asylums. They disappear quite suddenly when confidence is established, and local examination reveals a normal laryngoscopic picture. Any part or portion of the body may be affected. The regional paralysis is, moreover, usually associated with regional anes- thesia. The condition of the reflexes which are not exaggerated and the absence of spasticity in the muscles and the unaltered electrical reaction serve to differentiate it from the true forms. Spasmodic conditions, such as hiccough, dysphagia, anorexia, and vomiting, some- times occur and may be extremely troublesome. Spasmodic cough and purposeless screaming are especially seen in young girls. Hyper- esthesia and anesthesia are not so commonly observed as in adults, but when present are apt to distort the diagnosis if the physician is not on his guard. Disturbances of vision especially must be kept in mind in this relation. Organic lesions, however, should be carefully excluded before a diagnosis of hysteria is made. Prognosis. — This is better in children than in adults. Relapses are common if control is not absolute. Treatment.— The acute attack may often be interrupted in child- ren in the ordinary case by the use of the aromatic spirits of ammonia, not too well diluted, or by giving apomorphin in emetic doses. Cold douches, when unexpectedly applied to the face and chest may arrest the attack. In intractable cases the rest treatment should be faithfully tried. GENERAL NERVOUS DISEASES. 491 If this is not effective a change of environment is then most important. The neurotic parent influences the child not only through the inherently weak nervous system, but by improper training and defective example. Sometimes it is necessary to send these children to special schools whose principals have made a study of neurotic children. Improvement in general physique is always to be aimed at and is at- tained by aerotherapy and nutritious plain food. The dietary should be supervised and a special list prepared for the needs of the particular child. The suggestive influence of the physician who will exert his force of character and thus establish confidence can be made extremely powerful in its effect, and often produce a cure alone. Baths and douches have a distinctly favorable influence. The electrical currents are sometimes useful for their moral effect. Medicinal measures are rarely necessary if the above plan is feasible and strictly adhered to. Epilepsy. Epilepsy is a disease often occurring in early life, and character- ized by seizures which vary in their intensity, affecting only a portion of the body, or they are generalized. Etiology. — The children of neurotic parents, those who have themselves been afflicted with epilepsy, hysteria, chorea, and similar nervous diseases, may fall victims to this disease. To these may be added syphilis and alcoholism. Traumatism during or after birth and maldevelopment of the brain as a result of acute infective processes may later lead to epileptic seizures. Among the exciting causes the intestinal toxemias, visual defects and obstructive growths in the respiratory tract, such as adenoids and polypi, may be mentioned. Symptomatology. Petit Mai. — In this form there may at inter- vals occur momentary periods of unconsciousness. The child may suddenly cease playing or speaking and stare into vacancy. The parents may bring the child to the physician complaining of its " faint- ing attacks." If questioned, the child has no recollection or knowl- edge of these periods. If seen at the time of an attack, the pupils of the eyes may be seen to suddenly dilate and the face turn pale. Occa- sionally there is a period of drowsiness or the child seems dazed and is not willing to immediately resume its former occupation. Grand Mai. — There is no sharp limit between the mild and the severe forms. Grand mal is spoken of if there is an aura, a period of unconsciousness, a convulsion, and the involuntary passage of urine 492 DISEASES OF CHILDREN. and feces. It should be recollected that young children may not have an aura or may be incapable of interpreting it. Intelligent parents may sometimes foresee a coming attack by noting a change in the child's disposition or by observing certain unusual bodily movements. The sensation may be felt in the different situations, as the stomach, the eves, or noises in the ears. The child suddenly falls into unconsciousness and a convulsive seizure takes place simulating the ordinary eclamptic seizures de- scribed on page 485. Sometimes an initial cry precedes the fall. The dilated pupils do not react to light, the tongue may be bitten, and blood- stained saliva may appear at the mouth, although this is not usual in childhood. After a few minutes the spasm relaxes and the patient is found to have involuntarily passed his urine or even emptied the rectum. Following the return to consciousness, the patient is in a semicomatose or stupid condition, complains of headache, and often drops into a restless sleep. Nocturnal attacks may be discovered only by the bitten tongue or drowsiness on the succeeding day. The " epileptic voice sign" of Clark and Scripture may excite suspicion in the medical attendant. It is described as a monotonous voice, the melody proceeding by even steps and occurs in this disea c e alone. Diagnosis. — Hysteria is differentiated from epilepsy by the ab- sence of entire loss of consciouneess, the stage of excitation with laugh- ing and crying, and by the absence of dilated pupils and involuntary urination and defecation. Tumors of the brain may affect localized regions; they may have peculiarities of gait and changes in the fundus of the eye. Prognosis. — The gravity is determined to a great extent by the age. The earlier the seizures appear the poorer the prognosis. Fre- quent recurrences of well-marked attacks are less hopeful and may be followed by feeble-mindedness. Treatment. — During the attack the child should be placed in bed and guarded against personal injury. Little or no food should be offered after the attack until the period of drowsiness is past. The diagnosis once established, stringent prophylactic measures should be instituted to prevent recurrences. A life in a quiet country dis- trict with an unusual amount of sleep and little mental exercise is dis- tinctly beneficial. A diet consisting of simple food (coffee and tea being absolutely excluded), with plenty of vegetables and fresh fruits to insure daily bowel activity, is required. For the children of the poor, life in the epileptic colonies, where the children conform to a certain routine adds much to their chances of improvement. The bromids when administered in divided doses, five grains for GENERAL NERVOUS DISEASES. 493 a five-year-old child three or four times a day, while not curative, serve to reduce the number of attacks. When the latter occur at night only, it is best to administer one large dose, about twenty grains, at bedtime. This drug should be given to the point of toleration and resumed after a period of rest. Headaches. Headache is a symptom deserving of especial attention since it may be symptomatic of many functional or even organic disorders. Etiology. — It most frequently results among children from gastric or intestinal disturbances and from eye-strain. Anemic children who have been improperly fed and who are forced into competition with their schoolmates often suffer from toxic headaches. If the child remains in badly ventilated or superheated rooms frontal headaches frequently result. The cause may be more obscure and may be found to result directly or indirectly from adenoids, ear disease, neph- ritis, cardiac disease, and malarial poisoning. Young girls at the beginning of the menstrual period, especially if they are neurasthenic, may complain of frequent headaches. Many of the acute infectious diseases are preceded by cephalgia as a prodromal symptom. Men- ingitis and tumors of the brain cause persistent headaches which are referred to one area. Migraine or sick headache occurs in older children. It is usually unilateral in character and preceded by nausea and vomiting and dis- turbances of vision. Diagnosis. — The diagnosis depends upon a careful physical ex- amination to exclude organic disease, and in obscure cases of this type lumbar puncture, the opthalmoscope and the tuberculin tests may be necessary. Functional headaches when dependent upon intestinal derangements are accompanied by a coated tongue, a fetid breath, and constipation. Those due to anemia and general asthenia exhibit pallor of the mucous membranes, lassitude, and depression. In these cases a blood examination, at least the Talquist hemoglobin estimation, should be made. Headaches due to visual errors begin or are intensified at the end of the school day or whenever the eyes have been overtaxed. An examination with the test cards (see p. 573) should be made as a matter of routine, as a more detailed ocular examination may then disclose astigmatism or other refractive errors. The diagnosis of migraine depends upon the periodic unilateral attacks and the accompanying nausea and eye disturbances. Treatment.— This is directly dependent upon the cause. When the headache is the result of digestive errors acute attacks may be 494 DISEASES OF CHILDREN. relieved by clearing out the intestinal tract and prescribing a proper dietary which is to be strictly followed. Anemic headaches are cured by life in the open air or at least an abundance of fresh air and sun- shine in the rooms which the child occupies. Reducing the number of study hours and prohibiting special studies after school hours may alone be sufficient. Obstructions in the respiratory tract and errors of refraction must be removed before any progress can be made. A child suffering with migraine should be put to bed in a quiet dark room, during the attack, and analgesics, as phenacetin combined with caffein or the bromids, may be given. A hot-water bag or light massage over the forehead and temporal regions may be agreeable. Future attacks must be prevented by strict regulation of the child's life and diet. Insomnia. This symptom which occurs in infancy and childhood generally results from some functional derangement which can usually be removed when once recognized. The infant and child are dependent upon a sufficient amount of sleep to promote healthy growth. That it cannot or does not spend sufficient hours in sleep may be due to acute physical discomfort or from a perversion of its natural habits resulting from mismanagement on the part of its attendants. The following table will give a general idea of the daily amount of sleep required in early life: Healthy new-born, 20 hours, minimum 16 hours. Six months, 16 hours (2 naps). One to three years, 12 hours (and one nap). Three to six years, 12-10 hours. Six to ten years, 10-8 hours. When the infant is unable to approximate the normal amount of sleep a careful examination of its mode of life should be made followed by a systematic physical examination. Among the more frequent causes of sleeplessness are digestive disturbances, undue excitement, bad hygienic conditions, and localized pain. Physical examination may show that the child is suffering from an otitis, skin lesions, en- larged tonsils, adenoids, rachitis, extreme anemia, or the disease may be organic, such as meningitis or incipient disease of the brain or spinal cord. GENERAL NERVOUS DISEASES. 495 Treatment. — When the cause is found efforts should be made to remove or correct it before any other measures are undertaken. A careful regulation must be made of the child's daily life, not -omitting what may seem to be minor influences bearing upon its sleeplessness. A well-ventilated, cool, darkened room should be provided, which the infant or child should occupy alone; the bed clothing should be light and not too warm. The evening meal must be simple, not containing too much liquids. Reading of exciting stories to children should be prohibited. These changes with an outdoor life are often sufficient to correct insomnia. If a high temperature is the cause of the insomnia, baths or spong- ing with alcohol will often promote sleep. If temporarily any of the hypnotics are necessary, the bromids, in doses of one and a half grains for each year of age, or one grain of veronal for a two-year-old child will produce the desired effect. The bromids combined with chloral hydrate are effective in older neurotic children, especially if they also have night terrors. Pavor Nocturnus. (Night Terrors.) This condition occurs in children who have in some manner unduly excited their nervous system. They may or may not be the children of neurotic parents. Children from the third to the eighth year are more commonly subject to night terrors. In our experience the condition appears with the greatest frequency at the beginning of school life when unaccustomed responsibilities must suddenly be assumed. The reading of unnatural stories so often practised by nurses or unusual and grotesque sights, as in the circus, may induce an attack. A heavy meal just before retiring may also be a cause. The children awake suddenly, usually before the midnight hour, and cry out, exhibiting signs of fright or terror. They are soothed with difficulty and can give no explanation of their sudden awakening or dream. If questioned in the morning they remember nothing of the occurrence. The terrors may repeat themselves several times in a week, but they seldom occur twice in the same night. When the cause is removed the recurrences become more infrequent and finally disappear altogether. Treatment. — Every effort should be made to decrease the ner- vous excitability of the child by prohibiting school work at all for a time or decreasing the number of school hours. At home no supple- 496 DISEASES OF CHILDREN. mentary teaching should be allowed and association with older minds not encouraged. A healthy amount of physical tire, rather than mental strain should be the desideratum. The evening meal particu- larly should consist of light and easily digested articles, and should be eaten at least an hour before retiring. If these measures are carried out it will rarely be necessary to give bromids or hypnotics. Tetany. (Tetanilla; Arthrogryposis.) Tetany is a neurotic disorder characterized by intermittent or constant tonic spasms of the muscles of the upper and lower extremities. Etiology. — The disorder is dependent upon the absorption of toxic products which readily affect the highly sensitive nervous system of early life. It occurs most frequently from the sixth month F ^ 1 « 1 ' 1 . id?y_» ..J'' WyJ fl ^^ h\ e -.- -'* Fig. 131. — Tetany, with characteristic positions of hands and feet. to the end of the second year. We would give rachitis the first place in the role of etiologic factors, and the conditions which may produce this disease may also produce tetany. This is further borne out by the fact that convulsions and laryngismus stridulus frequently occur in those subject to tetany. It also results from intestinal or peripheral irritation and may follow exhausting diseases or secondary pneumonias. Symptomatology. — The condition begins without any warning in infancy, although older children sometimes complain or give evidence GENERAL NERVOUS DISEASES. 497 of an itching or tingling sensation. Attention is generally called to the condition by the muscular contractions of the hands and feet. A close examination will show that the arms are held quite closely to the chest, the forearms being partly flexed on the arms and the hand flexed at the wrist, while the fingers may either be tightly closed over the inverted thumb on the palm, simulating the driving position, or they may be hyperextended and held closely together like the obstetric Fig. '132.— Tetany. hand. In the lower extremities the thighs may be drawn up onto the abdomen and the legs flexed on the thighs; some degree of adduc- tion of the thighs is generally present. The foot itself is extended or hyperextended, and the toes are flexed. The position of talipes equino- varus being often assumed. We have also noted spasticity of the erector-spinse group of muscles, so that the child could be raised by the head retaining an erect posture. The child's expression is one of discomfort. Pain is elicited if attempts are made to replace the ex- 32 498 DISEASES OF CHILDREN. tremities in their natural positions. There is rarely any temperature which can be attributed to the condition itself and the mentality is not affected. After a variable time, sometimes a few days or it maybe weeks, the contractures intermit and the so-called latent period may be entered into, in which there is weakness and some slight spasticity of the affected muscle groups, or the symptoms may never return. In this disease certain phenomena may be elicited which are distinctly helpful in making or confirming a diagnosis. Trousseau's symptom can be produced in the latent period by pressing upon the main nerves and arteries of the extremities. In this way a characteristic paroxysm can be produced which ceases when the pressure is removed. Erb's symptom is dependent upon the increased electrical excita- bility in the peripheral nerves, muscular contractions being produced even by w T eak currents. Chvostek's symptom is a facial phenomenon w r hich is of value if obtained in conjunction with the others and is elicited by pressing the finger or any other blunt object over the facial nerve when contrac- tions immediately occur. Differential Diagnosis. — From tetanus it may be distinguished by the absence of trismus which is an early symptom, by the lack of fever, by the intermittent attacks, and the ability to elicit Trousseau's, Erb's, and Chvostek's signs. Cerebrospinal meningitis is distinguished by the presence of high irregular temperature, cerebral signs, and by lumbar puncture. Prognosis. — The prognosis is mainly dependent upon the under- lying cause. In itself it rarely endangers life except by predisposing to convulsive seizures. Treatment. — The underlying condition must be carefully sought for and treatment immediately directed toward its removal. It is a safe rule to thoroughly empty the bow r els by the use of a large dose of castor oil or calomel. An enema may be given for immediate relief. The stools should be kept for the physician's examination, as he may therein find the source of the peripheral irritation, such as badly digested food or intestinal parasites. Baths at a temperature of 110° F. may be given tw r o or three times during the day for their relaxing effect. In severe cases a mixture of chloral hydrate and the bromid of soda can be injected into the rectum. In the latent period dietetic meas- ures should be coupled with most favorable hygienic conditions. The food ordered must be such as to overcome the rachitic manifestations if present (see page 432), or produce an increase in weight if the neuro- sis has resulted from an exhausting disease. GENERAL NERVOUS DISEASES. 499 Myotonia Congenita. {Thomsen's Disease.) Myotonia congenita is a rare disease, mainly hereditary, charac- terized by a sudden rigidity of certain muscle groups when a voluntary movement is attempted. Etiology. — The disease may occur early in childhood, but the greatest number of cases are seen between the fifteenth and twenty- fifth year. Thomsen believes it to be a hereditary disease; five generations in his own family having been so afflicted. Inclement, cold weather and emotional states may bring on the attacks. Symptomatology. — The muscular contractions develop when the patient attempts some voluntary act, as rising from bed or from a chair. The muscular spasm prevents the completion of this effort, and repeated attempts are necessary before it is accomplished. These inhibited efforts in a child otherwise well developed are striking enough to fix the diagnosis. If a sharp blow is given over a muscle, a tonic contraction occurs which persists for some time. Erb has shown that the muscles react peculiarly to electrical stimuli. This "myotonic reaction," as he calls it, is a valuable confirmatory sign. Faradic currents stimulate the muscles, producing wavy, rhythmical long-continued contractions. The same effect may be produced by the galvanic current. Diagnosis. — The disease is distinguished from tetany by the con- tractions produced by mechanical stimulation and by the peculiar electrical reaction (Erb's myotonic reaction). Furthermore, there is no increase in mechanical excitability by pressure over the nerve or vessel trunks as in tetany. Congenital paramyotonia (Eulen- berg's modification) may be differentiated by the absence of the myo- tonic electric reaction and also of any increase in the mechanical excitability. Treatment. — Thomsen noted that the symptoms appeared less often the greater the muscular activity of the patient; he therefore advised a life which would necessitate a constant use of the muscles. Paramyoclonus Multiplex. This disease, although very rare in early life, is mentioned here mainly for the purposes of differential diagnosis. It is character- ized by the production of repeated momentary clonic spasms affecting a certain muscle or groups of muscles which are usually symmetrically involved. The muscles of the face are rarelv involved. A slight tre- 500 DISEASES OF CHILDREN. mor of the muscles may be observed between the attacks which usually follow some strong emotional excitement or physical effort. The myotonic reaction is rarely increased and no change in elec- trical excitability is noticed. Treatment. — We are almost powerless to effect a cure in this dis- ease, although amelioration of the symptoms is possible by the use of sedative baths, mild gymnastic exercises, and a life free from excitement. Angioneurotic Edema. (Acute Circumscribed Edema.) This is a vasomotor disturbance, trophic in origin, characterized by attacks of circumscribed edematous areas on the body. Gastrointestinal intoxication is the most frequent cause in chil- dren, although it sometimes appears without any discoverable reason. The edema may be well-marked a few hours after its inception and may just as suddenly disappear, only to reappear in some other portion of the body. There are no marked constitutional symptoms, the chil- dren simply complaining of the itching or the discomfort caused by the edema when it affects, for example, the face. In a recent case seen by one of us there were unquestionable signs of edema of the lungs, which appeared suddenly, and cleared up within forty-eight hours. The area affected is raised, pale in the center, with an irregular bluish-red margin, differing from the other edemas in that it does not pit on pressure. Fatal cases have been re- ported in wmich the larynx and pharynx were affected. Treatment. — Special treatment during the attack is hardly neces- sary. Compresses wrung out of warm boric acid solution are soothing to the patient. A saline purge should be given and future attacks inhibited by scrupulous attention to the dietary. Tics. A tic is the unconscious activity of a group of voluntary muscles resembling a purposeful movement, its frequent repetition classing it as a habit. They occur most frequently in children from the fifth to the fourteenth year of life. An underlying neurotic element can usually be found in the patient or he has been trained under attendants who by their management have not developed his self-control. These neurasthenic children may easily develop a tic from some primary GENERAL NERVOUS DISEASES. 501 source of irritation, as foreign objects or growths in the air passages or eyes, skin diseases, as eczema, phimosis, or even chorea. They may arise from emotional disturbances or as a result of imitation as pointed out by Scripture in children of unstable and willful disposition. The most common tic is the one involving the muscles about the eye in which the child rapidly winks the eye-lid several times in succession. This occurs at short intervals during the day. Not unlike these in motor characteristics are the tics affecting the face, scalp, ears, tongue, neck, and extremities. When tics are accompanied by mental disturbances, a child otherwise rational may repeat words or phrases of an obscene character without provocation or regard to the time and place. This is known as coprolalia. Differential Diagnosis. — Tics may be distinguished from chorea by the purposive, systematic nature of the movements which occur at intervals. The spasms of paramyoclonus multiplex affect only a certain muscle and are not controlled by fixing the attention. Habit spasms resemble normal movements, but differ from them in that they are unnecessary. They are unlike tics in that they are not con- vulsive in type. Stuttering and Stammering (Hyperphonia). — In this connection another class of tics forming a large part of the speech defects of child- hood may be considered. Scripture defines hyperphonia as a psycho- motor neurosis or a mental tic or habit over which the patient has no control and which is the result of a compulsive idea connected with speaking. A neurotic child may acquire the habit by imitating others or he may have some defect connected with his respiratory apparatus. The symptoms have been divided into spasms and hypertonicity, affecting the respiratory, laryngeal, and articulatory muscles; to these are sometimes added facial and bodily tics. Treatment. — A careful physical examination, including the special organs, and an inquiry into the details of the child's life should be made in every case. An underlying and neglected cause may be found in refractive errors, abnormalities in the nose, ears, or teeth. Peripheral irritation from any source must be removed; while this is not curative, it is conducive to a more rapid recovery and prevents recurrences. The physical condition of the child should be improved by nutritious food, tonic baths, ample amount of sleep, and a routine life under judi- cious discipline. A change of environment will often make the spe- cial treatment much more effective. Fowler's solution may often be given with benefit. In a number of our cases the method advocated by Scripture was remarkably effective. It depends upon the volun- tary imitation of his own act by which the child is trained to a con- 502 DISEASES OF CHILDREN. scious performance of the tic. In this way he is encouraged and en- abled finally to inhibit the act. The child looks into a mirror and is directed to imitate five times in succession his own tic when it appears. At first the imitation is a poor one, but improves with practice, until finally complete control is obtained. Scripture's method for stuttering and stammering consists in introducing melody into the monotone voice of the stutterer. The child is directed to repeatedly sing a line of some familiar song; he is then taught to speak a sentence in the same sing-song fashion. In this way the monotone voice is finally abandoned and cadences and inflections are introduced. The " melody cure" is founded upon the fact that a stutterer never stutters when he sings. This simple treatment is elaborated by encouraging the child in forms of elocution and graceful mannerisms. Finally, in some cases it is also necessary to distract the mind when the patient starts to speak; this is done by teaching him to beat time in a quick, vigorous manner as he starts to speak or to set him- self off by repeating one, two, and starting off to speak on three. These lessons are given at first three times a week for half-hour periods, the time and interval being lessened as progress is made. CHAPTER XXXVII. DISEASES OF THE PERIPHERAL NERVES. Multiple Neuritis. Definition. — An inflammation of the peripheral nerves, in some of which there is a tendency to acute degenerative changes. It may affect several nerves, usually symmetrically, or it may be general. Etiology. — Bacteria or at least bacterial toxins in all probability cause the disease. The infectious diseases, especially measles, malaria, influenza, typhoid, and tuberculosis, may be followed by a polyneuritis, but it is a rare complication, with the exception of diphtheria. Some- times exposure or cold and rarely alcohol, arsenic, or lead cause the disease. Alcohol must be considered as a factor in treating the chil- dren of our foreign population. Pathology. — There is an inflammation of the affected nerve, inter- stitial or parenchymatous in character, followed by more or less com- plete degeneration of the fibers. The appearance of the nerve at first is that of an acute inflammatory nature, with swelling, hyperemia, and minute hemorrhages in the nerve sheaths. Later degenerative changes in the nerve fibers only are seen. The muscles undergo paren- chymatous or even interstitial changes. Symptomatology. — The onset may be sudden, with a chill or a convulsion and fever; as a rule, however, it is gradual. The mother may notice that the child is unable to properly support itself on its feet; if forced attempts to walk are made the child stumbles or sinks to the floor. After a few days or sometimes within a few hours there is intense pain on handling. The child cries when approached, fearing the pain of motion. Occasionally the sensitiveness along the course of the nerve may be elicited. Paralysis now follows the muscular weak- ness and it progresses symmetrically. The child may continually moan or cry out with the pain, but does not refuse its food. Foot-drop and wrist-drop develop, and the muscular contractions may cause de- formities. Tendon reflexes are abolished altogether, or at least dimin- ished, and the reaction to the galvanic current is slow. Muscular atrophy develops, but is not marked. Diagnosis. — The history of an antecedent disease or a distinct casual factor, as alcohol, may be suggestive when pain and paralysis ensue. The association of motor and sensory symptoms or paralysis 503 504 DISEASES OF CHILDREN. along anatomical lines and the changed electrical reaction should cause no confusion. When there is lordosis present from involvement of the muscles of the back, it may be mistaken for Pott's disease, but the deformity is not angular and the position assumed will differen- tiate it. Course and Prognosis. — Cases with sudden onset in which the electrical reaction is rapidly changed and in which atrophy occurs early are not favorable for recovery. The average case begins to im- prove after the first month, recovery generally being complete in three months. The sensory symptoms clear up first, then the reflexes are obtained. In some cases the paralysis may be permanent. In- volvement of certain nerves, as the vagus, or intercurrent diseases may bring on a fatal issue. Treatment. — If the disease is due to a drug or alcohol poisoning this must be stopped at once and eliminatives given. An initial dose of calomel is always in order. The child should be placed in a comfortable attitude the limbs encased in cotton wool and lying on a down pillow. The pain should be controlled by analgesics, such as the bromids, phenacetin, or even codein if necessary for one or two doses. Rest and hot applications during the onset, and later massage and vibratory treatment as it is given in infantile spinal paralysis is effective. If the extremities are kept in a proper position while the disease is in progress, deformities are not likely to result and ortho- pedic appliances will not be necessary. Diphtheritic Paralysis. — This is a form of multiple neuritis worthy of special note. It is the most common cause in early life and affects for the most part only one region, this is the palate. We do not meet with the condition as frequently since antitoxin has come into general use. It is less likely to follow if the diphtheria has been recognized early and the child injected with the serum at once. We have, how- ever, seen a fatal issue in cases that were considered extremely benign and in which the prognosis was excellent. Children under two years of age are rarely affected. Malignant laryngeal cases are more sus- ceptible of involvement. It sometimes occurs during the active process, but usually it appears in the third or fourth week of convalescence. Symptomatology. — Inability to swallow well with regurgitation of fluids through the nose or a peculiar nasal twang in the voice may first attract attention. The eyes may next show the paralysis, and if this is more extensive the lower extremities are affected, followed by similar changes in the arms and the muscles of the trunk. Ex- amination of the throat will easily disclose a paresis of the pharynx and soft palate; it is relaxed, flabby, and does not take part in the DISEASES OF THE PERIPHERAL NERVES. 505 acts of speaking or swallowing. Closer examination of the eyes shows weakness of the ciliary muscles, the pupil reacting sluggishly and causing defective vision. When the external ocular muscles are paralyzed, strabismus results. Following the laryngeal cases the loss of voice is particularly marked and persistent, and if the paralysis occurs during the intubation period difficulty may be experienced in keeping the tube in place. Recovery is the general rule; fatal cases resulting from the involve- ment of the vagus, or from aspiration pneumonia when the epiglottis is involved. The course depends upon the extent of the paralysis and the regional involvement. The average case requires two months for recovery. The muscles of the eyes and the palate recover much more quickly than the muscles of the extremities. Weakness of the back and inability to properly support the head, with the loss of the reflexes, may persist for months. Treatment. — Rest in bed and close observation should be insisted upon when the first symptoms of paralysis appear. The manage- ment will depend upon the extent of the regional involvement. Cer- tain cases in which there is only aphonia or partial paralysis of the palate will require no special treatment, but the heart in all cases should be carefully watched and stimulation given if necessary. Strychnin nitrate has served us the best for this purpose. Where deglutition is interfered with gavage may be necessary, although care- ful feeding from the spoon in small quantities can usually be success- fully practised. The food should be as nourishing as possible, and the appetite and general health are improved by placing the patient as much as possible in the open air. Facial Paralysis. (Bell's Palsy.) Paralysis of the seventh nerve is not an infrequent affection in infants and children. Etiology. — During infancy it may occur as a result of pressure upon the nerve with the forceps or in contracted pelves from impac- tion upon the head. Caries of the petrous portion of the temporal bone accompanied with inflammatory exudates may cause paralysis by pressure on the nerve. In children over three years of age sudden exposure to cold, which in all probability induces an infection, is the commonest cause. It may also accompany or be produced by traumatism within the skull, basilar forms of meningitis, polioencephalitis, and tumors of the brain. 506 DISEASES OF CHILDREN. We frequently see this paralysis following the radical mastoid op- eration in which the nerve may be temporarily injured or destroyed, usually as a result of incompetent surgery. Symptomatology. — Inspection of the child's face will show a droop at the mouth on the affected side and the natural folds in this region almost or quite disappear, while the angle of the mouth is drawn down. The child cannot close its eye, and if attempts are made to do so the eye-ball moves upward. It can only blow out the cheek on the unaffected side. The protruded tongue deviates to the unaffected side and food particles may lodge between the cheek and gums. Speech may be affected, while attempts at whistling or laughing accen- tuate the paralysis. Prognosis. — This is good for those cases due to sudden chilling. Pressure palsies at birth may recover in whole or in part. If due to destructive disease in the petrous portion of the temporal bone or to intracranial diseases, the prog- nosis is bad. Following oper- ative procedures the prognosis depends upon the amount of traumatism the nerve has sus- tained, and many of these cases slowly recover even after complete section. Treatment. — In the mild cases recovery will take place without any treatment. The galvanic current is used in the severer cases and in those which follow operative procedures in conjunction with mas- sage and mild vibratory treatments. As the power returns the child may be encouraged to exercise the muscles by imitating grimaces ;_or blowing upon musical instruments. If a neglected otitis media is the cause, surgical procedures are indicated. Fig. 133.— Facial Paralysis. CHAPTER XXXVIII. DISEASES OF THE SPINAL CORD. Myelitis. Myelitis or inflammation of the spinal cord may be divided ac- cording to the course into an acute, a subacute, and a chronic form. Etiology. — It may result from injuries severe or even considered mild in character. It may follow the acute infectious fevers and septic processes anywhere in the body. It may extend or result from a meningitic process. It may also be caused by new growths in the spinal canal. Syphilis and Pott's disease, however, are the two causes which are most com- mon in children. Pathology. — The cord on section, in the affected areas, shows a congestion of its men- inges, while the cord itself has been changed to a soft pulpy mass. The white matter is with difficulty distinguished from the gray. Minute capillary hemor- rhages are found throughout the gray matter and the cells in the anterior horn show marked de- generative changes. The blood- vessels of the cord are dilated with proliferation of leukocytes, amalacious bodies, and degener- ated axis-cylinders. In the sub- acute or chronic forms some evidences of sclerosis may be found. Symptomatology. — In acute myelitis there is a sudden onset with a temperature which may rise to 104° F. as a result of the infective process. Painful areas may be elicited on pressure along the spine or the tenderness may be subjective. Clinical evidence will soon 507 : a—mumS** f*^L ■ ■■■■ Fig. 134. — Lumbar myelitis, showing con- tractures and deformities. 508 DISEASES OF CHILDREN. appear of functional disturbance of the cord and will vary with the intensity and localization of the process. The myelitis will affect motion and sensation and derange the functions of the bladder and rectum. Paraplegia results. Anesthesia will be present in the parts of the body supplied by the nerves which originate below the involved area. Thus there is loss of such sensory impulses as pain, touch, thermal and muscular sense. A hyperesthetic zone, due to the irrita- tion of the nerve fibers may be present above the anesthetic area. The reflexes are disturbed depending upon the area involved. Fig. 135. — Bed-sores in myelitis. Cervical lesions cause a paralysis in all four extremities. In the arms it will be flaccid in type, while in the lower extremities the palsy will be spastic in character. The whole body is anesthetic below the neck. In the dorsal region which is most commonly affected in children the upper extremities are not involved, while the lower become spastic. The patellar and plantar reflexes are increased and ankle clonus is present. Lumbar lesions produce a flaccid paraly- sis in the lower extremities which is later accompanied by some degree of atrophy. The urine dribbles away and the rectum is incontinent. The reflexes are lost and sensation is absent to a point above the lesion. Bed-sores, the result of trophic disturbances, cystitis, and infections of the urinary tract easily occur, and in fact may bring the case to a DISEASES OF THE SPINAL CORD. 509 fatal issue. Contractures and deformities may result in the extremi- ties unless measures are taken for their prevention. Diagnosis. — The etiological factor, the sudden onset, the paralysis of a flaccid type above and spastic below, accompanied with anesthesia and derangements of the bladder and rectum should make the diag- nosis easy. Prognosis. — Lesions in the cervical region are the most danger- ous to life. Myelitis in the dorsal and lumbar region may cause death from infective processes arising in the bladder, rectum, or from bed- sores. The younger the child, the more unfavorable the prognosis. Syphilitic cases, if the diagnosis is made easily, should give favorable results under specific treatment. Treatment. — Acute Stage. — Absolute rest in bed on an air mat- tress is essential. Ice bladders may be placed over the spine while the fever is active and for the relief of pain. The bowels are emptied by a brisk cathartic, and the bladder relieved by an attendant accus- tomed to surgical cleanliness. In syphilitic cases the mercurials with the iodids are given. If there is intolerance to these, the mercury may be given by inunction. If a specific infectious process can be dem- onstrated, such as streptococci, and isolated from the patient's own blood, treatment by vaccines may be tried. Bed-sores must be guarded against by scrupulous cleanliness, frequent change of position, and the daily application of alcohol or astringents. If they do develop they should be thoroughly cleansed and treated with stimulating antisep- tics, such as silver nitrate. After the subsidence of the acute symptoms, skilled massage may be employed in conjunction with warm tonic baths. Arrange- ments should be made so that the child can be taken out of doors on a roller bed or chair so that its nutrition may be preserved and its de- sire for food stimulated. Multiple Sclerosis. {Disseminated Sclerosis.) The disease may have its inception in, or it may be associated with any of the acute infectious diseases. Pathology. — Throughout the central nervous system patches of sclerosis are found. They may be more frequent in one area than in another, invading the brain, the pons, the medulla, the lateral and the posterior columns of the spinal cord, or even the spinal roots may be affected. Closer examination shows that the myelin sheaths 510 DISEASES OF CHILDREN. of the nerve fibers are destroyed, although the axis-cylinders in the sclerotic areas do not suffer. Symptomatology. — At first there may be weakness of the upper and lower extremities accompanied with some trembling of the hands and the development of a spastic gait. This is followed by an inten- tion tremor which is quite characteristic of this disease, and which is accentuated by voluntary action on the part of the patient. It disappears when the extremity is at rest. Later in the disease the tremor may be so intense as to prevent the ordinary activities, as dressing or eating, etc. A speech defect now appears; it is slow, de- liberate, careful, with a tremulous character. It is spoken of as scan- ning speech. Nystagmus or oscillation of the eye-ball appears at this time and is especially marked when lateral movements are attempted. The pupils usually are contracted and reaction of accommodation to light is sluggish. The mental faculties become impaired, memory particularly is poor, and sudden emotional changes occur on the least provocation. The expression of the face becomes dull and stupid. A spastic form of paralysis, not very apparent at first, later becomes well-marked, producing a spastic gait. As the disease advances the tremor becomes so intense that walking is impossible, and finally the patient is bed-ridden. After a long and tedious course the disease finally ends fatally, the patient dying of some intercurrent disease. Treatment. — All that can be done for this incurable disease is to regulate the life of the patient so that an unusual amount of rest is secured and the muscles kept in good condition by baths, massage, vibratory treatment, and the galvanic current. Drugs do not in- fluence the disease, and if given at all they should be prescribed for symptoms as they arise. Hereditary Ataxia. {Friedreich' 's Ataxia.) This is a disease occurring in the members of the same family and characterized by an ataxia with a slow but progressive course. Etiology. — The disease is hereditary in character, passing often through several generations. The males or the females of a family inherit the disease. The spinal symptoms in some cases predominate, and in others the cerebellar are more in evidence. The spinal form occurs in the ages of four to seven, while the cerebellar form is rarely seen before the twentieth year. Pathology. — The changes found are in the posterior roots. There is sclerosis of the posterior columns. The spinal cord as a whole is DISEASES OF THE SPINAL CORD. 511 smaller than normal. In some cases the lateral tracts and the columns of Clark are atrophic, especially in the type known as the cerebellar, in which there is a marked diminution in the size of the cerebellum and degeneration of its nerve tracts. Symptomatology. — The gait is the first symptom to attract attention. The walk is swaying in character with the legs held apart (sailor fashion) , even while sitting and standing the patient cannot control his position ac- curately. Athetoid movements or tremors are present, especially in the extremities. Hyperex- tension of the great toe may be an early symptom and later de- formities, as pes equinus, may develop. Romberg's symptom is obtained in the spinal cases, but is more strongly marked in the cerebellar type. The patellar reflex is variable and inconstant, and cannot be depended upon for much diagnostic aid. The cutaneous reflexes also remain quite normal. Atrophy of mus- cle after a time occurs and pro- duces such deformities as scoli- osis and thus destroys the normal spinal curves. Nystagmus is a quite constant symptom. The pupils are normal, but other ocular disturbances, as ptosis and strabismus, occur. Optic atrophy is not rarely found in the later stages. Dysarthria is commonly present. Sensation is unimpaired. The sphincters do not suffer. As the disease progresses signs of failing intellect are observed; these may be preceded by dizziness or hysterical phenomena. Differential Diagnosis. — Tabes dorsalis may be differentiated by the absence of lightning pains and sphincteric changes, and again the Fig. 136. -Hereditary ataxia (Friedrich'i disease). (Sachs.) 512 DISEASES OF CHILDREN. ataxic gait is rarely seen in infantile tabes, while the pupillary changes are frequent. New growths of the cerebellum might simulate a begin- ning ataxia, but the course is more rapid and there is headache and vomiting. Course and Prognosis. — The disease is extremely slow in its progress. Eventually, after years, the patient is bed-ridden after the musculature is invaded. Death occurs from some intercurrent malady. The prognosis is invariably bad. Treatment. — A nutritious diet, massage, hydrotherapy, and the best possible hygienic surroundings are our only recourse. Medicinal treatment is symptomatic only. Iron is necessary for the anemia. Primary Myopathy. (Muscular Dystrophy; Idiopathic Muscular Atrophy.) For the purposes of clearness and to prevent the confusion which must arise in the mind of the reader attempting to gain information on this topic, we will embrace all the various described types under this one general title of the myopathies. Clinically, these types have been separated on a basis of age, as the juvenile (Erb type) and the infantile type; on an anatomical basis, for example, the facio-scapulo-humeral type (Landouzy-Dejernie); and still another type is based on the distal involvement, i.e., those in which the proximal parts of the body remain intact for many years and only the distal parts are affected; finally on an objective basis, in which there is enlargement or apparent hypertrophy of portions of the body (pseudohypertrophic muscular paralysis of Duchenne). Pathological classification offers no relief at present from the ap- parent confusion, as the study of muscle components and muscle embryology has not as yet advanced sufficiently to warrant such a classification. Etiology. — Gowers suggests that the myopathies are due to an inherent defective vital endurance. Collins says they are an expres- sion of prenatal inadequate endowment. Maternal heredity seems to have a distinct place, while paternal heredity because of the early impotency of the diseased father is to be disregarded. Several members of one family may be attacked. The affection usually begins about the sixth to the eleventh years of life. Although cases have been reported occurring at birth, and as late as the thirties. Boys are more frequently seen with the disease than girls. A history of trauma is often given as a cause by the parents, but may be disre- garded in a disease of this causation. The acute exanthemata, espe- DISEASES OF THE SPINAL CORD. 513 cially scarlet fever, may so lower the resistance that the disease is more readily ushered in. Pathology. — Various anatomical changes have been found, but the reports are various and confusing. The nervous system does not seem to be involved insofar as modern technic can discover in the normal case. Gowers rejects the theory that the disease may be a Fig. 137. — Position assumed by myopathic patient climbing up stairs (Collins.) trophoneurosis. The cells in the dorsal ganglia have been found shrunken by Brooks and others. The muscles themselves show the true pathological changes. Atrophy and hypertrophy of muscle fibers may be seen in the same specimen. Fatty deposits and connec- tive-tissue increase are likewise found. In some cases (the pseudo- hypertrophic type) the adipose tissue is in excess, while in others (the so-called sclerotic type) the connective-tissue elements predominate. In the latter form the muscles become firm and thin and later simply 33 514 DISEASES OF CHILDREN. degenerate into fibrous bands. The lipomatous type is never hard, but soft and flabby. Symptomatology. — The first symptom noticed may be a weakness in walking or clumsiness in going up or down stairs; later the child stumbles or falls on slight provocation. These symptoms come on very gradually, so that they are often considered negligible in the Fig. 138. — Position taken by the myopathic when rising from the floor. (Collins.) dispensary patients, especially as they seem to be physically in very good condition. The calves may seem to the laity to be unusually well developed. When the disease is more advanced the gait be- comes waddling, the legs are not lifted much from the ground. If a test is now made a very characteristic attitude will be assumed, namely that of " climbing up on himself;" especially if the patient attempts to pick an object from the floor. If placed on his back on the floor, the patient is obliged slowly to turn face downward, get on his knees DISEASES OF THE SPINAL CORD. 515 with the aid of his arms, then raising his knees he forms an arch and now by grasping his knees he works his hands higher and higher up the thighs until he can assume the erect posture. In advanced cases even this is impossible and the child is finally bed-ridden. The knee and ankle reflex are diminished, and in terminal stages entirely absent. Fig. 139. — Myopathic boy in early stages, showing winged scapulae and lordosis. (Collins.) Fig. 140. — Myopathy (hyper- trophic) four years duration. (Collins.) The posture is also quite characteristic. Lordosis is sometimes seen quite early, and at this time it disappears if the child is asked to sit down. As the disease advances, the lordosis is more marked, the head and pelvis is held well back and no change is observed in the sitting position. The face loses its original expression, becoming dull and mask-like. When the disease is well advanced even closure 516 DISEASES OF CHILDREN. of the eye-lids is accomplished with difficulty and articulation is im- perfect. All these changes are due to atrophy of the facial muscles in some degree. The lower extremities, while mainly involved, are not alone affected. After several years the shoulder group muscles begin to lose their power, the patient is unable to raise his arms and flex his el- bows, but they still are able to perform the finer movements of the hand. The supraspinatus muscle Gowers describes as being almost the last to become affected. The atrophic muscles allow the shoulder blades to recede from the thorax, forming the winged scapulae so often observed in the myopathies. Electrical Examination. — Reaction of degeneration is not obtained. There is, however, lessened excitability to both currents. Complications. — Fractures, contractures, and deformities may oc- cur in these cases. The fractures are due to the stumbling or awk- wardness of the patient. Various theories have been advanced by neurologists for the contractures, but suffice it to say, that they are of all possible varieties that are reducible and subject to relapse. Collins and Climenko give the following order in which the mus- cles are involved: Dense, Thickened Muscles. — calves, sartorius, glutei, triceps, del- toids, infraspinati. Atrophy. — Pectoralis major, trapezius, serratus magnus (anterior portion), latissimus dorsi, biceps, quadriceps femoris, abductors. Differential Diagnosis. — The characteristic features are the disproportionately enlarged calves, the peculiar facies, the gait, the lordosis and the peculiar attitude assumed when arising from the prone position. Atypical cases are often puzzling and must be differ- entiated from anterior poliomyelitis in which there is a regular corre- sponding distribution of the affected muscles to the portion of cord involved, while in dystrophy this is not so. In chronic progressive anterior poliomyelitis, there is, besides the regular muscle grouping, the reaction of degeneration and the absence of pseudohypertrophy. In syringomyelia the early involvement of the finger muscles serves as a guide, for in the dystrophies these often remain unaffected to the last. Progressive muscular atrophy may be confusing, but the age, the origin in the digital muscles and the fibrillary twite hings which are present will distinguish the disease. Treatment. — These cases, unfortunately, are not amenable to cure. Much can be done, however, by obtaining complete control of the pa- tient's daily life. Directions should be given to supply a liberal nutri- tious diet. Exercises should be carefully carried out, especially valuable being those of the resistant form, the physician or a trained DISEASES OF THE SPINAL CORD. 517 assistant should by example teach the child the various movements. Electricity will assist the gymnastic movements if the faradic current is used. Massage will keep up to some extent the muscle nutrition, The orthopedist must be consulted and deformities corrected in their incipiency. CHAPTER XXXIX. DISEASES OF THE BRAIN. Meningitis. Pachymeningitis, an inflammation involving the dura mater, is rare in early life. It may occur in connection with injuries of the skull or ear disease, and, in acute cases, usually affects only the external portion of the dura. A more chronic form is seen in connection with hemorrhages on the vertex, when the pia as well as the internal surface of the dura are involved in the inflammation. Such hemorrhages are liable to occur in feeble infants suffering from some exhausting disease. This low grade of meningitis is more apt to be discovered at autopsy than during life. Acute leptomeningitis, or inflammation of the pia, has already been described in its two most common forms — acute cerebro- spinal meningitis and tuberculous meningitis. There is, in addition, a form that may be different in its causative factors from these two varieties, although there is a certain similarity in symptoms. Etiology. — Instead of the diplococcus intracellularis or tubercle bacillus acting as a cause, we may have a number of microbes, seen in connection with injuries of the skull, ear disease, or various infectious diseases, producing inflammation of the pia. In these cases it is more distinctly a secondary disease. Any traumatism of the skull from falls or blows, suppuration after cranial operations, disease of the middle or internal ear or mastoids, can afford access to the various forms of streptococci or staphylococci that may attack the pia. It may also be affected by the pneumococcus, the typhoid bacillus, the influenza bacillus and rarely by the Klebs-Loeffler bacillus and the gonococcus. A meningitis may thus be seen in connection with pneu- monia, typhoid fever, influenza, scarlet fever, diphtheria, and as a terminal infection in almost any chronic infectious disease. Symptomatology. — The symptoms of all varieties of meningitis are generally alike, although differing somewhat in the course, rapidity and sequence of the various manifestations. As a secondary condition the symptoms are apt to be masked at first by the course of the original disease. The occurrence of projectile vomiting, convulsions, irregular respiration and pulse, stupor, or coma will call for a diagnosis of men- 518 DISEASES OF THE BRAIN. 519 ingitis during the original infection. The symptoms will vary according to the part of the brain involved. Where the inflammation involves principally the convexity, as may be seen in pneumonia or malignant endocarditis, there may be no symptoms besides the stupor to dis- tinguish it from the original infection. Where the inflammation is at the base of the brain, the cranial nerves are apt to become involved and there will be various paralyses and some retraction of the head. Where the inflammation extends from the middle ear or mastoid, meningitis at the beginning will be unilateral and may continue so during the course of the disease, and facial paralysis may ensue on the affected side in addition to the other symptoms. The meninges over the first and second temporal convolutions are apt to be especially involved in the ear cases. In all varieties, when the meningitis is well under way there will be hyperesthesia of the skin, and there may be local or general convulsions, photophobia, stupor or coma, and irregularities of the pulse and respiration. The temperature is irregular and is influenced by the primary disease. The duration of secondary meningitis is usually short, from a few days to a week, and the prognosis is bad. We have, however, seen a few cases recover where the original dis- ease was controlled and the meningitis apparently not extensive. Diagnosis.— Lumbar puncture will aid in differentiating the various forms of meningitis by a discovery of the causative microbe in the fluid withdrawn. On the clinical side, the secondary nature of the meningitis will be shown by its onset during the course of some general infectious disease or when there is a recognized lesion in the ear that is probably being treated. Acute cerebrospinal meningitis is sudden in its onset, without any previous disease, and as the lesion is apt to involve all the surface of the brain as well as the cord, the symptoms are general and severe from the first. Tuberculous meningi- tis is very slow and irregular in its onset, sometimes taking as long as several weeks to attain its maximum intensity, and the brunt of the lesion is usually at the base of the brain. Treatment. — The principal effort must be directed toward a free drainage of any localized suppuration in the ear or skull that may be causing the infection. We have seen cases of sinus thrombosis induc- ing meningitis, both relieved by surgical measures. The general man- agement is the same as in other forms of meningitis. The bowels must be freely opened and bromids given to relieve pain. An ice-bag may be intermittently applied to the head, and, if there is much evi- dence of intracranial pressure, lumbar puncture may be employed. Small doses of iodid of potash may also be tried. The nourishment must consist of milk, meat broths, or similar easily assimilable foods. 520 DISEASES OF CHILDREN. Acute Encephalitis. This is an inflammation of the brain tissue usually occurring in connection with meningitis from an extension inward of the inflam- matory process. The symptoms are largely the same as those caused by inflammation of the pia. They will vary, however, as to whether the convexity or base of the brain is the principal seat of the disease. In the former case there will be convulsions, paralyses, and coma, and in the latter, cranial nerve paralyses will form the dominant symptoms. Strumpell describes a hemorrhagic encephalitis occurring in connection with influenza or other infectious disease. It may then be seen without a coexisting meningitis. There is severe pain in the head followed by stupor and eventually by coma. In other cases there will be great rest- lessness, alternating with drowsiness. There is apt to be rigidity of the neck; in some cases there may be loss of power in an arm or leg, and in others hemiplegia may ensue. Fever is present and the pulse and respiration are irregular. In mild cases, recovery may occur after one or two remissions, but, in the severer types death usually takes place in coma after an interval of from one to three weeks. The treat- ment is the same as in meningitis. Abscess of the Brain. Cerebral abscess, single or multiple, may occur in early life. The white matter is more apt to undergo suppuration than the gray matter, and hence abscesses form more frequently within than on the surface of the brain. The temporosphenoidal lobes, the frontal lobes, and the cerebellum are most frequently attacked. Etiology. — Boys are more often affected than girls, and the most frequent cause is ear disease, especially if there is a secondary involve- ment of the petrous portion of the temporal bpne, when the abscess is usually located in the temporosphenoidal lobes or occasionally in the cerebellum. Injuries of the skull due to trauma and sinus thrombosis occurring in connection with such injuries or with ear disease may cause abscess. Infective processes within the nose may spread to the brain and induce an abscess, and rarely septic em- boli from pus formations in distant parts of the body may be carried to the brain and produce a similar effect. Symptomatology. — As the abscesses -do not commonly form in the motor area of the brain, the objective symptoms are often very ob- scure. If, however, the abscess does form or spread into a motor area we will have localized symptoms, the same as seen in the pressure effects from tumors or hemorrhage. The early symptoms are much DISEASES OF THE BRAIN. 521 the same as those of meningitis. There is vomiting, pain in the head, fever, and occasionally localized or unilateral convulsions. The fever is irregular in type and may be accompanied by chills. If these symp- toms ensue in connection with acute or chronic disease of the ear, traumatism of the cranial bones, or more distant foci of suppuration that may give off septic emboli, we may suspect cerebral abscess. In case the abscess becomes encapsulated, there may be no symptoms at all, in this respect differing from the disturbing effects of solid tumors. Optic neuritis is occasionally present. Where the abscess is located at the base of the brain, the different cranial nerves may become af- fected. If the speech centers are involved in the abscess, aphasia may be noted. In some cases the pus may rupture into the ventricles, thereby producing serious and urgent symptoms. Diagnosis. — It is often impossible to differentiate abscess from meningitis, encephalitis, or tumors of the brain. If, in connection with the symptoms of brain disturbance seen in common with the latter conditions, there is a high, irregular fever with chills, and if ear disease or trauma of the skull exists, we may strongly suspect the formation of an abscess. A differential blood count and lumbar puncture may aid in establishing the diagnosis. Prognosis. — The prognosis is bad, but if the abscess can be located and treated surgically, recovery occasionally takes place. Treatment. — Any suppurating area involving the ear or bones of the skull must be carefully watched and thorough drainage maintained. If the symptoms point to internal abscess the surgeon must trephine and endeavor to open and drain the abscess. The first and second temporal convolutions are most often the seat of abscess following ear disease. The deeper-seated abscesses may be located by inserting a needle into the part of the brain suspected. Brain Tumors. Tuberculous tumors predominate, consisting usually of a caseous tumor of the cerebellum. Gliomata, sarcomata, and cysts occur usu- ally in the cerebellum and pons. Males are more prone than females. Infants under six months very rarely have brain tumors. Tubercu- lous and sarcomatous growths are secondary to growths elsewhere in the body. Symptomatology. — These are produced by pressure, irritation, exudation, or interference with the blood supply and vary also with the location involved. Headache. — This is persistent and boring in character, causing ")22 DISEASES OF CHILDREN. restlessness, insomnia, rolling of the head, cephalic cry, and photopho- bia. Occasionally the pain is well localized at the site of the tumor. Nausea and Vomiting. — This is persistent and without causal re- lation to food. It is projectile in character. Vertigo or dizziness are common symptoms, elicited by change of position. The gait may be reeling. Ocular symptoms are particularly helpful — optic neuritis in one or both eyes is usually present, and especially so when the cerebellum is affected. Optic atrophy may follow and is seen early if the chiasm is involved. Convulsions occur when the cortex and motor areas are involved. They are general or local in character. Tumors which have not as yet invaded the cortex produce paralysis and later convulsions. Localization. — Special symptoms will be caused by involvement of areas with known functions, and are not different from those mani- fested in adults. They will not be enumerated here. Diagnosis. — From abscess of the brain, tumors may sometimes be distinguished by the absence of local causes, lack of temperature, and the slower course. Septic symptoms, if present, are indicative of abscess, and are confirmed by blood examination. MacEwen's sign may be of help if other confirmatory signs are obtained. Tuberculous tumors occur generally in the cerebellum, and there may be evidences of tuberculous infection elsewhere in the body. Lumbar puncture should always be performed if any doubt remains. Treatment. — Operative procedures are carried out with great risk in early life even when the conditions for removal of the growth are favorable, but often this is the only hope for relief or cure. Medi- cal treatment should be directed to the relief of urgent symptoms and in the syphilitic cases specific medication should not be delayed. Infantile Cerebral Palsies. (Spastic Diplegia; Paraplegia or Hemiplegia.) There may be a paralysis of various parts of the body due to congenital defects, birth injuries, or hemorrhages in the brain in later infancy or early childhood. Etiology and Pathology. — We may divide the causes into those operating before birth, during birth, and some time after birth. During intrauterine life the growth of the brain may be arrested by hemorrhage, by lack of cortical development, or by cysts. A condition known as porencephaly may sometimes be present. The exact cause of these accidents or defects is difficult to ascertain or explain. They have DISEASES OF THE BRAIN. 523 been referred to accidents during pregnancy, such as falls or blows on the abdomen, to uremic convulsions, to severe illness in such forms as pneumonia and typhoid fever, and to sudden shocks in women with a neurotic hereditary tendency. The causes operating during birth are due to prolonged pressure on the fetal head in tedious labors or to the unskillful use of the forceps, as already noted in the chapter on Birth Injuries. The hemorrhage is nearly always on the cortex, and may be followed by meningoencephalitis, sclerosis, the formation of cysts, or by atrophy of the underlying tissue. In later months or years, cerebral palsy may follow a severe convulsion or a prolonged paroxysm of whooping-cough, and occasionally certain infectious diseases, such as scarlet fever, small-pox, measles, and typhoid fever, may be responsible for the condition. Direct injury to the skull may also act as a cause. The rupture of cerebral vessels usually takes place on or near the cortex instead of in the lenticular nucleus as in adults. This has been explained by the delicate, fragile structure of the small blood-vessels on the surface of the brain. Thrombosis and embolism may act as a cause of cerebral palsy in children, but not so frequently as in later years. Rheumatism, valvular disease, or pneumonia favor embolism, while any exhausting condition may lead to thrombosis. Various changes occasionally take place in the brain following a hemorrhage. Chronic meningitis, sclerosis, softening, or atrophy, with various degrees of secondary degeneration and cysts, may be mentioned in this connection. The following tabular classification of infantile palsies is taken from Sachs and gives an admirable com- pendium of the subject: Groups. Morbid Lesions. { Large cerebral defects (porencephaly). , T3 , *•*■*-■ + J Defective development of pyramidal tracts. 1. Paralyses of intrauterine onset.. j Agenesig cortic £ lis (hi gf est nerve ele- ( ments involved). [ Meningeal hemorrhage, rarely intracerebral 2. Birth palsies J hemorrhage. Later conditions: Meningo- 1 encephalitis chronica, sclerosis, and cysts; [ partial atrophies. f Hemorrhage (meningeal, and rarely intra- cerebral); thrombosis (from syphilitic endarteritis and in marantic conditions); | embolism. Later conditions: Atrophy, 3. Acute palsies (acquired) \ cysts, and sclerosis (diffuse and lobar). | Meningitis chronica. | Hydrocephalus (seldom the sole cause). Primary encephalitis; polioencephalitis [ acute (Strumpell). 524 DISEASES OF CHILDREN. Symptomatology. — The form and character of the paralysis depend on the extent and situation of the lesion. A double brain lesion is apt to occur early, either before or during birth. Diplegia or paraplegia may thus result. Hemiplegia is occasionally seen, although not so often, in this early paralysis, and monoplegia is rarely, if ever, encountered at this time. The loss of power is not apt to be complete, and the affected muscles are usually in a spastic condition. Very rarely the muscles may be flaccid. Contractures early take place and give rise to various de- formities. The groups of muscles most markedly affected by these contractures are the flexors of the legs and feet and the flexors and pronators of the arms. There is usually a marked exaggeration of the tendon reflexes. Later on there may be athetoid and occasionally choreiform movements in the palsied muscles. Sooner or later other evi- dences of cerebral defect, besides the paralysis, are apt to manifest them- selves. Epilepsy is perhaps the most common of these disturbances. Many cases of epilepsy that are seen in later life have had their origin in some hemorrhage or defect that originally produced a palsy in which recovery may have largely taken place. Another unfortunate sequel in these cases is idiocy of a mild or severe grade. The latter type is more apt to follow the widespread palsies produced by double brain lesions, and shown by diplegia or paraplegia. In cerebral palsy occurring after birth, the onset is usually sudden and the form hemiplegic. It is rare to have both sides of the brain involved, as so often occurs before or during birth. In hemorrhage on the cortex, there is excitation as well as loss of function, and hence convulsions are usually present at the beginning. In later life, when the hemorrhage is usually in the lenticular nucleus, there is loss of function, but little or no excitation. Aphasia will be noted in older Fig. 141. — Spastic paraplegia crossed-leg progression. DISEASES OF THE BRAIN, 525 children if the speech centers are involved. The paralysis is usually not complete and may be followed by contractures and athetoid movements. While there is not the marked and rapid atrophy seen in spinal affections, there is usually a failure of proper development in the palsied muscles. There is likewise no reaction of regeneration as in spinal paralysis. Considerable recovery of function often takes place, and in some cases the prin- cipal disturbance will finally be shown by athetoid or choreic movements rather than by paraly- sis. Fortunately, mental impair- ment and epilepsy do not so fre- quently follow as in the birth palsies. We may say, in general, that these acute cerebral palsies occur only in early childhood, usually under five years. Diagnosis. — We may try and distinguish the prenatal and birth palsies from those occurring later by the history of the case and the extent of the paralysis, the diple- gias and paraplegias being nearly always of the early class. The cerebral is distinguished from spinal palsy by its incomplete form, the absence of rapid atrophy, by the spastic muscles, contractures or athetosis, exaggerated reflexes, and normal electrical reactions. Treatment. — The greatest Fl( efforts must be directed toward prevention. The expectant mother must lead a quiet, healthy life during pregnancy, avoiding undue excitement and exposures that may lead to accident. The labor must not be unduly prolonged nor the fetal head allowed to undergo pressure for too great a time in the maternal passages. The forceps may be required to prevent this, but they must be applied with care, as extreme pressure from this source may likewise provoke a hemorrhage. After labor, if there is any evidence of cerebral injury, extra care must be taken to keep the infant very quiet. If it cannot suckle, the mother's milk may be carefully given by a medicine dropper. Where there are twitchings or :g. 142. — Hydrocephalus, with spastic paraplegia, mentality normal. 526 DISEASES OF CHILDREN. convulsions, small doses of bromid of sodium (2 to 3 grains) may be given every few hours. In the later cases of cerebral apoplexy, cold may be applied to the head, and a free movement of the bowels induced. Small doses of the bromid of sodium may likewise be given, and later on this may be combined with the iodid of potash. Massage and electricity may be used in trying to overcome contractures, but in old cases orthopedic appliances are usually required to overcome the various deformities. The services of the surgeon in cutting tendons and thus relieving tension and deformity are likewise often required. Hydrocephalus. Hydrocephalus is an enlargement of the skull due to fluid within the ventricles or in the subdural spaces. Several classifications have been made of this condition. We are inclined to accept the etiological as offering the greatest help to the student. 1. Congenital hydrocephalus ( Internal— usual, ventricular. \ External — rare, subdural. f Acute — inflammatory diseases of the men- inges. 2. Acquired hydrocephalus \ Chronic — result of inflammation of the external or internal coverings of [ the brain. Congenital External Hydrocephalus. — Very few cases of congenital external hydrocephalus have been reported. The condition seems to result from an intrauterine meningitis or from congenital maldevelop- ment of the brain. Congenital Internal Hydrocephalus. — As a result of intrauterine disease, there is an abnormal exudation of fluid which either, appear- ing early, arrests the development of the brain, or, appearing later, causes its atrophy. Etiology. — Parental alcoholism, tuberculosis, syphilis, and neurotic diseases have a distinct influence in its causation. Symptomatology. — The fluid within the cranium which may be as much as 5,000 c.c. does not allow normal ossification to take place; hence the tremendous enlargement of the vault; the sutures are widely separated, and the enormously large fontanels may bulge. The bones themselves are thin plates covered with a tense skin, and the superficial veins are prominent. The overhanging forehead and the pressure within causes dislocation of the eyes, so that only small por- tions of the pupils are seen; the face appears abnormally small and is DISEASES OF THE BRAIN. 527 usually emaciated. The expression is dull and staring, strabismus, nystagmus, lack of accommodation of the pupils and even atrophy of the optic nerve may be present. The child is pale, wasted, has a pur- poseless cry, and does not, as a rule, thrive even on a well-regulated diet. The extremities may be held in a characteristic position, that is, the arms are flexed and the hands clinched. The infants do not show any interest in their surroundings, may not recognize their parents, nor care for toys. Convulsions may occur from time to time. In older children pressure over the motor areas due to the fluid produces Fig. 143. — Congenital internal hydrocephalus. spasticity, rigidity or paralysis. Walking is delayed because of im- proper musculature, lack of intelligence and a tendency to the spastic gait. The patellar reflexes are increased. Children who have a con- siderable amount of fluid are unable to support the head, on account of muscular weakness and the weight. A peculiar so-called hydroceph- alic cry is occasionally heard in these cases. In some cases the en- largement of the head may increase gradually or suddenly with cere- bral symptoms after a period of quiescence. Diagnosis. — In well-marked cases it is simple. The relation of the circumference of the head to the chest and the delayed men- tality should arouse suspicion. The fluid contains a trace of albumin and sugar. The large head in rickets is square, and other evidences of the disease are found in the osseous system. 528 DISEASES OF CHILDREN. Prognosis. — This is directly dependent upon the amount and increase of cranial enlargement as indicated by measurements. As a rule, these children, especially the congenital types, succumb to inter- current diseases, dying soon after birth or .in early childhood. Those cases in which the intellect is not greatly altered may be fairly bright, but their deformity and peculiar gait necessitates special school facilities. A certain number live to be bright and useful members of society. Treatment. — Medicinal treat- ment is of little avail. Those with a syphilitic history should be given the benefit of the mercury and iodids. Surgical treatment of all sorts has been advised and soon abandoned, because of the poor results obtained. Pressure ban- dages, puncture of the ventricle, injections and insufflations into the ventricles, permanent drainage from the ventricles into the sub- dural space are among the various means which have been tried at the Post-Graduate Hospital, and each has been disappointing. Lumbar puncture, or aspiration of the ventricles for the relief of pressure symptoms, is the only procedure which temporarily gives good results. Fig. 144. — Acquired hydrocephalus. Microcephalus. By microcephalus we understand that condition in which there is arrested or defective development of the brain with a correspond- ingly small cranial cavity. Microcephalus probably originates during fetal life or soon after birth. The fontanels are closed and premature ossification of all the sutures takes place. The vertex is, as a rule, dome-shaped, al- though it may be asymmetrical with a sharply receding forehead. When the conditon begins later in infancy, it is considered to be the result of minute hemorrhages into the cortex arising from a meningeal disease or an eclamptic seizure. DISEASES OF THE BRAIN. 529 The diagnosis of this form of idiocy is made upon the abnormality of the head. The measurements are taken of the head, chest, and length of the infant, and the relations compared to those of the normal infant of corresponding age (see chapter on Development). The symptoms do not differ from those of idiocy or imbecility, as described on page 530. The operative treat- ment of craniotomy which was formerly advanced for these cases we have entirely abandoned as giving no results. Idiocy, Imbecility, Feeble- mindedness. Idiocy may be divided into three groups: the prenatal, the acquired, and the myxedematous. In each of these the undeveloped intellect has been more or less permanently impaired. Minor degrees of idiocy are designated as imbecility or feeble-minded- ness. The mental impairment being dependent upon the extent of the cerebral lesion. Etiology. — The children of in- sane parents or of those who have been the victims of alcoholism, epilepsy, hysteria, chorea, or syphilis may be born idiotic. Consanguineous marriages, especially among those who have suffered from some neurotic disease, may produce idiotic children. The acquired types are generally the result of injuries received at the time of birth and from convulsions, both of which result in the rupture of delicate blood-vessels, with later sclerotic changes. This latter change may also take place after attacks of inflammation of the brain or its meninges. The relation of idiocy to hydrocephalus and epilepsy has been considered elsewhere. Symptomatology. — From the physical standpoint an idiot may resemble a normal child. He radically differs, however, in his powers of cerebration. He is unable to acquire any conceptions and he has no sense of fear. As a rule, the diagnosis can be made by observation alone. The expression is vacant and the eyes are continually roving 34 Fig. 145. -Microcephalus, hare-lip. with double 530 DISEASES OF CHILDREN. from place to place. In younger children saliva dribbles over the chin. The teeth may be irregularly erupted and usually are sharp and carious. Other stigmata of degeneration may be seen. The child cannot distinguish its parents, it has no acquired speech, but makes unintelligible animal sounds, it becomes irritated or laughs without provocation, and when awake keeps in constant motion. Fig. 146. -Imbecile with marked strabismus. Fig. 147. — Idiocy, with blindness. There are no habits of cleanliness. Food is eaten ravenously and not selected with any relation to taste or desire. Imbeciles and feeble-minded children differ from idiots in that they may be able to recognize their parents and appreciate some simple objects, as toys. A few words may be learned and habits of personal cleanliness may after a time be acquired. Prognosis. — The prognosis for the idiotic child is invariably bad. DISEASES OF THE BRAIN. 531 The feeble-minded are capable of some degree of development when placed under special tuition. Treatment. — The parents of idiots should be advised that an institution is the proper place for their afflicted child, especially if there are other children in the family. Here he will be unmolested and allowed more freedom than is possible when in his home. Fig. 148.— Idiocy. Feeble-minded children, if the circumstances permit, may be placed in institutions arranged for the care and training of mental defectives, where under almost private tutelage they may be trained along the lines in which they show any aptitude. In some of our States such institutions have been provided for these unfortunates, so that even the children of the poor may receive this beneficial training. Mongolian Idiocy. This form of idiocy because of several simulating features is often mistaken for cretinism. The resemblance to cretinism is seen 532 DISEASES OF CHILDREN. in their stunted development, in the large and often protruded tongue, the thickened lips, and open mouth. A Mongolian idiot, however, may. even in infancy be distinguished by the peculiar expression of the face, which when analyzed is seen to result from slanting eyelids like those seen in the Mongolian race. Although the eyes converge, they are relatively further apart than in the normal, the nose is small and flat and the contour of the head is distinctly rounded. The skin in the early months is not harsh and dry, it may be soft and velvety. A rather characteristic feature is seen in the flabby muscles and Fig. 149. — Mongolian idiocy mobility of the joints, which allow the thighs, for example, to be flexed with extraordinary ease upon the body. The head is not held erect until the age is well advanced, the fontanels remain open late and the nutrition is impoverished in spite of good feeding. The bones of the hands and wrists show deviations from the normal which are best seen in a radiograph, although the incurvation of the little finger and the short second phalanx is often easily discernible. The mongoloid idiots further differ from the cretins in that they are not influenced by thyroid therapy, and if they pass through the period of infancy they may show some degree of intelligence. DISEASES OF THE BRAIN. 533 Amaurotic Family Idiocy. This is a disease occurring in Hebrew families and dependent upon arrested cerebral development and characterized by blindness and changes in the region of the macula lutea. Tay, an oculist, first described the ocular symptoms, while Sachs, in this country, further elaborated the clinical and pathological picture. Etiology. — The causes of this disease are still undetermined. More than one case may occur in the same family, and all the cases thus far observed have been among Hebrews. Fig. 150.— Amaurotic family idiocy. (Sheffield.) Symptomatology. — The 'first symptoms appear about the sixth month. Up to this time the child may have been considered healthy and robust. The first symptoms noted are that the child makes no effort to hold up its head, moves its limbs only slightly, and takes no interest in those about him. If some degree of nystagmus is present the fact that the child is blind escapes the attention of the parents or even of the physician. If seated the head falls back and the lower extremities give evidences of complete paralysis. Later in the disease spasticity occurs in these extremities with increase of the reflexes. As the disease advances the weakness becomes intensified, and usually after the first year there is total blindness and evidences 534 DISEASES OF CHILDREN. appear of mental deficiency. Strabismus is occasionally observed and is usually associated with the nystagmus. Convulsions are rare. The hearing may be abnormally acute, the infant being startled from its apathy, for example, by clapping the hands. Ophthalmoscopic examination fixes the diagnosis when Tay-Kingdon's 6herry-red spots on a white background is found in the region of the macula lutea. Subsequently, optic nerve atrophy results. Before the fatal ending emaciation and other subjective and objective symptoms of marasmus appear. The prognosis is invariably bad, the children rarely living beyond the second year. Treatment. — Beyond giving the prognosis as to the duration of life we are powerless to give aid in this disease. SECTION XIV. CONGENITAL MALFORMATIONS AND DEFORMITIES. CHAPTER XL. CONGENITAL MALFORMATIONS AND DEFORMITIES. A careful examination should always be made of the newly-born child. Any deviation from the normal condition may be due to pre- natal malformations, as well as to injuries received during the process of birth. Tongue-Tie. A short frenum causes this deformity. The tip of the tongue is depressed and fixed in the floor of the mouth so that often it cannot be protruded. Sucking and articulation are difficult, and when allowed to persist there is often a lisp in the speech. The treatment is surgical, and consists in dividing the frenum with blunt scissors and stripping back the divided tissue with the finger-nail. Parents often attribute backwardness in talking to a possible tongue-tie. Mental defects or deafness may instead be found as the real cause if the child is much beyond the age when it showed be talking. Harelip. When the central process fails to fuse with the lateral processes which go to make up the upper half of the face in fetal life, a condition known as harelip results. This may be unilateral or bilateral, the fissure varying in extent from a slight cleft to a fissure extending through the entire length of the lip into the nasal fossa. The treatment is surgical, and should be undertaken as soon as possible after the child is well started in its feeding— three months of age being the time selected by the majority of surgeons. Nursing is sometimes impossible, but the maternal milk should be pumped out and fed by the dropper or the Breck feeder (see Fig. 3). A nipple shield can sometimes be used to advantage, or the milk can be fed 535 536 DISEASES OF CHILDREN. from a nursing bottle when the babe cannot suckle the mother's breast. Nursing should not be discontinued except for exceptionally good reasons. Cleft Palate. In this condition a fissure is seen in the roof of the mouth, in- volving the soft palate, the hard palate, or both. It occurs when the palatal arches in fetal life fail to fuse. Cleft palate often occurs with harelip, particularly when the latter con- dition is double. Owing to the gap in the mouth the infant usually cannot nurse nor feed from a bottle, and it is often necessary to resort to feeding with a dropper or by gavage. Nipples with a flexible wing have been devised to accommodate these cases for bottle feeding, the flap being so arranged that it fits snugly to the upper lip and covering the cleft. Such deformities as cleft palate and harelip make feeding very difficult, and these cases frequently die of inanition. The treatment is surgical; the operation should be performed as early as possible. The surgeon who is to operate must decide upon the preferred age, which depends upon the character of the operation and the nutrition of the child. Some surgeons operate at the end of the second year, while others prefer to wait until the arches are well developed. Congenital Branchial Cysts. Certain tumors of the neck in infants and young children have their origin in an incomplete closure of one of the branchial clefts. Early in the fetal life of the vertebrata there appears under the pro- jecting frontal process a series of four plates, bounding the cavity of the pharynx on the side. These plates unite to form four parallel arches separated by transverse clefts. The branchial clefts unite, and by a process of morphological change form various structures of the neck. If this regular process of development is interfered with from any cause, various abnormalities may result, as a condition intended to be merely temporary remains more or less permanent. Hence, according to the various grades of arrested development, we may have marked deformities, branchial cysts, or the remains of fetal epithelial tissue destined to proliferate at a later day and form a cyst. There likewise may result fistulous tracts from non-union of the branchial clefts, particularly from the lowest one. These have been divided into : (a) complete branchial fistulse, open the whole length of CONGENITAL MALFORMATIONS AND DEFORMITIES. 537 the tract; (b) fistulae having only an external orifice and ending in a cul-de-sac, which is the commonest form; (c) fistulae with only an inter- nal orifice. More frequently the branchial tract is closed at'both the pharyngeal and cutaneous ends, and a cyst is formed between. Senn has made the following classification according to the cystic contents: 1. Mucous branchial cysts, due to imperfect closure of the upper portion of the branchial tract with retention of its physiological secretion. 2. Atheromatous branchial cysts, usually located in the second and third branchial tracts in the region of the hyoid bone. 3. , y -■■■ ' i". ^Mkr Fig. 151. — Branchial cyst in an infant. Fig. 152. — Branchial cyst in a boy 8 years old. Serous branchial cysts, having a thin-walled capsule lined with pave- ment epithelium, and followirig the defective obliteration of any of the branchial clefts. 4. Hemato-cysts of branchial clefts, in which the serous fluid of the cyst has been discolored by hemorrhages into the sac. The contents of these cysts are always such as may be produced by some kind of epithelium, and in this they differ from 'true dermoid cysts that may contain the secretion of the various glands and append- ages of the skin. The two illustrations show branchial cysts in an infant five days old and in a boy of eight years (Figs. 151 and 152). Treatment. — The object of treatment in these cases is, of course, 53S DISEASES OF CHILDREN. to radically destroy the membrane that secretes the serous contents of the tumor. In structure, the cyst consists of a thin capsule of connective tissue, lined on its inner surface by a matrix of epithelial cells, which must be destroyed by an inflammation set up in the sac or removed by the knife, before recovery can take place. As these cysts may be connected with the sheath of the deep cervical vessels, complete removal by operation may be attended by severe hemorrhage unless very great care is exercised. When fistula? exist, they may be destroyed by passing in a probe which has been dipped in a 10 per cent, nitrate of silver solution. If excision of the cyst is not feasible, it may be opened and packed with gauze. Malformations of the Esophagus. This malformation is quite rare. The diagnosis is generally made probable by the inability of the infant to take or retain any feedings, or the return of such feedings through fistulous tracts. The stomach-tube cannot be passed at all or meets an obstruction or stricture. Various degrees of malformation occur, such as narrowing in its entire length, leaving only a band-like process, openings into the trachea or externally into the neck. Blind pouches also have been found. Treatment. — Skilled surgical treatment may avail in the minor degrees of malformation, but the early age and severity of the operative work mitigate against success where prolonged procedures are necessary. Malformations of the Rectum and Anus. A stenosis of the anus may be present, due to abnormal encroach- ment of the skin upon the anal mucocutaneous tissue. The rectum itself may be congenitally too narrow. The treatment of both these conditions is mechanical dilatation with the fingers or a bougie. The anus may be imperforate due to non-absorption of the cuta- neous envelope, the integrity of the rectum being normal. Treat- ment of the abnormality is by incision and removal of the obstructing tissue. There may be an obstruction in the rectum, the anal structure being normal; that is, the large intestine may terminate in a blind sac having no communication with the anus, or it may have a small fistulous connection. Occasionally there is a membranous velum CONGENITAL MALFORMATIONS AND DEFORMITIES. 539 with a very small aperture across the rectum. The treatment is surgical. Careful inspection and examination of the newly-born by the attendant will reveal the deformity, and immediate steps should be taken to obtain surgical correction. The time of the passage of the first stool and its size and character should always be investigated by the attending physician. Minor degrees of stenosis of the rectum or anus are not infrequent in the newly born. Although the thin feces of infancy may escape without diffi- culty, when the child grows older and the excreta become more solid stenosis may occasion much inconvenience. Fig. 153. — Hypospadias. Hypospadias. The anomaly in male genital organs in which the urethra opens on the under surface of the penis instead of at the point of the glans, is known as hypospadias. This exit may be located at any point on the penis from tip to base, and is designated according to location, as glandular, penile, peniscrotal, or perineal. In the perineal type, hermaphrodism may be suspected, as the testicles are often unde- scended, the penis rudimentary, and the scrotum divided by a deep fissure. The passage of urine is usually difficult, Dripping of urine from an overdistended bladder is the cause of incontinence in these cases. 540 DISEASES OF CHILDREN. The treatment of hypospadias is surgical and often is tedious, but ex- perienced operators now obtain very satisfactory results with flap- method operations. Extrophy (Ectopia) of the Bladder. This deformity is characterized by Ahlfeld as "a fissure in the abdomen of an otherwise well-formed fetus, which is lined with a bright red, velvet-like skin (the bladder membrane), and which is constantly Fig. 154.— Extrophy of the bladder. kept moist by the urine which trickles upon it. Below the fissure, in the abdomen and bladder, are to be seen incompletely developed external genitals." The only treatment is plastic surgery, and the results are often quite brilliant, although several operations are usually necessary before a satisfactory repair is made. Congenital Dislocation of the Hip. The cause of this deformity is not known, but some cases are doubtless due to fibroid tumors in the uterine wall producing a mal- position in utero. Lange distinguishes three forms: the supracoty- loid, the supracotyloid and iliac, and the iliac. The condition is rarely noted in early infancy, as the symptoms are CONGENITAL MALFORMATIONS AND DEFORMITIES. 541 not in evidence until the patient begins to walk. The leg is short- ened and flexed on the pelvis, and when the dislocation is bilateral there is a considerable lordosis present when the patient stands erect. If the dislocation be unilateral a scoliosis results. A peculiar waddling gait is quite characteristic of these cases. When there is much con- traction of the adductors the lower ends of the femurs cross each other, forming the scissor-leg deform- ity. This, however, is rare. A Roent- gen photograph will clear up any question as to the diagnosis. A re- duction of the dislocation is more readily made when the patients have not done much walking, as owing to the shallow acetabulum it is impossi- ble to keep the femoral head in place unless the patient remains in bed. Treatment. — The bloodless re- duction method advocated by Lorenz is usually selected by the surgeon as offering the best results. A plaster dressing is applied which must be worn for months, and later massage and exercises are ordered. This operation should not be delayed too long, as in older children good results are rarely secured. Congenital Absence of the Bones. Among the rarer bony deformities there is occasionally seen an ab- sence of the radius. This is a bilateral defect, and produces a serious incapacity in the physical strength and ability of the extremity af- fected. An incurvation due 'to abnormal muscular attachments results, as illustrated in the radiograph (Fig. 158). Fig. 155 is a radiograph showing absence of the greater portion of the phalanges. Fig. 157 shows an absence of the hands beyond the carpals as a result of intrauterine amputation. Talipes. (Club-foot.) Congenital talipes results from malformation or lack of develop- ment of the bones about the ankle. A small uterus with deficient Fig. 155. — Congenital deformity of the hand. 542 DISEASES OF CHILDREN. liquor amnii may produce a talipes by abnormally compressing the parts, the normal position of the feet in utero being a talipes varus. All acquired talipes are due to pathological conditions; for example, following anterior poliomyelitis or contractions of tissues after exten- sive burns or diffuse suppurations, and as the result of the overaetion of certain muscle groups when the nerve trunk supplying their equilib- rants is affected. Fig. 156. — Double congenital dis- location of the hip. Fig. 157. — Intra-uterine amputation of the hands. In fact, any process which will change the normal equilibrium of muscle groups about the ankle will produce a talipes. The cause may be found in the bony or ligamentous structures or in the muscles. Talipes varus is the most frequent variety seen in congenital cases. In this form the patient walks on the outer surface of the ankle, the inner surface of the foot being raised. Talipes equinus results when the heel is elevated and the patient walks on his toes. This form results from paralysis of the extensor muscles of the leg with secondary contractions of the muscles of the CONGENITAL MALFORMATIONS AND DEFORMITIES. 543 calf, and occurs following anterior poliomyelitis or injuries to the anterior tibial nerve. In talipes valgus the patient walks on the inner surface of the ankle, the outer border of the foot being raised and everted. A paralysis of the tibial muscles produces this deformity. Talipes calcaneous is rare; the patient walks on his heel with the toes elevated. This deformity arises when the calf muscles are paralized. Fig. 158. — Congenital absence of the radius. Treatment. — In congenital cases daily manipulation of the foot and ankle should be instituted at once until the deformity is overcorrected, the foot being retained in good position by mechanical means such as a cast or apparatus. . In paralytic cases manipulation and massage is indicated, special attention being given to the weakened muscle groups, toning them up by the use of faradism and friction. A proper splint should be applied to retain the foot and ankle in the correct position. Tenotomy and other operative measures may be necessary in neglected cases. 544 DISEASES OF CHILDREN. Webbed Fingers and Toes. (Syndactylism.) In this condition two or more fingers or toes are joined laterally by a web which, if thin, consists mainly of skin, but if thick more or less fleshy tissue is present. If the fingers be affected, the web must be divided, care being taken to insure full separation to the base of the fingers and the separation maintained. If the web be thin the oper- ation consists in incision only; but if the web be fleshy, skin flaps must be made and the denuded surfaces covered. Webbed toes need not to be treated unless for the cosmetic effect. Fig. 159. — Congenital club feet in an infant with a spina bifida. Meningocele and Encephalocele. Owing to a congenital opening at some part of the skull, a portion of the cranial contents may protrude. The defect is most common in the occipital bone, in any portion of which the defect may be present, from the peripheral part to the center. If it exists in the anterior CONGENITAL MALFORMATIONS AND DEFORMITIES. 545 portion of the bone, it may extend to the posterior fontanel; if in the back part, it may connect with the foramen magnum. The size of the tumor depends, of course, upon the extent of the opening in Fig. 160. — Webbed fingers. the bone. Similar defects may also be present in the nasofrontal region, and less frequently in the basilar, temporal, and parietal seg- ments of the skull. The openings may contain meninges alone, men- ! Fig. 161. — Supernumerary thumb. inges with brain matter, or the latter with fluid in the interior; in the latter event the anomaly is termed hydrencephalocele. The tumors appear at or soon after birth. 35 546 DISEASES OF CHILDREN. A meningocele is usually small, with little tendency to increase in size. It may be more or less pedunculated: it presents fluctuation, but no pulsation, and is usually reducible. In encephalocele there is distinct pulsation, and efforts at com- pression will be accompanied with evidences of marked cerebral irritation. The tumor, though not large, has a wide base, and is partly reducible. A hydrencephalocele is apt to be large, lobulated, with sometimes a distinct peduncle. Pulsation is usually absent in the tumor, which, Fig. 162. — Meningocele. however, is fluctuating and mostly translucent. Compression is not apt to be successful in reducing the tumor. Sometimes there is more brain substance in the tumor than in the cranial cavity, and the infant is then microcephalic. Prognosis.— The prognosis in hydrencephalocele is bad, as the tumor usually grows rapidly, and there may be rupture, with im- mediate death. In meningocele and encephalocele the prognosis is better, especially if the tumor be small. Treatment. — Treatment in these cases is of little avail, although the withdrawal of fluid and even stimulating injections have been tried. CONGENITAL MALFORMATIONS AND DEFORMITIES. .147 Spina Bifida. Owing to congenital failure in the development of the vertebral arch, one or more of the laminae may be absent, with resulting pro- trusion of the spinal meninges. The lumbar region of the spinal column is the part usually affected. Occasionally, however, we have meningocele 01 encephalocele. The tumor is round, fluctuating, and by compression the cerebrospinal fluid can be forced back into the spinal canal. Too severe pressure, however, may produce eclampsia or other grave cerebral symptoms. The base of the tumor depends upon the size of the opening, being pedun- culated if it is small, but more sessile if large. The tumor is usually covered with skin, which, however, may be absent, exposing the dura mater. If there is not much tissue covering the tumor, transudation may occur through the walls or rupture of the sac may take place if growth is rapid. Some portion of the lower segment of the cord or the cauda equina is apt to be imprisoned in the sac. The extent of the involvement of nerve-tissue can be measured by the paraplegia or other evidences of lesion in the spinal cord and nerves. Gradual absorption of the fluid may occur, and the child may grow up with little inconvenience from the shrivelled tumor. This, of course, takes place only when the nerves are not involved. In most cases there is a gradual increase in the size of the tumor, with final ulceration or rupture, followed by convulsions or coma and death. The fatal ending may also come with a gradual emaciation accompanying paraplegia. Treatment. — The treatment of small tumors consists in the application of a soft compress to avoid friction and to support the parts. When the tumor is growing, however, more energetic measures may be tried. The simplest procedure is to withdraw the fluid by aspiration, and follow this with gentle but constant pressure. The fluid must be slowly and cautiously removed, for fear of active nervous Fig. 163. — Spina bifida. 548 DISEASES OF CHILDREN. disturbance and even eclampsia. Injections with iodin of various strengths have been tried, but without much success. In some cases the tumor can be surgicalty removed by completely excising the sac. This may be successfully accomplished in the pedunculated variety where the opening in the lamina is small. It should never be attemped if there is evidence that the cord or cauda equina may be involved in the tumor. SECTION XV. THE COMMONER SURGICAL DISEASES. CHAPTER XLI. THE COMMONER SURGICAL DISEASES. Anesthesia. The administration of an anesthetic to a child is often rightly viewed with apprehension by the practitioner, and questions arise as to the best method and safest anesthetic to employ. The same phenomena are observed in early life as in adults, but the margin of safety is less, and thus the use of any anesthetic should be regarded as a factor by itself and given the consideration it de- serves in relation to the age, the physical condition of the patient, and the character of the operation he is to undergo. It should be recollected that any anesthetic given beyond its proper limits is a cardiac depressant. Choice of Anesthetic. — Ether is preferable if the anesthetist is not thoroughly experienced; if the period of insensibility is to be a long one; in cardiac diseases and in operations for the relief of obstructed respiration, as Ludwig's angina, papillomata of the larynx or deep cervical adenitis. It is also to be preferred if the patient must be kept in an erect or semi-erect posture. Chloroform in the hands of an expert in anesthesia is preferable to ether. Children are rapidly brought under its influence as they usually cry and thus inspire rapidly. Plenty of air, constant vigilance, and the utilization of the drop-by-drop method, depending on each minim administered to add to the effect, is the proper procedure. In minor surgical affections in which only a primary anesthesia is required, chloroform is of advantage, as the patient rapidly comes out of its influence without the nausea and vomiting which are so often seen with ether. Chloroform is preferable if nephritic condi- tions are present, or a possibility, as in suppurative adenitis following scarlatina. Lividity of the lips, with an ashen-pale face and weak slow pulse are indications that should be met by immediately stop- ping the anesthetic, inducing free respirations and by hypodermatic stimulation. 549 550 DISEASES OF CHILDREN. Gas -ether anesthesia, in the hands of professional anesthetists, is the method to be selected for older children, but in infancy and the first years of life the nitrous oxid gas is poorly borne and liable to cause suffocative cyanosis. Anesthesia, according to the method of Schleich, or the spray method with ethyl chlorid are satisfactory in the hands of those accus- tomed to them, but cannot be commended for general use. Preparation for Anesthesia. — Feeble children should not be denied food for a longer period than three or four hours before administering the anesthetic. Often a small amount of a hot liquid, such as thin gruel, will be effective in preventing collapse of the infant. The bowels should be moved by a soap-suds enema, and in older children a dram or two of licorice powder should be given the night before. As the bodily heat is easily dissipated, especially in infants, they should not be unduly uncovered, and artificial heat may be applied during the operation with favorable effect. A preliminary stomach washing in cases of intestinal obstruction with incessant vomiting should precede the operation. Hopodermocylsis and a nutrient enema may also be indicated in certain feeble or anemic infants in whom collapse is feared. Hernia in Early Life. Hernia occurs in young children as a result of arrest or defective development of the fetus, which allows the protrusion of some of the abdominal contents through a natural opening. Etiology. — Hernia in early life may be in the order of their fre- quency, inguinal, umbilical, ventral, and femoral. Inguinal hernia occurs more commonly in boys than in girls, and we are inclined to agree with Russell that this form is essentially due to a preformed sac or an obliterated portion of the vaginal process. Such a sac results when a part of the peritoneum coming down in front of the testicle as it passes into the scrotum in fetal life fails to be obliterated and separated from the remainder of the peritoneal cavity. Thus oblique or indirect hernia is congenitally formed. Coley sug- gests that the terms " congenital" and " acquired" be abandoned and that we adopt instead the classification of total or partial funicular sacs. Direct and femoral hernias are in the majority of cases acquired, as they rarely result from congenital sacs. The most common predisposing causes other than the anatomic are constipation, pertussis, tympanites, crying, straining, and coughing. Symptomatology. — The signs do not differ very materially from those found in the adult. A tumor may appear and reappear several THE COMMONER SURGICAL DISEASES. 551 times before attention is directed to it. The tumor gives an impulse to the finger on crying or laughing; it may disappear spontaneously on lying down, it may cause discomfort or even pain at this time of life, and if the intestine has protruded a sensation of gurgling is felt when the tumor contents slip into the abdominal cavity. Strangulation is not common, and when it occurs results from constriction at the exter- nal abdominal ring, from tough and inelastic fibrous bands or rings which may be found within the sac (De Garmo) or from fecal impac- tion. The symptoms of this complication are, besides the tumor itself, nausea and vomiting, constipation with abdominal distention, pains of a colicky character which are increased on urination, increased pulse rate, a variable amount of temperature, restlessness, and if relief is not obtained at this point vomiting becomes stercoraceous with sub- normal temperature, and a fatal issue will result. Diagnosis. — The differential diagnosis is given on page 47S. Treatment. — The great majority of children under three years of age can be cured by mechanical means. This implies the proper ap- plication of a suitable truss. This should be made of hard rubber with a slightly convex pad of the same material, or consist of a water pad covered with impervious, water-proof material. These are recom- mended because they can be readily adjusted and kept clean. Leather trusses soon become soiled or soaked with urine and produce excoria- tion. The physician himself should select and fit the truss, the spring- should be just strong enough to properly retain the hernia even when the child cries or strains. It should be applied only in the prone posi- tion and worn continually day and night. Parents should be warned not to unnecessarily remove it unless the child is lying down and the hernia meanwhile digitally retained. A cure is generally affected within a year, although it is advisable to retain the support for a year and a half. If after this time the tumor still protrudes on exertion, recourse must be had to operation. Children over six years of age are rarely, if ever, cured by the application of a truss. The treatment of umbilical hernia has been discussed and illus- trated on page 16. Operation is indicated immediately in all cases of strangulated hernia, It is necessary in hernia complicated with irreducible hydrocele, in femoral hernias, and in children over four years of age who have not been cured by the application of a properly fitted truss worn over the prescribed period. The Bassini operation, which is founded upon the etiological factors involved in the production of hernia, almost invariably gives most satisfactory results in competent hands. 552 DISEASES OF CHILDREN. Circumcision. Many male infants need circumcision. The operation promotes cleanliness and inhibits the formation of the habit of masturbation. In cases in which the adhesions about the glans penis have been separated and the prepuce still does not sufficiently retract, circum- cision is indicated. It is certainly necessary in all cases in which the prepuce is tight enough to hold drops of urine or when it balloons out on urination. The prepuce should be so trimmed that the corona is covered and only enough should be cut away so that the prepuce can move freely over the glans. In this way its physiological purpose will be preserved. This operation should be performed in the early months of life. It should be unnecessary to say that surgical cleanliness is to be ob- served. With a pair of hemostatic forceps stretch the prepuce, and insert a director between it and the glans. Then incise along the dor- sum in the middle line to a point just proximal to the corona. Sepa- rate all adhesions until the coronal sulcus is defined and remove all smegma. Cut away the redundant tissue, including both skin and mucous membrane from both sides down the frenum. After all the edges have been carefully trimmed put in three or four fine plain cat- gut sutures to prevent any exposure of raw surface. Bleeding is slight and probably no ligatures will be required. Use plain gauze strips covered with sterile vaselin for a dressing. If the suture mate- rial used is non-absorbable, remove the sutures on the fifth day and powder the wound with aristol. Appendicitis. Etiology. — Appendicitis is comparatively rare in early life. In infancy it is extremely uncommon. Invasion of the lymphoid struc- ture of the appendix by bacteria is made possible by traumatism from within or without, by intestinal parasites, mucous inclusion, or con- strictions harboring fecal masses. From a pathological standpoint the disease in children does not materially differ from that found in the adult. It should be recol- lected, however, that the appendix in children is normally not larger in diameter than a goose-quill; that it is more apt to be found in diverse situations and that it normally lies higher in the abdomen. Suppuration takes place more readily and localized abscess forma- tions are not unusual. In quite a number of our cases, children with THE COMMONER SURGICAL DISEASES. 553 appendicitis were willing to walk about or sit up even when ulcerative conditions were subsequently found at laparotomy. Symptomatology. — In the acute inflammatory form the child may complain of indefinite colicky pains which are often attributed by the parents to some indiscretion in diet, especially when vomiting occurs early. The fever is not high, rarely rising above 102° F. If the patient is walking about, he usually stoops and his movements are made cautiously. After being placed in bed he may prefer to lie on his back, drawing up the knees to relax the abdomen. Although if asked to do so he may not hesitate to turn to either side or extend the thighs. The area of pain may not be definitely located by the patient in the right iliac fossa; in fact, he very often refers it to the umbilical region. Examination. — On inspection the contour of the abdomen is usually found to be normal; there may be slight distention observable. Palpation, carefully performed, so as not to excite undue muscular effort may elicit some resistance and tenderness in the right iliac fossa. In children it is seldom that a definitely localized spot of tenderness is found over McBurney's point. In thin subjects, however, it may be possible to definitely locate the inflamed appendix. If the diag- nosis is still in doubt, bi-manual rectal examination should be made according to the method described on page 48. A low grade of leu- kocytosis is usually found in this type. Such a case of appendicitis may subside under medical treat- ment, but recurrences are almost sure to follow at some future time making the prognosis graver than if operation is performed at once or in the interval. The suppurative form with a tendency to perforation at or near the tip occurs more commonly and the symptoms are more severe. The pain may come on suddenly with fever, nausea, and vomiting, constipation and tympanites occur, the patient generally seeks his bed and is satisfied to lie quietly, in the recumbent posture. The legs are drawn up and the patient localizes the pain more definitely to the right iliac fossa. The temperature varies between 101° and 103° F. and rarely rises above this point; the fever may not reach higher than 101° F. The pulse rate is increased, especially so if perforation takes place. Gangrenous changes may occur and may be suspected if the subjective or constitutional signs are more marked. Examination.— On inspection, the attitude of the patient with the knees drawn up, the facies showing distress, the coated tongue and the distended abdomen with suppressed abdominal respiration should be suggestive. On palpation of the right side the muscular rigidity 554 DISEASES OF CHILDREN. is marked and a distinctly painful area of tenderness may be mapped out. In some cases the tumefaction or mass can be quite easily felt. Rectal examination should confirm these findings. Repeated blood examinations will show varying percentages of polynuclear elements ranging from 85 to 95 per cent. If peritonitis has resulted, the ab- dominal rigidity is increased and vomiting again occurs, the abdomen is distended with gas, obscuring the liver dullness. When the peri- tonitis is localized about the caput coli the inflamed appendix may be walled off from the general cavity. This is indicated by a diminution of the general symptoms. An abscess may form within this area from perforation, gangrene or rupture of the appendix. Fluctuation may be obtained, but even before this a sudden drop in the temperature curve points to a focus of pus. A differential leukocyte count will also act as corroborative evi- dence when the percentage of polymorphonuclear leukocytes is greater than eighty. Diagnosis. — Cases presenting the classical symptoms of pain in the right iliac fossa with rigidity of the right rectus muscle, tumefac- tion, fever, and vomiting should occasion little or no difficulty in diag- nosis. Examination under a general anesthetic may sometimes be necessary in doubtful cases, especially if a skilled surgeon is not at hand. Intestinal obstruction is to be differentiated by the absence of initial fever, the presence of a palpable sausage-shaped mass, tenesmus, and discharges of blood and mucus. Not infrequently a pneumonic process involving the base of the right lung causes pain which is referred to the ileocecal region, and the unwary may mistake this for appendicitis. Prognosis. — The tendency toward suppuration and the develop- ment of general peritonitis make this disease a grave one in early life. The mortality, however, will be distinctly lessened when early diagnoses are made followed by prompt surgical intervention. Treatment. — The medical treatment of appendicitis should con- sist in immediately placing the patient in bed, allowing him to assume a position of comfort. A light ice bladder is placed over the point of greatest tenderness. The bowels should be moved with a soap-suds enema. A liquid diet, consisting of milk, ice cream, and thin gruels is given if the vomiting permits. The question of operation should be left to the judgment of a competent surgeon. Children bear the operation well, and, unless the circumstances contraindicate it, immediate operation is to be preferred to the chances of perforation or general peritonitis. THE COMMONER SURGICAL DISEASES. 555 Intussusception. {Invagination) . This very frequent form of intestinal obstruction in children is caused by a prolapse of a portion of intestine into the lumen of the adjoining bowel. While other causes, such as volvulus, Meckel's diverticulum, bands, and foreign bodies, may produce intestinal obstruction, they occur so rarely that they need not be considered here. Etiology. — We are inclined to believe that the condition can be accounted for by irregular peristaltic action taking place in a gut, the walls of which are thin and undeveloped and only loosely held by mesentery. The exciting cause may be undiscoverable. We have seen it in breast-fed infants who appeared healthy in every way. Overloading of the intestine, producing fermentation, colic and an irritative form of diarrhea may induce it. Constipation, tenesmus in the intestinal wall as polypi, appendicitis, and cathartic drugs have been held respon- sible for its onset. It occurs more frequently in males and the majority of cases occur in poorly nourished children in the first year of life. The fourth to the sixth month being the time of greatest incidence. Symptomatology. — The onset is sudden and acute in the majority of cases. Only in such situations as the rectum or low down in the colon may the symptoms come on at all gradually. An infant appar- ently healthy may suddenly begin to cry violently with pain which is usually regarded as colicky in nature, the extremities may be kept incessantly moving. Vomiting soon occurs, the child's appearance changes. The face is pale, showing marked evidences of distress and prostration. The first movement of the bowels after the intussuscep- tion may contain a single amount of fecal matter; thereafter the move- ments consist only of blood and mucus which are passed with some tenesmus. The vomiting which is almost projectile occurs at very frequent intervals. After the stomach contents have been emptied, bile-stained mucus or even fecal matter may be vomited in the final stages. There is little or no fever, but the pulse is extremely rapid and thready. On examination of the abdomen a sausage-shaped tumor may be felt, which if firmly palpated may feel harder. This tumor may be found in different situations, but generally is found in the left iliac fossa along the line of the colon. Bi-manual rectal examination may confirm its presence. In some instances it may protrude from the rectum and may be mistaken for a prolapse. It must not be for- gotten that intussusception can occur without the presence of a pal- 556 DISEASES OF CHILDREN. pable tumor. Sometimes a depression or flattening in the opposite iliac fossa is observed. Unless relief is obtained the prostration be- comes more intense, subnormal temperature and death may ensue from exhaustion. Cases of spontaneous reduction and relief by gan- grenous sloughing of the intussusceptum have been reported, but are so rare as to merit recognition only as curiosities. Diagnosis. — This may be founded upon the following symptoms: A sudden onset, a paroxysmal colicky pain, vomiting, prostration, discharges of blood and mucus. In our experience dysentery is most often confounded with in- tussusception. The presence of some fecal matter in the stools, the constant fever, and the moderate vomiting with prostration only proportionate to the severity of the disease, should distinguish the conditions. Prognosis. — Unless the condition is promptly recognized and immediate treatment instituted, a fatal issue may be expected. The mortality statistics vary from 60 to 70 per cent. The younger the infant the graver the prognosis. Treatment. — An attempt and only one should be made to reduce the intussusception if the diagnosis is quite certain within a few hours after the onset of the acute symptoms. It may then be successful, especially if the invagination is in the colon. The child is placed on its back, the buttocks elevated, and a warm saline solution from a two-quart fountain bag, held four feet above the patient, is allowed to distend the gut. The fluid should be retained by holding the buttocks firmly together. A long large catheter is preferable to the ordinary hard-rubber tip. While the child is in this position gentle manipulations to assist the reduction may be made. If the result is successful the tumor disappears with a gurgling intes- tinal sound. Undue efforts in this direction should not be made. If reduction is unsuccessful or the case of longer standing immediate operative interference is demanded. A preliminary stomach washing and stimulation hypodermatically in the form of strychnin or brandy, will better prepare the patient to withstand operative interference. Acute Peritonitis. In the New-born. — The diagnosis of the acute forms in infancy are too often made only at necropsy. This is so because of the uncom- monness of the affection, the meager history obtainable, if any, the lack of distinctive physical signs, and the inability of the patient to relate subjective symptoms. THE COMMONER SURGICAL DISEASES. 557 Fortunately, acute peritonitis is not a frequent occurrence among children, although in the new-born it is not as rare as it may be com- monly supposed. Through the umbilicus pathogenic bacteria may gain entrance and cause peritoneal infection. The streptococcus and the bacterium coli communis can be held responsible for the majority of the cases occurring in the new-born. When a general sepsis results the diagnosis is not as difficult as when the infection is localized in the peritoneum. Symptomatology. — In the new-born, the disease must be considered when there is a localized umbilical infection followed by a sudden abrupt change in the infant's condition. The extremely rapid gasping breathing may first attract the attention of the attendant. The in- fant cannot or will not nurse, the temperature is persistently high, 104° to 105° F. with a rapid weak pulse. The position assumed by the infant is one of tension. Its legs are drawn up and pain is sharply elicited by attempts to even gently move the legs. The breathing if closely observed is seen to be mainly costal in type and extremely shallow. The distress caused makes abdominal palpation almost impossible. The constant rigidity encountered is quite characteristic. The urine is almost entirely suppressed. Pallor soon becomes marked, and death usually results in two or three days. In Early Life. — A similar train of symptoms occurs in the early years of life in peritonitis resulting from disease processes in other parts of the body as appendicitis, intussusception, perforation, trau- matism, strangulated hernias, lung involvement, or following the acute infectious diseases. Besides the streptococcus, we have the pneumo- coccus, gonococcus, colon bacillus, or the ordinary pus organisms as etiological factors. Pneumococcic and gonorrheal peritonitis are almost distinctively diseases of childhood. The diagnosis is likely to be obscured by the underlying affection. The medical attendant is likely to center his attention on the primary disease and is not attracted by the insidious train of symptoms in the abdomen. Invasion of the peritoneum is evidenced by sudden high increase of temperature, or a subnormal temperature with signs of collapse, extreme pallor, feeble rapid pulse, 120 to 180, and cold ex- tremities. The eyes are fixed and sunken, nausea and finally bile- tinged vomiting may follow. Any attempt to give medication or food by mouth is apt to be followed by vomiting. Constipation is the rule. The postural picture is the same as that just described for the new-born, except that a tympanitic condition is more apt to occur and the young child may feebly attempt to ward off any attempts at palpation of the abdomen. The pain may be referred 558 DISEASES OF CHILDREN. to the navel or localized in the iliac fossa. The leukocytes are moderately increased. Peritonitis of gonorrheal origin should be suspected where such a train of symptoms in a female child are accompanied by a specific vulvovaginitis. Pneumococcic peritonitis may result from any pulmonary disease, and especially from an empyemic process. It occurs here probably by direct infection through the lymphatics of the diaphragm. Hema- togenous infection seems to be the usual mode, since pneumococcic men- ingitis and abscess formations are not unknown. Since the exudation of pus is in this variety considerable in amount, the diagnosis is more readily made by the finding of accumulated fluid in the lower segment of the abdomen. If recognized early and proper measures of rest and posture are instituted, encapsulation is apt to occur, and the prognosis is correspondingly improved. Paroxysmal pains, chills, vomiting, severe diarrhea, and abdominal distention are noted in the early days of the disease. On palpation, there may be fluctuation, corroborated by dullness on percussion. Pneumococcic infection of the peritoneum, though a dangerous disease, is not necessarily fatal, as the pus may discharge through the umbilicus. If, however, surgical measures are not instituted at the beginning, rapid emaciation and prostration usually take place. Diffuse suppurative peritonitis may then result, and a serious prognosis is inevitable. The diagnosis as to the exact form can only be made by examination of the pus which will show the presence of the diplococcus pneumoniae. Diagnosis. — The diagnosis in older children with a well-marked train of symptoms is not so difficult. In infancy it is often extremely puzzling and can often be made only by a process of exclusion. The symptom of pain cannot always be depended upon, as it is often rela- tively less than in adult life. From intestinal obstruction it is not always easy to differentiate peritonitis, but the lesser amount of abdominal tenderness, absence of fecal vomiting, and the passage of some gas or feces may be of as- sistance. It should not be forgotten that, these conditions may be combined. Diaphragmatic pleurisy, or even pneumonia, when the pain is referred to the abdomen may occasion a mistake, if a complete physi- cal examination is not made. Prognosis. — In infancy it is invariably bad. In children peri- tonitis must always, be regarded as a grave affection, although the encapsulated forms offer some little hope. If a perforation has taken place or if the process is general a fatal issue is to be expected. THE COMMONER SURGICAL DISK AS 1 58, 559 The gonorrheal variety, especially in older children, has a better prognosis. Treatment. — An early diagnosis will be of value to the patient if prompt measures are taken to insure bodily and intestinal rest. If the case is seen very early, calomel or a saline may be given, before the application of an ice-coil. Paregoric for young children and codein hypodermatically for older cases will be required to alleviate the pain and to inhibit peristalsis. No attempt should be made to feed the patient. Pieces of ice or sips of ice-water to which brandy has been added are grateful and often allay vomiting. Hypodermo- clysis and stimulants may be required for the pulse. The surgeon should be consulted as early as possible and decide as to the feasibility of operative interference. Ascites. By ascites is meant the condition produced by an effusion of serum into the peritoneal cavity. It may occur as a secondary condi- tion in peritonitis in any of its varieties, in chronic nephritis and in certain blood diseases. Obstructions to the portal circulation, and chronic diseases of the heart and lungs may also produce ascites. Diagnosis. — The physical signs differ in nowise from those obtained in the adult, and therefore may be omitted here. Chylous Ascites. — The diagnosis of this rare form is made only after aspira- tion. Several cases have lately been re- ported. Its causation is unknown, but is attributed to some obstruction or disease of the thoracic duct. The ascitic fluid is milky white in color and usually contains fat globules in a fine emulsion. Leuko- , r i i t j n u Fig. 164. — Characteristic shape cytes and a few red blood-cells may be of beUy in asc j te s. (Cabot.) found. Treatment. — Withdrawal . of the fluid for the relief of pressure symptoms may be necessary in advanced cases, otherwise the treat- ment resolves itself into measures directed to the primary condition. Ischiorectal Abscess. These abscesses are more commonly observed in children of poor nutrition who have been reared under unhygienic circumstances. 560 DISEASES OF CHILDREN. Through the lymphatic channels of the rectum, the perirectal lymph nodes become infected and form an abscess. The diagnosis is made on inspection or by rectal examination. Treatment. — Free incision, cleansing with antiseptic solutions, such as the peroxid of hydrogen and stimulation with a 2 per cent, silver nitrate solution, or packings saturated with balsam of peru and castor oil, one to ten, will effect a cure. In tuberculous children these abscesses may be exceedingly intractable and do not tend to heal until the general nutrition is improved. Rectal Polypus. The growths are commonly found low down in the rectum and attached by a pedicle. Rarely are they multiple and sessile. On examination they are found to be adenomatous or fibromatous in structure. They vary in size, but rarely are larger than a hazel nut. Symptomatology. — The case is usually brought to the attention of the physician because of intermittent hemorrhages which may or may not t>e accompanied with tenesmus. Sometimes only the fecal masses are blood-streaked. If the straining is persistent prolapse of the rectum may result. Rectal examination is indicated with the above train of symptoms and the source of bleeding will then be found. Treatment. — The removal of the pedunculated ,tumors is easily accomplished by twisting the pedicle or passing a ligature about it before cutting it. If it cannot be withdrawn the use of an anesthetic and a speculum will be required so that bleeding from the stump may be arrested. Fissure of the Anus. This may occur following the passage of a hard constipated movement. It is also seen in children suffering from marasmus, syphilis, and eczema. Occasionally a fissure is produced by undue dilatation of the sphincter by injections, suppositories or rectal ex- aminations. Pain, some bleeding, and tenesmus are the signs which should lead to a careful inspection of the anal region. Treatment. — The buttocks should be separated as widely as pos- sible and the fissures touched daily with a solution of silver nitrate, dram one to the ounce. If constipation is present laxatives or enemas with careful oversight of the diet will promote healing. In intractable cases the rectum should be gently dilated, a feat which is easily ac- complished in children by the successive introduction of well-greased fingers beginning with the smallest. This procedure should cause little or no pain, and generally effects a cure. THE COMMONER SURGICAL DISEASES. 561 Prolapse of the Anus and Rectum. Prolapse of the rectum is more commonly observed in children of the second and third years of life. The protrusion may be partial, being only a simple eversion of the mucous membrane, or complete, in which all the layers of the rectal wall protrude outside of the sphincter, sometimes for one or two inches. Etiology. — The causes provoking this condition are those accom- panied by much tenesmus, such as colitis, straining in chronic consti- pation or diarrhea, or with calculi. Rectal polypi will often lead to a prolapse. A neglected cause is the use of stooling chambers too E J! 1 ^s* ^H Fig. 165. — Adhesive plaster dressing for prolapse of the rectum. large to give proper support to the buttocks. Anemic and badly nourished children are particularly prone to this affection, as in them the pelvic musculature is incompetent. Symptomatology. — The protrusion of a dark red cone-shaped mass covered by transverse folds of mucus membrane, and with a rounded opening at the apex of the tumor is diagnostic. In some cases blood- streaked mucus soils the clothes. The mass can usually be readily replaced, but the protrusion will be apt to recur after straining or coughing or with the next defecation unless preventive measures are taken. Diagnosis. — Although the diagnosis is generally easily made, one of us has seen a mistake made in a case of intussusception in an infant in whom the invaginated gut protruded from the rectum. Treatment. — This consists in replacing the tumor and retaining it. A piece of gauze covered with vaselin is placed over the tumor, and by gentle pressure exerted over the entire mass the prolapsed tissues will slip back into place. If the reduction has been delayed too long 36 562 DISEASES OF CHILDREN. it may be necessary to apply ice or ice-cold cloths for a short period and then to repeat the above manipulation. Two wide bands of adhesive plaster applied over the buttocks, above and below the anus, so as to exert firm pressure and give added support to the pelvic attachments, will retain the prolapse. Local con- ditions, such as constipation, colitis, and polypi, should be remedied and conditions of malnutrition cor- rected before a hope of permanent cure can be entertained. The child must lie on a bed- pan during defecation and the movement should be induced by a mild enema of oil or glycerin. He should be taught to avoid excessive abdominal pressure. Local applications of astringents, such as the fluid extract of kra- meria or tannic acid ointment, are helpful. The diet should be so regulated during the cure that the movements passed will be soft and unformed. Mild laxatives as cas- cara or the milk of magnesia may be necessary. In exceptionally severe or ne- glected cases, the prolapsing mu- cous membrane must be linearly cauterized by the thermocautery to produce cicatrix, or a radical oper- ation mav be necessarv. Fig. 166. — Sarcoma of the lower abdomen. Malignant Tumors in Children. While almost any form of benign or malignant growth may occur in early life, it may be said that carcinoma is quite rare, while sarcoma is much more frequent. When this form occurs in children it is much more malignant than in adults. Three types are known, the round cell, spindle cell and giant cell varieties, the first being the most malignant. Xevi sometimes become sarcomatous, but the bones, kidney, testes, and epidermal tissues are more frequently involved. The ends of the long bones showing a special predilection. THE COMMONER SURGICAL DISEASES. 563 jl Sarcoma of the face often causes confusion in diagnosis. Sarcoma of the kidney which is often congenital may attain an immense size. Their growth is exceedingly rapid and they are never bilateral. 1 5 p. 466). Fig. 167. — Osteosarcoma of the temporal bone. Fig. 168.— Sarcoma of the face. Diagnosis. — The shape and size of the tumor is determined by its site and the tissues involved. The tumors are a L first freely movable if located in soft tissues; they are seldom hard and firm; on the eon- 564 DISEASES OF CHILDREN. trary, they may even feel fluctuant. Particularly suggestive are the superficial veins, usually dilated, which are found over these tumors. The skin covering them may be somewhat dusky or bluish in color. Metastases occur by way of the blood stream, consequently ad- jacent lymphatic glands are not involved. Treatment. — Sarcoma is of relatively rapid growth and ex- tension and this fact makes an early diagnosis essential, as complete removal is the only treatment. Coley's fluid which contains the toxins of streptococcus, ery- sipelatous and bacillus prodigiosus can be tried in inoperable cases with the hope of arresting the growth. It is administered hypoder- matically the injection being made into the periphery of the growth. Begin with injections of one minum, and as tolerance is produced the dose may be increased to five minims twice a day. In certain situations as on the face, considerable pain is experi- enced unless fairly powerful analgesics are given. SECTION XVI. DISEASES OF THE EAR AND EYE. CHAPTER XLII. DISEASES OF THE EAR. General Considerations. Familiarity with the anatomy of the organs and structures of hearing, at least in a general way, is incumbent upon those whose prac- tice is among infants and children. At birth the external bony canal has not developed and there is present only a cartilaginous canal. The walls of the soft meatus may in infants be found almost in contact so that the tympanic mem- brane is examined with difficulty unless these are separated. In structure the walls of the meatus are thicker than in the adult. The vault of the tympanum is disproportionately large and may have an in- complete tegmen. The Eustachian tube is shorter, horizontal, and relatively wider, the pharyngeal outlet being on a line below the hard palate. The mastoid process is entirely undeveloped at birth, and it is not until puberty that it assumes the adult characteristics. The antrum, however, is developed, surrounded by thin bony walls. The close relationship of the sutures and the lateral sinuses to these struc- tures accounts, in greater part, for the frequency of intracranial com- plications in early life. Otoscopy. For this purpose a good light and a properly shaped speculum (see Fig. 169) is necessary. The child's arms should be fastened to its side by wrapping in a large sheet or towel; the attendant holds the child with one arm thrown about the chest and with the other on top of the head keeps the ear in the right direction. By drawing the auricle downward and backward a better view can be obtained. Accumula- tions of wax or exfoliations of the drum membrane must first be re- moved by the use of a fine cotton-tipped applicator before a good view of the drum can be had (McKernon). 565 566 DISEASES OF CHILDREN. If the ears of normal children are first examined the method and a working knowledge of the normal appearance will soon be obtained and otoscopy will then be more frequently made a part of the routine examination, and aural complications will go unrecognized less fre- quently, and more serious complications, such as mastoid involvement and deaf-mutism, prevented. The descriptions in this section are for diagnostic purposes and the reader is referred to books on this special subject for details of treatment. Fig. 169. — Properly shaped ear-speculum. Otitis. This is very common in early life, occurring almost always second- arily to the acute exanthemata, gastroenteritis, influenza, adenoid vegetations, and chronic rhinitis. ( Less commonly it may follow such diseases as typhoid infection, diphtheria, acute follicular tonsillitis, and cerebrospinal meningitis. It may also be induced by improper methods of nasal irrigation or by violently blowing the nose; the bacteria in the nasopharynx being forced into the Eustachian tube. According to Liebman, the streptococcus is most frequently found (52 per cent.), streptococcus mucosus next in frequency (8 per cent.), then the pneumococcus (6 t 4 -q per cent.). Symptomatology. — Unfortunately, in many instances otitis occurs during the course of an illness, as, for example, in measles, and unless DISEASES OF THE EAR. .",07 daily otoscopic examinations are made, the first intimation of the proc- ess is a discharge from the external ear. If after the acute symptoms of the primary disease have subsided a sudden and rather constant elevation of temperature, with and frequently without earache, occurs, otitis should be suspected. In some cases rupture takes place even without elevation of temperature. When in infants there is restless sleep with sudden unexplainable outcries, pulling at the ear, with pyrexia higher at night, inflammation within the ear should certainly be thought of. Older children who are able to localize and speak of their pain describe it as "stinging" in character. The pain conies on at intervals and is worse toward evening and during the night. Otoscopic examination in these cases will disclose a much reddened, swollen, or bulging membrane. If the process has not advanced to the point of actual suppuration there may only be found a crescentic area above Shrapnell's membrane with absence of the normal shining appearance of the lower half. If the perforation has occurred, the opening is usually seen in the posterior and lower quadrant. The discharge may be serous, sero- purulent, or purulent in character. Chronic otitis media, sinus throm- bosis, and meningitis sometimes follow. In most of the cases, how- ever, following spontaneous rupture or incision of the membrane the discharge after a time ceases, healing takes place and restitution to normal occurs, often with little or no disturbance to the hearing. Treatment. Prophylactic. — Daily examination of the tympanum in the course of the acute infectious diseases, the removal of adenoid growths and hypertrophied tonsils, and the inculcation of habits of cleanliness, such as the nasopharyngeal toilet (see p. 71), will do much to prevent the involvement of the ear. General. — Early incision of the drum membrane should be practised in the acute cases if the condition of the membrane warrants. Hot irrigations of saline solution at 110° F. with a fountain bag held two feet above the ear, give considerable relief, and in the milder cases the symptoms may entirely subside under this form of treatment. Chronic conditions require copious irrigations with a warm solution of (1-10,000) of bichlorid of mercury several times a day. It is best to refer these cases to the specialist for more radical treatment if they do not show improvement after a few weeks. Mastoiditis. This most frequently results as a complication of acute or chronic middle-ear suppuration and the same etiological factors as given under the article on Otitis concern us here. The anatomical structures as 568 DISEASES OF CHILDREN. outlined in the general consideration and the greater tendency toward necrosis of bone in early life favor the involvement of the mastoid process. Symptomatology. — The symptoms appear after a variable time during the convalescence following an artificial or spontaneous rupture of the drum. A sudden or gradual pyrexia may be the initial symptom. This, as a rule, is not high, but continues several days, reaching its highest point in the evening. Otoscopy, if there has been a previous perforation, may show a decrease in the amount of discharge, but the pus may show that some retention in the deeper structures has taken place by appearing in drops after cleaning the canal. Sometimes there is seen prolapse and bulging of the superior and posterior por- tion of the canal wall. Restlessness with frequent periods of crying, especially at night, is present in most of the cases. Occasionally the temperature reaches 104° or 105° F. in the evening, and the lymph- glands in the neighborhood are swollen. The tissues over the mastoid may become edematous and the auricle is pushed out from the scalp. In unrecognized cases a perimastoid collection of pus takes place, especially in infants, and pressure over this tumefaction causes a dis- charge of the pus which has collected in the external canal. Meningeal symptoms may appear or in neglected cases the cerebral symptoms may predominate and obscure the diagnosis. Treatment. — An early diagnosis is imperative in mastoiditis, for it is only by the radical operation which drains the middle ear that the mortality in this serious disease may be lowered or more serious complications, as infection of the jugular bulb, avoided. Infective Cerebral Sinus Thrombosis. {Jugular Bulb Infection.) The most frequent cause of local infection of the cerebral sinuses is suppuration in the middle ear and mastoid cells. A general sep- ticemia as a result of aural complications may also produce sinus thrombosis through the general circulation. Streptococci are most frequently found to be the direct cause of the infection. Symptomatology. — The disease should be considered if there is a sudden rise of temperature in a patient who has a discharge from middle-ear disease. This fever is extremely irregular, septic in charac- ter, rising often to 105° or 107° F., with remissions to the normal or sub- normal. The pulse rate is correspondingly high, the infant is at first highly irritable and restless and soon becomes apathetic and finally stuporous. There may be evidences of meningeal involvement. DISEASES OF THE EAR. 569 Vomiting and convulsions occasionally occur. If the disease has re- sulted from the mastoid there may be edema in this region, and per- haps, a clot in the jugular vein. The percentage of polynuclear ele- ments is high, ranging from 80 to 90 per cent. Prognosis. — This is extremely unfavorable. A fatal issue usually results in a few days unless operative interference is successful. Treatment. — Early diagnosis followed by prompt operative pro- cedure is the only recourse. Recent reports show encouraging results. CHAPTER XLIII. THE COMMONER DISEASES OF THE EYE. Foreign Bodies. — Foreign bodies are frequently caught under the eye-lids of children, and if not washed away by their own tears which are usually copious, they should be quickly removed to prevent in- flammatory changes. The upper lid can be everted easily if the child is prone and correctly held to prevent interference. The foreign sub- stance can usually be easily removed by a fine probe, the end of which has been wrapped with a few strands of absorbent cotton. Metallic substances may require local anesthesia, which is accomplished with two drops of a 2 per cent, solution of cocain. If the particle is not readily removed, the patient should be referred to a properly equipped ophthalmologist. Blepharitis. — This is often observed in tuberculous, anemic, or poorly nourished children, especially when they have a dermatitis elsewhere on the body. The secretion as it dries produces further excoriations and aggravates the trouble. Treatment should be directed to the general condition, improving the nutrition by proper diet, cod- liver oil and iron tonics for the anemia. General cleansing baths daily with bicarbonate of soda will prevent reinfection. Locally, the eye- lids are bathed with a 2 per cent, boric acid solution until all the crusts are removed and applications of an ointment of yellow oxid of mercury (1-100) are then made morning and night until a complete cure is produced. Conjunctivitis — Acute. — Injuries and the infectious diseases pro- duce acute inflammations quite readily in children and the mucoid se- cretions are apt to be more profuse than in adults. The eye-lids should be gently separated and the secretions flushed out. Microscopical examination of a purulent secretion should be made to determine the possibility of infection by the Klebs-Loeffler bacillus or the gonococcus of Neisser. A careful search should be made for foreign bodies. If there is no secretion, applications of a 2 per cent, warm boric acid solu- tion every fifteen minutes may suffice for a cure. If the secretion is purulent, argyrol in 12 per cent, solution ma}^ be ordered or silver nitrate (1-100) may be applied by the physician and quickly flushed out with sterile salt solution. Ice-cold applications are often necessary and should be freshly applied every ten minutes until the inflammation 570 THE COMMONER DISEASES OF THE EYE. 571 subsides. A drop of atropin sulphate (1-200) may be necessary two or three times a day to procure rest for the eye. Diphtheritic. — The membrane is tenacious, with an absence of secretion and much exudation and edema in the eye-lids. The ex- treme rapidity of the involvement and the presence of a possible nasal diphtheria should excite suspicion. The treatment is that of diph- theria elsewhere. An injection of 5,000 units of antitoxin should be given, and locally the eye should be flushed with boric acid solution and kept cold with ice compresses. Protecting the sound eye from infection may be accomplished by the use of a shield or the instillation of a 25 per cent, solution of argyrol every two hours. Chronic. — A careful examination for ocular defects should always be made in these cases and the child's habits as to study, etc., inquired into. Not infrequently the condition is improved by appropriate general treatment or a change from urban to rural life. Locally, astringent applications of zinc sulphate (1-250) or silver nitrate (1-500) may be made by the physician several times a week and one of the organic silver salts supplied for home use, as argyrol in ten per cent, solution one or two drops, twice a day. Internally the syrup of the iodid of iron is often of assistance. Trachoma (granular conjunctivitis). — Routine examination of the school children in New York City has brought to light many cases of chronic conjunctivitis which are classed as trachomatous. The condition occurs in several children of a family and certainly appears to be of a microbic nature. Ordinarily the type seen is mild in charac- ter and is often classed as a granular conjunctivitis. The heaped-up granulations and deposits are plainly seen when the lids are pulled down. The upper lid should also be everted and examined. Mar- ginal ulcerations may occur if the disease is allowed to run its course untreated. Treatment is proportionate to the severity of the condition. Prophylactic measures to protect other children in the family and school should be insisted upon, such as individual towels and wash cloths. Constant supervision and treatment will finally eradicate the con- dition and lessen the host of cases now in our schools. Locally, a solution of zinc sulphate (1-250) or the cupric stick may be used by the physician several times a week on the granulations and a solution of bichlorid of mercury (1-5000) or argyrol 10 to 20 per cent, may be ordered for home use, one drop being instilled twice a day in each eye. Severe cases will require the expression operation with forceps under a general anesthetic. Chalazion. — A chalazion is a cyst which results from retention 572 DISEASES OF CHILDREN. products of the Meibomian glands. There is rarely any pain, although discomfort is complained of by older children. They are generally excised if they tend to recur. Hordeolum or stye is found on the margin of the eye-lid and acts like a furuncle on any other part of the body. The evacuation is hastened by hot applications and early incision. Strabismus. — Strabismus (squint) may be either paralytic or non- paralytic. Paralytic squint is due to partial or complete paralysis of one or more of the muscles of the eye. It may be congenital, or it may be acquired from trauma or from an acute infectious disease, such as diphtheria or cerebrospinal meningitis. It may also result from photophobia, phlyctenular keratitis, and interstitial keratitis. Non-paralytic squint in children is more common, and it is usu- ally convergent. Contrary to a common belief, children seldom "grow out " of it. If neglected, the squinting eye usually becomes am- blyopic. Neglected "cross eyes" are responsible for many blind eyes in adults. If prescribed sufficiently early, correct glasses accomplish cures in many of these cases. Even young children can wear glasses without danger. Keratitis. — This is usually found in tuberculous and rachitic children, secondary to other ocular and dermal conditions, although syphilis itself causes the interstitial or parenchymatous variety. The condition begins with congestion and involvement of the tissues about the cornea. There is photophobia, orbicular spasm, pain, and an abnormal flow of tears. Later a haziness is observed and vision is impaired. The superficial lesion, if untreated, soon invades the cornea, and ulceration or even suppuration results. The phlyctenular variety is most frequent in early life. Begin- ning with small vesicles on the palpebral conjunctiva, it spreads to the ocular conjunctiva and here forms characteristic ulcerations which may leave permanent opacities of the cornea. Treatment should be directed to the underlying constitutional condition. The inter- stitial form generally reacts to antisyphilitic treatment. Children poorly nourished or badly housed must be removed to hygienic quarters to effect a cure. Good food, fresh air, and baths add greatly to the possibilities of local treatment. Any fissures in the angles should be treated with silver nitrate solution (dram one to the ounce), followed by a flushing with normal saline. A shade is to be worn in preference to a dark room where this is practicable. Bathing with hot boric acid solution three or four times a day is soothing and helpful. An ointment of yellow oxid of mercury (1-100) may be supplied for use on the eye-lids at night in phlyctenular THE COMMONER DISEASES OF THE EYE. 573 keratitis, and an ointment of bichlorid of mercury (1-5000) applied for the other varieties. A solution of atropin sulphate (h per cent.) may be necessary in some cases to give rest until the child responds to the general treatment. The Diagnostic Significance of Ocular Affections. The eye may so often be of assistance in establishing a diagnosis that a short article will be devoted to the interpretation of certain ocular lesions or manifestations. Every physician should be prepared to make certain simple tests in his office to discover ocular defects in the routine examination, and the eyes should be examined even when the patient is not presented for defective eye-sight. In this way he may find the cause for back- wardness in school studies, headache, and dizziness. Of still greater importance is the fact that recognizing unsuspected deficiencies in visual acuity he will refer the child to an oculist for more rigid and detailed tests and correction of refractive errors while the eye is still in the formative period. All that is required for these tests is a Snellen's test card, a picture card for children unable to read, a candle placed at twenty feet and the multiple rod of Maddox for testing the functional balance of the ocular muscles. Valk has shown that the Americans as a nation are found to be far-sighted with astigmatism. There is no doubt that many of the children of this generation suffer from overuse of their eyes because of the competition of school life and the multiplicity and cheapness of all forms of reading matter to which they have unrestrained access. Parents must be warned of these conditions and prophylactic measures advised to protect the vision of their children so that arti- ficial aid may not be required. The study room should be well-lighted and ventilated, with the desk or table so placed that the light will come over the left shoulder. The use of vertical writing is to be com- mended. Reading in the recumbent position or during convalescence should be prohibited. Badly printed books should not be tolerated in these days of modern printing. Diagnostic Hints. Ptosis as seen in children is usually a congenital defect as lesions of the oculomotor nerve are exceedingly uncommon in childhood. Photophobia is not uncommon and usually indicates some in- flammatory affection of the structures of the eye, for example, corneal ulceration. It does not usually occur with conjunctival diseases. 574 DISEASES OF CHILDREN. Exophthalmos, or prominence of the eye-ball, is sometimes seen in older children who have the symptoms of goiter. Diplopia indicates parlaysis of any of the straight ocular muscles, and it may result from any cause which will prevent both eyes being fixed on the same point. The form varies with the muscle affected. It is sometimes a symptom in hereditary ataxia. Strabismus appearing suddenly, convergent in character and accompanied with diplopia, is one of the signs of basilar meningitis. It may also be seen in hysteria, but here is functional only in character. Nystagmus, or the rapid oscillations of the eye-balls, may be lateral, vertical, or rotary movements. It usually is bilateral. It rarely occurs congenitally, and is then without serious significance. It is observed in many cerebral diseases, especially those associated with congenital defects, in disseminated sclerosis, and in Friedrich's ataxia. Tumors of the cerebellum or pons may produce this ocular symptom. It is sometimes seen in the later stages of hydrocephalus. Optic Neuritis (Choked Disk), Papillitis. — This condition may be found on ophthalmoscopic examination and indicates some form of intracranial lesion or affection of the orbit. Papillitis is seen in meningitis, particularly of the tuberculous variety; sometimes it occurs with tumor and abscess of the brain. SECTION XVII. DISEASES OF THE SKIN. CHAPTER XLIV. DISEASES OF THE SKIN. Introduction. Diseases of the skin form a very important part of the affections of early life. In infants this is particularly true owing to the hyper- sensitiveness of the skin which is suddenly bereft of its covering of vernix caseosa at birth and exposed to irritants of varying degree either from without or from within. It must also be recollected that faulty metabolism will account for many of these skin lesions. Young protoplasm is very irritable, and hence comparatively slight causes may produce severe lesions of the skin. The causative factor should be carefully sought after in each case and treatment should be directed not alone to the local lesion, but to the systemic condition as well. When prescribing local treatment the tenderness and sensitiveness of the infantile epidermis should not be forgotten. Better and more permanent results are obtained if soothing and unirritating drugs are employed and if the skin is pro- tected from further injury by prevention of scratching or further in- fection. The latter condition often masks the nature of the original disease, hence the most recent lesion must always be sought for diagnostic purposes. A certain number of skin diseases are congenital or are seen mainly in infancy. These will be mentioned first and then the commoner diseases met with in the early years of life, and finally those seen for the most part in the school age. Ichthyosis. (Xerodermia) . Ichthyosis or fish-scale disease is regarded as a congenital skin affection, mainly transmitted by heredity. It is characterized by a dry scaling condition of the skin whose outer layers are hard, dry, and thickened and without any inflammatory phenomena. Several mem- bers of a family may be affected. 575 570 DISEASES OF CHILDREN. Symptomatology. — The whole body, as a rule, may be covered with a scaling, wrinkled, papery skin, especially on the outer surfaces of the arms and legs. In the flexures of the joints fissures are sometimes formed. The general health remains unaffected. Irritants easily cause pruritis and local inflammatory reaction. Diagnosis. — The disease is rarely mistaken on account of its dis- tinct characteristics. The history and its non-inflammatory charac- ter would distinguish it from trophoneuroses or pityriasis. Prognosis. — It is an intractable disease requiring long and patient treatment to affect any amelioration. It is never really cured. Fig. 170. — Pigmented nevus. Treatment. — If the treatment is begun in early infancy much more can be accomplished than when seen later. Baths of green soap followed by inunctions of lanolin or vaselin and protection of this greased surface with gutta percha tissue, later a 5 to 10 per cent, sulphur ointment can be applied. Life in the tropical countries is favorable to comfort and possible cure. Nevi. These congenital growths may be vascular or pigmented (moles). The latter may also be hairy or rough and warty. The color varies from a light brown to black. Vascular nevi are due to local excessive proliferation of blood-vessels at or soon after birth. These disfigure- DISEASES OF THE SKIN. .">,, ments are found for the greater part in the corium, and vary from t he familiar port-wine stains to pulsating angiomata. They arc apt to increase in size soon after birth and do not grow beyond certain limits. Prognosis. — Vascular nevi of the cavernous type may be danger- ous to life because of the danger of bleeding or from their effect on neighboring structures. Pigmentary nevi have shown metamorphic changes into later growths of a malignant character. Treatment. — This is accomplished by electrolysis or cauterization acting upon the corium only. Radiotherapy occasionally is success- ful. Excision offers the best results; occasionally skin grafting is necessary following excision of large nevi. A needle may be heated to a cherry-red color and plunged into the margin at three or four points. This may be repeated at subsequent sittings until the nevus has been entirely eradicated. A white scar remains over the site. Ice made from liquid carbon dioxid is often suitable for the removal of port-wine stains or superficial nevi. Dermatitis Exfoliativa Neonatorum. (Ritter's Disease.) Badly nourished infants, usually nurslings, are affected by this disease. It is quite rare. It begins, as a rule, on the lower half of the face as a reddened area with exfoliation. This erythema soon spreads over the entire body and the resulting scaling is profuse. Fissures ap- pear at the mouth and anus. Constitutional symptoms are those of malassimilation or, in severe cases, those of sepsis. Even when resti- tution to the normal takes place after patient and diligent treatment, relapses are not uncommon. Ritter gives the cause as a general sepsis. Course and Prognosis. — The two cases coming under our observa- tion in hospital practice both died. The mortality is 50 per cent. Occurring as they do among the poorer classes, medical attention is not drawn to them until the vitality has suffered beyond repair. Treatment.— Maintain the body heat by the use of lanolin and such clothing as is recommended for the premature (see p. 2). Care- fully examine the breast milk, and if abnormal a wet-nurse may be indicated. Strychnin in doses of gr. ^ every two or three hours is given if the vitality is low. Pemphigus Neonatorum. This is a contagious skin disease characterized by the formation of bullae containing a purulent fluid. No specific microorganism has as yet been isolated. The large vesicle? or bullae may suddenly make 37 578 DISEASES OF CHILDREN. their appearance on any part of the body causing little or no systemic disturbance. The blebs vary from transparent to grayish forms. The distended vesicles may rupture, leaving a crust and a reddened base, but no scar formation results. The exudate may infect new areas or even those in contact. The disease usually runs a favorable course tending to complete recovery in a few weeks. They should be differ- entiated from the bullous syphilo- derm, sometimes called syphilitic pemphigus, which occurs mainly on the soles of the feet and palms of the hands with usually an ulcerated base, and is accompanied with other mani- festations of infantile syphilis. Treatment. — Evacuate each bleb carefully by pricking with a sterile needle and apply zinc stearate for desiccation. A daily bath in a solu- tion of bichlorid of mercury (1-10,000) is indicated if self-inoculation is evi- dently going on. Impetigo Contagiosa. This skin disease usually attacks the face at the corners of the mouth and nostrils, although any portion of the body may exhibit the lesions. These consist of grayish-yellow sticky crusts which have a honey-like dis- charge. They are seated upon a red base. The child eagerly picks at these crusts and infects other areas. Treatment. — The general health, if deficient, will require proper feed- ing — iron or cod-liver oil. The crusts are softened by green-soap poultices and removed. The areas are then covered with benzoated lard or lanolin with bichlorid of mercury gr. i to the ounce. Seborrhea Capitis. Overactive sebaceous glands produce a crust of sebum which soon becomes dry and scaly. It commonly occurs upon the scalp and forehead in infants, and is known by the laity as "milk crust." It is a dirty yellow, firmly adherent mass lying upon an uninflamed Fig. 171. — Impetigo. DISEASES OF THE SKIN. 579 surface. It is more commonly found in poorly nourished children than in lusty breast-fed babies. Treatment. — Attention must be given to the general nutritional requirements together with local applications of warm olive oil or boric acid ointment (10 per cent.) under an oil-silk cap. Applications of the ointment are made twice a day, until finally the crust has softened. They are then removed with a superfatted soap or a glycerin soap and the scalp annointed daily for a time with a 2 per cent, sulphur ointment. Erythema Multiforme. This is an acute inflammatory disease, in which are variously produced areas of erythema, macules, papules, or vesicles. Some constitutional disturbance may usher in the attack. This is usually mild in character; there may be fever and malaise with or without rheumatic pains. The lesions, as a rule, appear on the extensor sur- faces of the hands, arms, feet, and legs. The face and upper chest are often involved, although any part of the body may exhibit the erup- tion. The color varies from a light red at first to a deep red in older lesions. Only occasionally are hemorrhagic areas seen. Pruritus, is not a marked symptom. Accompanying the erythema in children there are usually observed symptoms of intestinal derangement, autointoxication, ptomain poisoning, etc., which have undoubtedly produced this external manifestation. The disease is liable to recur- rence, lasting as a rule, for a few weeks before subsiding. Treatment. — This should be mainly directed to the underlying viceral derangement. An initial purge is indicated in the form of calomel or castor oil. A careful history of the child's diet will nearly always disclose some radical fault which needs correction. A specially arranged dietary should be provided. The emunctories should be kept active. Locally, if there is pruritus, an ointment containing resorcin or acid carbolic may be applied. Acute Exfoliative Dermatitis. This condition is of interest because of the confusion which it may cause in children from its resemblance to scarlatinal infection. Intestinal toxemia will commonly be found to be the underlying cause. Following an erythema of the scarlatiniform type, in a few days or sometimes hours, there occurs a profuse exfoliation. Con- stitutional symptoms are more pronounced than in scarlatinal ery- thema. The exfoliated scales of large and papery strips are cast off (see Fig. 8, Plate IX). The hair and nails may drop out before the 580 DISEASES OF CHILDREN. process is complete. Furnuncles and pustules are sometimes en- grafted on the dermatitis with involvement of the neighboring lymphatic glands. ♦ Diagnosis. — The differential diagnosis in the erythematous stage and in that of exfoliation is given under the article on Scarlet Fever (see page 236). Treatment. — Correct the toxemia by unloading the intestine and prescribing a diet that will not cause fermentation. Repeated examinations of the urine for indican will assist in properly meeting this indication. Fowler's solution with iron is of value after the dietary error has been corrected. A 2 to 5 per cent, ichthyol ointment is soothing to the skin. The cure is slow and recurrences are frequent. The exfoliation may occur two or three times a year. Eczema. (Tetter; Salt-rheum.) This is a protean disease of unknown origin assuming an acute, subacute, or chronic course, characterized by an erythematous eruption of varying intensity which goes on to scaling or crusting and is asso- ciated invariably with marked pruritus. It is the most common of all the skin diseases observed in early life. Etiological Factors. — Irritants either of external or internal origin or both are responsible for the affection. Children who have nutri- tional or blood disorders are particularly susceptible. The usual pyogenic bacteria found on the skin are no doubt responsible in- directly for many cases. Their growth is facilitated or increased by mechanical or chemical irritants with which the child comes into contact. The so-called " predisposition" to the disease is often accounted for by careful investigation for the cause along the lines above enumerated. Parasitic skin diseases, discharges from various parts of the body, badly prepared soaps and powders, and irritating underclothing are among the more common external causes. Excess- ive feeding, in general or in kind, and constipation are the prominent internal causes. Varieties. — Depending upon the degree of the exudative inflam- mation in the epithelium, there is produced an erythematous, papular, vesicular, or pustular eczema. These forms either remain distinct or merge one into the other, somewhat masking the original type. The erythematous variety is characterized by redness and swelling over certain areas, especially the DISEASES OF THE SKIN. 581 face. The papular type is known by the formation of small red pap- ules which tend to group and coalesce. In the vesicular phase the upper layers of the epidermis are raised by the exudative process, form- ing vesicles or blebs which tend to coalesce and exude a viscid serum. These, however, are evanescent and are rarely seen because they are rapidly dissolved off, leaving a wet surface. If the latter form becomes infected by pyogenic skin bacteria or over- loaded with leukocytes the pustular form develops. Sub-varieties. — When the discharge in the vesicular form dries readily it forms crusts (E. crustosum). If the exudation is profuse and the rete is uncovered, the weeping or moist form results (E. madinans vel rubrum). A squamous variety is superimposed or develops from the crusty, papular, or vesicular form when consider- able epidermal infiltration and scaling appears. Chronic Varieties. — These result from repeated recurrences, or exacerba- tions, or neglect of the etiological factors. The chief characteristic is the infiltration into the upper layer of the skin. Symptomatology and Diagnosis. — All the varieties described above have certain common features, namely, redness, itching, and burning, accompanied by the forma- tion of papules, vesicles, or pustules. The skin being either dry, moist, infiltrated, or scaling. In infants the scalp, face, and napkin region are most frequently attacked. The diagnosis is, as a rule, not difficult if the above description and classification is kept in mind. Erysipelas is distinguished by the rapidly spreading margin and high fever. Scabies is often confounded with eczema or the two are combined. The distribution and the itching which is worse at night, the history of the other children or members of the family similarly affected, or the burrows and their contents themselves can be depended upon to establish the diagnosis. Psoriasis is rare in early life; it is never moist, it is commonly found upon the elbows and knees and has silvery scales. Syphilides occasionally are difficult to distinguish. The infiltration is deeper and greater; they Fig. 1" -Chronic eczema. 5S2 DISEASES OF CHILDREN. do not burn or itch and are usually accompanied by other manifesta- tions. In difficult cases the Wasserman test may be employed. Im- petigo contagiosa has discrete vesicles upon slightly reddened skin, with abrupt margins. They are contagious and the child easily inoculates itself in different parts of the body. Prognosis. — This is variable, depending upon the underlying cause and the time of instituting treatment. Acute cases are favor- able but the chronic varieties are often intractable and persist with exacerbations and recurrences for years. Fig. 173. — Child with eczema fitted with metallic glove to prevent scratching. Acute Eczema. — Treatment. General. — The underlying cause should be carefully sought for and removed. If this is accomplished the cure will be well under way. Especially important is the proper regulation of the diet. If there is present such a condition as rickets, marasmus, or anemia the diet must be so arranged as to overcome the nutritional disorder. Cod-liver oil is often helpful. If, on the other hand, there has been overfeeding or indul- gence in special articles as the sugars or potatoes, such indiscretion must be stopped. The constipation should be relieved by correct- ing the diet or adding thereto such articles as fruits, the drinking DISEASES OF THE SKIN. 583 of plenty of water and appropriate massage and exercises. In in- fants the milk of magnesia may be added to the milk for its laxative effect. Local. — Never allow soap or water to be used on any eczema- tous surface. Cleansing can be satisfactorily accomplished with olive or linseed oil. The irritated skin must be treated by bland, soothing ointments or powders and scratching absolutely prevented. Rest for the inflamed area is imperative. Scratching is prevented by the use of masks, bandages, or sleeves as shown in the illustration (Fig. 174). The mild cases of the erythem- atous, papular, or moist types may be dusted with stearate of zinc, car- bonate of magnesia, oxid of zinc, or boric acid. In the inflammatory stages lotions of 2 per cent, boric acid, cala- min, or a 1 per cent, solution of aluminum acetate are applied as moist dressings. These soothe and reduce the inflammation. Occasionally small areas of weeping eczema may be rapidly improved by the primary ap- plication of 4- per cent, solution of the nitrate of silver. Among the oint- ments, Lassar's paste (N. F.) has given us the best results. It is applied thickly over the inflamed area and a retaining bandage or mask is applied. If thick crusts are present these must first be removed with applica- tions of olive oil or boric acid ointment. The dressings are removed daily, the ointment carefully removed with absorbent cotton dipped in oil and the ointment reapplied. Subacute Eczema. — If for any reason treatment has been delayed or has been unsuccessful in the acute stage more stimulating applica- tions are necessary. The amount of oxid of zinc in the pasta Lassar (N. F.) may be increased, and small amounts of tar in the form of tincture picis liquids may be added, or the following may be used: 1$. Picis liquidae oss Sulphuris praecipitati oj Unguenti zinci oxidi ■ • • oij Misce et signa.— Apply morning and evening. Fig. 174. — Eczema mask with stiff sleeves to prevent scratching. 584 DISEASES OF CHILDREN. The same precautions must be observed to prevent scratching or irri- tation of the area and the diet and bowels regulated. Chronic Eczema. — Perseverance and careful watchfulness as to the action of the drugs used in this form will be necessary to effect a cure. The thick crusts must first be removed by applications of oil, boric or bismuth ointment. Stimulating ointments are then to be used. The majority of children bear the ointments well, but occasionally they are not well tolerated and stimulating lotions or baths must be substituted. Tar is added in greater proportion to the ointments which have been recommended above. The tincture picis liquidae or the liquor carbonis detergens act advantageously by producing stimula- tion and at the same time preventing itching. If large areas are affected, it is well to apply the tar ointment to limited portions of the skin first and observe its effect. After it has produced an acute reac- tion, the milder pastes are applied. Psoriasis. Psoriasis among the skin affections is quite commonly observed in apparently healthy children. It begins as a papular affection with silvery scales on their summits. Their growth causes the commonly observed irregular patches with well-defined edges, of a bluish-red color, somewhat raised above the surrounding skin. Invariably silvery scales are found in these plaques which can be readily removed, leaving a reddish glazed base. The extensor surfaces of the extremi- ties are the favorite seats, next to the trunk and scalp. The affection is a chronic one with a great tendency to return in spite of well-directed treatment. Spontaneous cure in the summer months is not uncommon. Treatment. — Bulkley emphasizes the dietetic treatment and as the youthful patient is apt to be indiscreet, this should be the first consideration. A vegetarian diet may be appropriate for the child with a rheumatic history, although obviously unfitted for an anemic child below weight. Outdoor life at the seashore with sea-bathing- is productive of much good. As soon as the lesion appears an applica- tion of green soap and a full bath are ordered to remove the super- ficial scales. A crysarobin ointment is applied to a small area in the strength of 5 to 10 grains to the ounce (except to the face) twice a day until the skin is clean. Latterly X-ray treatment has produced rapid results. Warning should always be given as to its liability to return and the importance of renewing the treatment early. DISEASES OF THE SKIN. 585 Miliaria. {Prickly Heat; Strophulus.) Miliaria is an affection developing at the sudariporous glands, usually during the summer months. It consists of numberless minute reddish papules and vesicles which appear with or after an unusual amount of perspiration. It is accompanied by itching and burning. After a few days to a week it subsides, although fresh outbreaks are likely if weather conditions are favorable. Evidences of scratching are often seen in children in connection with miliaria. Treatment. — A 4 per cent, solution of boric acid is soothing, or with infants bran baths may be used. Frequent bathing and light clothing are prophylactic measures with children in the summer months. Removal to the seashore and sea-bathing produce rapid amelioration and cure. Urticaria. (Nettle-rash; Hives.) Urticaria consists of large wheals made up of a localized area of edema in the papillary layer of the skin. Their centers are pale, while the margins are reddened. These wheals are distinctly felt by the hand and cause intense itching, especially at night. In the majority of cases urticaria results reflexly from intestinal causes. External irritants, such as the stinging nettle (hence, one of its names), insect bites, etc., may bring on a typical attack. Certain fruits, as strawberries, and certain kinds of drinking water produce urticaria in the predis- posed. A small papular urticaria, consisting of minute papules, the tops of which are soon scratched off, causing a drop of serum or blood to exude, may often be seen in early life. This form may persist for months and, if neglected, will eventually result in a form of papular eczema. This variety is in all cases the result of a prolonged faulty diet. Strophulus is a name sometimes given to this condition. Treatment. — Discover the offending cause, whether external or dietary. Locally, baths containing bicarbonate of soda, salines for the bowels, and local applications of ointments containing menthol, camphor, or carbolic acid. Small doses of salicylate of sodium or aspirin will relieve the intestinal fermentation that is often the under- lying cause of urticaria. Furunculosis. This is a condition in which boils occur over any part of the body, but especially about the head. They are due to an infection of the skin with pyogenic organisms. The staphylococcus pyogenes aureus 5S6 DISEASES OF CHILDREN. is the predominating cause. . They differ in their virulency and occasionally cause marked systemic infection. Lowered vitality from malnutrition, improper feeding, previous debilitating diseases, and skin diseases predispose to the formation of furuncles. They are usually small in size, multiple, and tend to rapid for- mation of pus. If uncared for, they rupture and the pus may in- oculate other abraded surfaces. The areas are painful to the touch, reddish or bluish-red, and discharge a yellowish, creamy pus. A case is seldom observed in the very young. Children with furuncles are restless, sleep badly, may have a low-grade temperature, cry inor- dinately, and lose flesh and strength. Treatment. Local. — A general bath in bichlorid of mercury (1-5,000) is first ordered; surround the furuncles in which suppuration has occurred with lanolin and incise and drain completely, exercising care not to infect neighboring regions with the pus. Remove local causes, if any, as scabies. General. — Improve by diet and fresh air the general tone, pre- scribing strychnia, nux vomica, or the bitter wine of iron in the anemic. The opsonic index may be raised by the injection of sterilized emul- sions following Wright's method in cases in which recurrences are common or in which the systemic infection is marked. Angioneurotic Edema. (Acute Circumscribed Edema.) This affection is characterized by circumscribed areas of edema which appear suddenly and have a tendency to disappear as sud- denly as they came. Parents of children so attacked are usually alarmed and ascribe the edema to some form of insect bite. Neurotic children with faulty digestive disturbances are especially prone, and recurrences are not unusual. Parts of the face, chest, or an extremity may be involved. The intestinal tract is sometimes said to be atta eked. We have seen the lungs involved, producng alarming s3 r mptoms which disappeared after a few hours. Treatment. — Correct the habits and mode of life if necessary. Rhubarb and soda mixture internally and applications of aluminum acetate solution (N. F.), externally, promote relief. Herpes Zoster. (The Shingles; Zoster.) Herpes zoster is a painful acute inflammatory affection charac- terized by the production of a vesicular eruption appearing over the DISEASES OF THE SKIN. 587 course of distribution of the cutaneous nerves. It is accompanied by an inflammation of the peripheral nerves or of the sensory ganglia of the posterior nerve roots. Following a day or two of localized pain, there appear on one side of the body a crop of vesicles having a reddened inflamed base, which are seen to follow the distribution of an affected nerve. The vesicles Fig. 175. — Herpes Zoster. (Walker.) as a rule, dry up without pustulation, unless infected by unclean chil- dren. Adults suffer more intensely with this affection than do children. It is recognized by its unilateral distribution over a nerve tract em- phasized by the symptom of pain. Treatment. — Locally, stearate of zinc as a dusting powder and a protective dressing are required. Small doses of phenacetin or codein may be required for the relief of pain. The incandescent lamp has given relief in some cases, as have the X-rays. CHAPTER XLV. PARASITIC SKIN DISEASES. Children are more liable to this group of diseases because of their vulnerable, tender skin, and because even clean children are apt to mingle with their uncared-for schoolmates. Pediculosis. These are insects readily seen under a low-power glass. The head louse is from 1 to 2 mm. in length, has a head, thorax and abdo- men, and a sharp proboscis by which it attaches itself. They are ex- tremely prolific, the female laying about fifty eggs, and the young being ready to multiply their kind after three weeks of life. The ova are en- veloped in a capsule and are attached to the hair. These are commonly known as nits. The parasite feeds by imbedding its proboscis in the scalp and sucking. Thus the intense itch- ing is caused. Scratching causes further irritation and patches of eczema may appear. The post- cervical glands are enlarged in neglected cases, and a red line at the base of the hair behind is often -Ped cu- visible to confirm the diagnosis, lus capitis. Micro- The nits are distinguishable from ^Shoemaker ) ^ dandruff scales by their position on the hair, their tenacity to it, and the ability to move them up and down the hair. Treatment. — Cut the hair as closely as possible in long-standing cases if no great objection is made. Apply a cap made of a light towel soaked in coal-oil (kerosene) or pour alcohol over the scalp, be- ginning at the base with the head held over a basin, the parasites will then move on before it and are washed away. In the daytime a 10 per cent, boric ointment is rubbed into the scalp in aggravated cases to allay the irritation. Scabies. (The Itch.) Scabies is a disease of the skin produced by the Sarcoptes scabiei or itch-mite which by its entrance into the skin produces burrows and 588 Fig. 177. — Nits of pediculus capitis. (After Anderson .) PARASITIC SKIN DISEASES. 589 an eruption of vesicles, pustules, and nodules. To these are added the scratch-marks produced by the patient's finger-nails. Infanta and young children are greatly annoyed by the irritation and the evidences of scratching are observed early. The interdigital spaces, the wrists and flexor surface of the forearms, the toes and inner surf; of the thighs are especially affected. The whole body may be invaded in unrecognized or neglected cases. The prominent symptom, itching, is worse when the patient is in a warm bed. If the child is predisposed to eczema this is almost sure to supervene, and, in fact, sometimes masks the original cause. The disease is com- monly seen in dispensary children, who are apt to sleep with others and receive meager bodily attention. The itch-mite can with care be seen by the naked eye. The female is larger than the male. They are ovoid in shape, covered with hairs and have a pair of mandibles by which they attach "themselves to the skin in burrow- ing. The female deposits its eggs and per- ishes, while the colony work their way to the outer skin and start burrows of their own. FlG - 178.— The itch-mite _ „. .., (Neumann.) Treatment. — The disease is readily amen- able to cure if certain rules are followed faithfully. Remove all the clothing and bedclothes and sterilize them by boiling or baking in an oven. Follow a vigorous soap and hot-water bath with the applica- tion of sulphur ointment drachm one to the ounce. If eczema is present, use mild detergents, especially in the case of infants. Pow- dered sulphur may be used in children or a solution of styrax in the strength of half an ounce to the ounce of lanolin. The ointment selected should be applied to the whole body twice a day and two weekly baths taken. If there is a superadded eczema, treat the latter along the lines outlined for that disease. Tinea Tonsurans. (Ringworm of the Scalp.) This is a contagious disease produced by a vegetable parasite. beginning as a mass of minute vesicles which soon affect the hair. The lesion consists of a rounded patch showing broken-off hairs (shaven beard appearance) or a partly bald area, with extension taking place into the periphery. The central area is more or loss reddened with a dirty scaly margin. The disease is almost entirely confined to children, rarely appear- 590 DISEASES OF CHILDREN. ing after puberty; children infect each other directly or through articles of clothing or toys or through their pets. The patches are rarely seen by the physician while vesicles are present. The diagnosis must be made on the presence of the gnawed-off hairs in a rounded, reddened, scaly field in which the fungus can be found on the hairs. Examination for the Fungus. — A loosened diseased hair may be placed on a slide and soaked in a 10 to 20 per cent, potash solution, and examined for the parasite under the microscope with at least a J- inch lens. Treatment. — Ringworm does not respond quickly to treatment. If depilation is first performed, a better response to antiparasitic remedies is obtained. The scalp should be cleansed for several days with green soap and water. The surrounding hair is best kept short or if possible shaved about the lesion. A solution of potash applied on a piece of gauze and rubbed in will remove any debris that remains after the washings. An antiparasitic ointment is now daily applied and a protective dressing or cap used. We have tried to our satisfaction applications of oil of cade and castor oil, equal parts, or betaiiaphthol one-half to one drachm to the ounce. Ten per cent, of aristol in flexible collodion has commended itself in children who are in asylums and apt to infect others. The X-rays are highly spoken of by dermatologists as a rapid and permanent means of cure. Tinea Favosa. Favus is a feebly contagious parasitic disease, caused by the Achorion Schonleinii. The lesion consists of sulphur-yellow areas on the scalp through which the hairs appear. The hair shaft is broken off, being diseased by the fungus. Closely examined, it is found that each hair is surrounded by a cup-shaped area; these coalescing produce a thick matted cake, dirty yellow in color, sometimes having a peculiar characteristic odor. Some pruritus is nearly always complained of. When the crusts are removed a scarred area with no hairs present is found. The diagnosis may be confirmed by an examination for the fun- gus under the microscope. Alow power will answer (250 diameters). A fragment of hair passed through a potash solution will show the thick broad threads. The spores seen are of many shapes and sizes. Treatment. — The treatment takes much time and patience, and at best, bald areas will occur at times. Depilation offers the safest and best chance of cure. This is performed after cutting short all the hair of the head, removing thoroughly all the crusts and debris with 10 per cent, boric acid ointment. The hairs are removed best PARASITIC SKIN DISEASES. 591 with Bulkley's adhesive, made up with burgundy pitch or by repeated collodion applications. The hairs are thus removed en masse. Ten per cent, oleate of mercury is then applied night and morning with frequent soap and hot-water washings. When new hairs appear the microscope should again be used to guard against the reappearance of the parasite. The X-ray may here also give good results in com- petent hands. Alopecia Areata. (Baldness.) This is a disease of the hairy scalp producing areas of baldness. The affection is apt to come on quite suddenly without any subjective symptoms. The underlying skin is white, clean, and soft. When the hair returns, which it does in children, it is soft, downy, and colorless at first. Later it slowly shows some color and the hairs themselves Fig. 179. — Alopecia areata. become firmer and of coarser texture. Schamberg believes there are two varieties : the parasitic and the trophoneurotic, thus explaining the divergence of opinion as to the etiology. After a variable time, sometimes months, the hair in children returns, although even in early life relapses are seen. Treatment. — Locally — many remedies have been advanced as serviceable. Measures which will increase the blood-supply in the scalp are helpful.. Vigorous massage, followed by applications oi 90 per cent, alcohol has been useful in our hands. Lately the high- frequency current and the actinic rays have been extolled in the euro by dermatologists. INDEX. Abdomen, as aid to diagnosis, 85 enlarged, 85 prominent, 85 tumors of, localized, 85 Abdominal wall, tumors of, 86 Abnormalities in breathing, as aid to diagnosis, 83 Abscess, cerebral, 520 ischiorectal, 559 of brain, 520 of liver, 224 of lung, 378 peritonsillar, 352 pulmonary, 378 retropharyngeal, 352 subphrenic, 381 Absence of bones, congenital, 541 Acetonuria, 455 Achondroplasia, 422 diagnosticated from cretinism, 426 Addison's disease, 418 Adenie, 418 Adenitis, acute, 419 chronic, 420 tuberculous, 318 Adenoids, 350 etiology, 350 examination, 351 symptomatology, 350 treatment, 351, 352 Administration of drugs, 60 of food for infants, 165 Adolescence, 39 Adrenals, disorders of, 417 hemorrhage into, 418 Aerotherapy, 66 Albuminuria, cyclic, 454 functional, 454 physiologic, 454 Alopecia areata, 591 Amaurotic family idiocy, 533 Amygdalitis, acute, 347 Amyloid liver, 223 Anemia, 401 pernicious, 403, 406 secondary, 401 simple, 401 splenic, 406 von Jaksch, 405, 406 Anemias, table of, 406 treatment of, 408 38 Anesthesia, 549 chloroform, 549 gas-ether, 550 preparation for, 550 Anesthetic, choice of, 549 Angina, Vincent's, 348 Angioneurotic edema, 500, 586 Animal parasites, 211 found in childhood, 211 Ankylostomum duodenale, 216 Anopheles mosquito, 305, 306 Anterior poliomyelitis, 292 Antitoxin, diphtheria, 255, 256 Anuria, 450 Anus, fissure of, 560 imperforate, 538 malformations of, 538 prolapse of, 561 stenosis of, 538 Aortic obstruction, 392 regurgitation, 392 Aphthae, 183 Bednar's, 184 Apoplexy, meningeal, during birth, 9 Appendicitis, 552 abscess formation, 554 diagnosis, 554 etiology, 552 examination, 553 pathology, 552 prognosis, 554 suppurative form, 553 symptomatology, 553 treatment, 554 Appendix of infant, 34 Arthritides, infectious, 303 Arthritis, diagnosed from rheumatism, 301 tuberculous, 305 Arthritis deformans, 304 Arthrogryposis, 496, and see Tetany Artificial respiration, 12 Articular rheumatism, acute. 299 Ascaris lumbricoides, 212 Ascites, 559 chylous, 559 Asphyxia, during birth, 10, 13 artificial respiration in, 12 direct insufflation in. 1 1 preventive treatment of, 11 Aspiration of pleural cavity, technic of.. ">4 593 594 INDEX. Assimilation, infants differ in power of, 135 most efficient in early infancy, 135 Asthma, bronchial, 363 thymic, 357 Ataxia, Friedreich's, 510 hereditary, 510 Atelectasis, congenital, 12 Athrepsia, 439, and see Marasmus Atrophic paralysis, acute, 292 Atrophy, idiopathic muscular, 512 infantile, 439, and see Marasmus Attitude, typical, of normal infant, 29 Auscultation of infants and children, 47 Babinski's reflex, 47, 289 Balanitis. 473 Baldness, 591 Barlow's disease, 437 Basedow's disease, 421 Bathing, in infancy, 26 Baths, artificial Nauheim, 71 bed, 68 brine, 69 carbonic acid, 71 hot, 69 hot air, 69 mustard, 70 sheet, 68 soothing, 70 special, 69 sponge, 68 warm, 69 Bed baths, 68 Bednar's aphthae, 184 Beef juice, to make, 158 Beef-tea, to make, 157 Bell's palsy, 505 Biliary ducts, inflammation of, 222 Birth, injuries during, 6 palsies, 8 Bladder, calculus in, 481 diseases of, 480 ectopia of, 540 extrophy of, 540 inflammation of, 480 of infant, 34 spasm of, 481 Blennorrhea, urogenital, 474 Blepharitis, 570 Blood, 398 cells, red, 399 nucleated, 399 number of, 399 corpuscles, white, 399 corpuscular element of, 398 diseases of, 398 examination of, 51 in urine, 453 plates, 401 pressure, 382 Blue disease, 383 Boils, 585 Bone, caries of, 334 congenital absence of, 541 fractures of, during birth, 7 injuries to, during birth, 7 swollen, 88 tuberculosis of, 334 Bowels, regularity of, in infancy, 27 Brain, abscess of, 520 diseases of, 518 tumors of, 521 Branchial cysts, congenital, 536 fistulse, 536 Breasts, preparation of, for lactation, 101 Breast-feeding, 100, and see Nursing importance of, 100 intervals of, 101 management of, 101 not possible, 107 preparation for, 101 regularity of, 101 scanty supply of milk, 102 Breast milk, examination of, 104 for premature infants, 3 reaction of, 105 specific gravity of, 104 pumps, 106 secretions, 92 composition of, 93 properties of, 93 Breathing, abnormalities in, as aid to diagnosis, 83 exercises in, 79 mouth, in nasal obstruction, 83 Breck feeder for premature infants, 4 Bright's disease, acute, 456 Brine bath, 69 Bronchial asthma, 363 stenosis, 84 Bronchiectasis, 379 Bronchitis, acute, 359 diagnosis, 360 etiology, 359 physical signs, 359 prognosis, 360 symptomatology, 359 treatment, 360 capillary, 364 chronic, 361 Bronchopneumonia, acute, 364 aerotherapy in, 368 clinical forms of, 366 complicating the infectious dis- eases, 367 complications of, 367 course of, 368 diet in, 368 differential diagnosis of, 367 hydrotherapy in, 369 local applications in, 369 medication in, 369 pathology of, 364 physical signs of, 365 IXDEX. 595 Bronchopneumonia, prognosis of, 368 symptomatology of, 364, 366 treatment of, 368 tuberculous, 322 Buhl's disease, 18 Buttermilk, 160 Calculi, renal, 452 vesical, 481 Calmette test for tuberculosis, 54, 324 Calorie feeding, 162 Calx chlorata, as a disinfectant, 314 Cancrum oris, 187 Cap, ice, 68 Capillary bronchitis, 364 Caput succedaneum, 6 Carbohydrates, forms of, used in infant feeding, 112 of cereals, 121 Carbolic acid, as a disinfectant, 314 Carbonic acid baths, 71 Cardiac disorders, functional, 393 Caries of bone, 334 of spine, 335 Catarrhal fever, acute, 273 Central paralysis, during birth, 9 Cephalhematoma, 6 Cereal gruels, percentage, 140, 142 Cereals, 120 properties of, 120 carbohydrates of, 121 Cerebral palsies, infantile, 522 paralysis, 483 Cerebrospinal fever. 287 Cestodes, 211, 214 Chalazion, 571 Changes in the features, as a sign of illness, 58 Chapin's cream dipper, 140 infant urinal, 445 Chest, abnormal shape of, 84 as aid to diagnosis, 84 Chest-wall, tumors of, 84 Chickenpox, 247 Child, height of, 38 mental growth of, 39 moral growth of, 39 relative measurements of, 32, 33 weight of, 38 Childhood, diet during later, 179 growth during, 36 pulse in, 45 respirations in, 41 Children, auscultation of, 47 mensuration of, 48 percussion of, 47 rectal examination of, 48 Children's hospitals, diet lists for, 177 Chlorid of lime, as a disinfectant, 314 Chlorin, as a disinfectant, 313 Chloroform anesthesia, 549 Chlorosis, 402, 406 Choked disk, 574 Cholera infantum, 206 Chondrodystrophy, fetal, 422 Chorea, 486 complications, 488 course, 488 diagnosis, 488 etiology, 486 forms of, 489 pathology, 487 prognosis, 488 symptoms, 487 treatment, 488 Huntington's, 489 insaniens, 489 major, 489 minor, 486 Sydenham's, 486 Chvostek's symptom in tetany, 498 Chylous ascites, 559 Circumcision, 552 Cirrhosis of liver, 224 Claw hand. 88 Cleft palate, 536 Clothing, in infancy, 25 Clubbed fingers, 88 Club-foot, 541 Colic, 199 Collapse, pulmonary, 361 Colles' law, 278 Colon, dilatation of, congenital, 206 flushing the, 72, 73, 74 irrigation of the, 72, 73, 74 Colostrum, 93 Compresses, 69 Condensed milk, 119 mixtures, 159 Congenital absence of bones, 541 atelectasis, 12 branchial cysts, 536 dislocation of hip, 540 malformations and deformities, 535 Congestion of liver, 223 Conjunctivitis, acute, 570 chronic, 571 diphtheritic, 571 granular, 571 of the newly-born, 21 Constipation, 208 Convulsions, 484 description of the symptom-com- plex, 485 differential diagnosis, 4S6 etiology, 485 prognosis, 486 treatment, 486 Cow's milk, 113 composition of, 113 influence of breed on, 113 influence of breed on composition of, 113 one, 113 Coxalgia, 336 596 INDEX. Cream, 117 centrifugal, 117 gravity, 117 Cream dipper, Chapin's, 140 Creches, diet lists for, 178 Cresol, as a disinfectant, 314 Cretinism, 424 differential diagnosis, 426, 532 etiology, 424 prognosis, 428 symptomatology. 425 treatment, 429 Croup, 252 catarrhal, 353 false, 353 spasmodic, 353 diagnosticated from laryngismus stridulus, 356 tent, 355 Croupous pneumonia, 371, and see Lobar pneumonia Cryptorchidism, 477 Culex mosquito, 305, 306 Cyanosis, 383 in premature infants, 5 Cystitis, 480 Cysts, branchial, congential, 536 Dactylitis, 88 syphilitic, 283 tuberculous, 334 Day nurseries, diet lists for, 178 Dead-born infant, 13 Dead, from infectious diseases, care of, 315 Death, fetal, 13 Deformities, congenital, 535 exercises for developing children with, 78 of head, 6 Delayed growth as aid to diagnosis, 86 Dentition, 34 first, 34 delayed, 35, 83 disturbances of, 35 Dermatitis, acute exfoliative, 579 diagnosticated from scarlet fever, 236 exfoliativa neonatorum, 577 Development of digestive tract, 93, 95 of infant, 30 Dextrinized gruel, to make, 156 Diabetes insipidus, 451 mellitus, 443 Diacetonuria, 455 Diagnosis, suggestive scheme for, 81 Diarrhea, infectious, 200 summer, 200 Diet during later childhood, 179 during second year. 174 during third year, i76 from third to sixth year, 177 Dietary during second year. 174 from 12 to 18 months, 174 from 18 to 24 months, 175 from 2 to 3 years, 176 from 3 to 6 years, 177 Diet-lists, for children's hospitals, 177 for day nurseries and creches, 178 Digestive organs, comparative anatomy and physiology of, 94 tract, development of, 93, 95 diseases of, 189 Dilatation of colon, congenital, 206 of stomach, 192 Diphtheria, 250 antitoxin, 256 complications, 254 conjunctival, 254 differential diagnosis, 251, 252 etiology, 250 extubation, 261 feeding of intubated cases, 262 general treatment, 255 intubation, 257 laryngeal, 252 local treatment, 256 nasal, 253 pathology, 250 pharyngeal, 251 prognosis, 255 prophylaxis, 255 serum treatment, 256 symptomatology, 250 tonsillar, 251 tracheotomy, 262 treatment, 255 Diphtheritic paralysis, 504 Diplegia, spastic, 522 Diplopia, 574 Discharges, state of, as a sign of illness, 58 Disinfectants, 312 aerial, 312 chemical, 312 Disinfection, 312 of discharges, 315 of room, 315 Dislocation of hip, congenital, 540 Disseminated sclerosis, 509 Dosage, 60, 61 Drugs, administration, 60 dosage of, 60, 61 elimination of, in milk, 103 frequently used in pediatric prac- tice, 61 Duchenne's paralysis, during birth, 8 Ductless glands, diseases of, 414 Duke's disease, diagnosed from scarlet fever, 237 Dyspepsia, acute, 190 Dysphagia, false, 83 true, 83 Dyspnea, expiratory, 84 inspiratory, 83 mixed, 84 INDEX. 597 Dystrophy, muscular, 512 Ear, 565 diseases of, 565 speculum, 565, 566 Eclampsia infantum, 484, and see Convulsions' Ectopia of bladder, 540 Eczema, 580 acute, treatment, 582 general, 582 local, 583 chronic, 581 treatment, 584 crustosum, 581 diagnosis, 581 etiological factors, 580 erythematous, 580 madidans, 581 papular, 580 prognosis, 582 pustular, 580 rubrum, 581 subacute, treatment, 583 sub varieties, 581 symptomatology, 581 varieties, 580 Edema, acute circumscribed, 500, 586 angioneurotic, 500, 586 of glottis, 354 Eggs, 121 Emphysema, 362 acute, 362 Empyema, 374 exploratory puncture, 375 symptomatology, 374 treatment, 376 Encephalitis, acute, 520 Encephalocele, 544, 546 Endocarditis, acute, 385 diagnosis, 387 etiology, 385 pathology, 385 prognosis, 387 symptomatology, 386 treatment, 387 malignant, 386 septic, 386 ulcerative, 386 Enemata, nutrient, 76 Enlargement, general, 88 Enteralgia, 199 Enteroclysis, 72, 73, 74 Enterocolitis, acute, 202 Enuresis, 468 treatment, 470 Eosinophiles, 400 Eosinophilia, 398, 401 Epidemic hemoglobinuria, 17 paralysis in children, 297 Epilepsy, 491 diagnosis, 492 etiology, 491 Epilepsy, grand mal, 491 petit mal, 491 prognosis, 492 symptomatology, 491- treatment, 492 Epistaxis, 341 Erb's myotonic reaction, 499 paralysis, during birth, 8 symptom, in tetany, 498 Erysipelas, 309 etiology, 309 prognosis, 311 symptomatology, 309 treatment, 311 Erythema multiforme, 579 scarlatiniforme, diagnosticated from scarlet fever, 235 Erythemata, diagnosed from scarlet fever 235 Erythrocytes, 398, 399 Esophagitis, corrosive, 189 Esophagus, congenital occlusion of, 189 inflammation of, see Esophagitis malformations of, 538 Essential paralysis of children, 292 Examination of sick child, 41 blank for, 42 Examinations, special, 51 Exanthemata, 225 table of, 249 Exercise and fresh air in infancy, 26 Exercises, breathing, 79 for developing children with de- formities, 78 for increasing respiratory capacitv, 79 resistant, 79 Exophthalmic goiter, 421 Exophthalmos, 574 Exploratory puncture in empyema, 374 Expression of face, 82 Extremities, as aid to diagnosis, 87 rigidity of, 87 spastic, 87 Extrophy of bladder, 540 Extubation, 261 Exudates, examination of, 53 Evaporated milk, 119 Eye, affections of, diagnostic hints regarding, 573 diagnostic significance of, 573 diagnostic hints regarding affec- tion of, 573 diseases of, 570 foreign bodies in, 570 test for tuberculosis, 54 Face, as aid to diagnosis, 82 expression of, 82 Facial paralysis, 505 during birth, 8 598 INDEX, Fat in milk, to decrease amount of, 172 to increase amount of, 172 percentages of, in different portions of milk, 138 Fats, forms of, used in infant feeding, 112 Fatty degeneration of the newly-born, 18 liver, 223 Favus, 590 Features, changes in, as a sign of illness , 58 Feeblemindedness, 529, and see Idiocy Feeders for premature infants, 4 Feeding, and see Nutrition calorie, 162 directions, outline of, 146 forced. 74 in typhoid fever, 272 infant, chemical and biological standards in, 97 laboratory, 160 mixed, 107 of intubated cases, 262 of premature infants, 3, 4 on large scale, to make, 171 prepared at feeding station, 173 rectal, 76 station, feedings prepared at, 173 substitute, see Substitute Feeding table, suggestive, 149 Fetal death, 13 Fever, acute catarrhal, 273 Fingers, clubbed, 88 webbed, 544 Fissure of anus, 560 of mouth, 82 of tongue, 82 Fistulae, branchial, 536 Fontanels, abnormal, 81 Food, adaptation of, to infant, 152 care of, in infant feeding, 163 dispensaries, 170 essential unity of, 91 for acutely ill infants, 156 for healthy infants, 147 for infants, administration of, 165 for infants of feeble constitution, 155 for infants previously badly fed, 153 for infants who fail to thrive on fresh milk, 158 of first nutritive period, 91 specialized, 92 Foot, club-, 541 Forced feeding, 74 Foreign bodies in eye, 570 in nose, 342 in respiratory tract, 380 Formaldehyd, as a disinfectant, 312 generators, 312 Formalin, as a disinfectant, 314 Fourth disease, diagnosticated from scarlet fever, 237 Fractures during birth, 7 Fresh air, in infancy, 26 in treatment of disease, 66 Friedreich's ataxia, 510 Functional cardiac disorders, 393 Furunculosis, 585 Gangrene of lung, 378 Gas-ether anesthesia, 550 Gastric catarrh, acute, 190 indigestion, acute, 190 Gastritis, acute, 190 chronic, 191 Gastroenteritis, acute, 200 Gastrointestinal indigestion, chronic, 204 Gavage, 74 danger of, in premature infants, 4 Genital organs, diseases of, 472 German measles, 230 Glands of infant, 33 Glomerulonephritis, acute, 456 Glossitis, desquamative, 181 Glottis, edema of, 354 Goiter, exophthalmic, 421 Gonitis tuberculosa, 338 Grand mal, 491 Graves' disease, 421 Growth, delayed, as aid to diagnosis, 86 during childhood, 36 mental, of child, 39 moral, of child, 39 of infant, 29 Gruels, cereal, percentage, 140, 142 dextrinized, to make, 156 directions for making, 151 Gums, bleeding, 83 spongy, 83 swollen, 83 Hand, abnormal, 88 claw, 88 Harelip, 535 Head, as aid to diagnosis, 81 deformity of, 6 injury to, during birth, 6 fontanels, abnormal, 81 motion of, abnormal, 81 of infant, 30 position of, abnormal, 81 shape of, abnormal, 81 size of, abnormal, 81 tumors about, 81 Headaches, 493 Heart, the, 382 beats, 383 disease, congenital, 383 diseases of the, 382 functional disorders of, 393 location of valves of, 390 palpitation of, 394 INDEX. 599 Heart, valvular disease of, 389 aortic, 392 mitral, 391 tricuspid, 393 Height of child, 38 Hematuria, 453 Hematoma of sternocleidomastoid, 7 Hemic murmurs, 394 Hemiplegia, spastic, 522 Hemoglobin, estimation of, 53 Hemoglobinuria, 453 epidemic, 17 Hemophilia, 412 Hemorrhages, as aid to diagnosis, 86 causes of, general, 86 special, 87 from nose, 87 from rectum, 87 into adrenals, 418 of new-born, 87 of stomach, 87 spontaneous, in the newly-born, 23 umbilical, 15 Henoch's purpura, 411 Hereditary ataxia, 510 course, 512 differential diagnosis, 511 etiology, 510 pathology, 510 prognosis, 512 symptomatology, 511 treatment, 512 Hernia, 550 diagnosis, 551 etiology, 550 symptomatology, 550 treatment, 551 umbilical, 17 Pisek's dressing for, 16 Herpes zoster, 586 Hip, congenital dislocation of, 540 tuberculous disease of, 336 Hip-joint disease, 336 Hirschsprung's disease, 206 History of sick child, 41 blank for, 42 Hives, 585 Hodgkin's disease, 418 Hook worm, 216 Hordeolum, 571, 572 Hot-air bath, 69 Hot baths, 69 Hot pack, 69, 70 Hot weather, infant feeding in, 167 Huntington's chorea, 489 Hutchinson's teeth, 285 Hydrencephalocele, 545, 546 Hydrocele, 477 congenital, 477 encysted, of the cord, 477 infantile, 477 of tunica vaginalis, 477 Hydrocephalus, 526 Hydrocephalus, acquired, 526 classification of, 526 congenital, 526 diagnosis, 527 etiology, 526 prognosis, 528 symptomatology, 526 treatment, 528 Hydronephrosis, 466 Hydrotherapy, 68 Hygiene of infancy, 25 Hyperleukocytosis, 398, 401 Hyperphonia, 501 Hypertrophy of pylorus, congenital, 193 Hypodermoclysis, 73 Hypospadias, 539 Hypostatic pneumonia, 370 Hysteria, 489 etiology, 489 prognosis, 490 symptomatology, 489 treatment, 490 Ice cap, 68 poultice, 69 Icterus in premature infants, 5 neonatorum, 18 Ichthyosis, 575 Idiocy, 529 etiology, 529 prognosis, 530 symptomatology, 529 treatment, 531 Idiocy amaurotic family, 533 Mongolian, 531 Imbecility, 529, and see Idiocy Immunization, reaction of, 77 Impetigo contagiosa, 578 Inability to walk, 87 Incontinence of urine, 468 Incubator, for premature infants, 2. 5 Indican, test for, 53 Indicanuria, 454 Indigestion, gastric, acute, 190 gastro-intestinal, chronic, 204 Infancy, assimilation in, 135 bathing in, 26 clothing in, 25 exercise and fresh air in, 20 general habits in, 27 habits of sleep in, 27 hygiene of, 25 pulse in, 45 regularity of bowels, in, 27 respirations in, 41 signs of illness in, 57 urine in, 445 Infant, and see Newly-born a mammary fetus, 91 acutely ill, food for, 156 adaptation of food to, 152 appendix of, 34 attitude of normal, 29 600 INDEX. Infant, auscultation of, 47 bladder of, 34 dead-born. 13 development of, 30 difference of, in digestive and assimilative efficiency, 135 glands of, 33 growth of, 29 head of, 30 healthy, food for, 147 intestines of, 34 lacrimal glands of, 33 length of, 29 liver of, 34 loss of weight during first few days, 28 mensuration of, 48 muscles of, 34 nutrition of, 89, 98 of feeble constitution, foods for, 155 pancreas of, 33 percussion of, 47 premature, see Premature infants, previously badly fed, food for, 153 rectal examination of, 48 relative measurements of, 31 salivary glands of, 33 sebaceous glands of, 34 shape of, 30 skull of, 30, 31 spine of, 32 stillborn, 13 stomach of, 34 teeth of, 34 tendency of, to adapt themselves to their food, 134 testicles of, 34 thymus of, 34 viscera of, 33 weighing of, 28, 167 importance of, 166 weight and development of, 28 chart, 168 who fail to thrive on fresh milk, foods for, 158 Infant-feeding, 89, 98 among the poor, 170 carbohydrates used in, 112 care of food, 163 of utensils, 166 chemical and biological standards in, 97 directions for mother or nurse, 163 education of mother necessary, 163 fats used in, 112 fundamental errors in, 127 how to interpret results, 166 in hot weather, 167 methods of modifying milk for, 130 percentage milk mixtures in, 136 practical, 136 basis of, 136 proteins used in, 111 Infant-feeding, scientific, rise and de- velopment of, 126 when away from home, 169 when traveling, 168 Infant-foods, administration of, 165 dispensaries, 170 proprietary, 122 classification of, 122 composition of ; 123 Infantile atrophy, 439, and see Ma- rasmus cerebral palsies, 522 paralysis, 2.J2 scurvy, 437 stridor, congenital, 357 Infantilism, 424 Brissaud type, 424 diagnosed from cretinism, 426 Lorain type, 424 Infection, how carried, 314 Infectious arthritides, 303 diarrhea, 200 diseases, bronchopneumonia com- plicating, 367 disinfection in, 314 of the newly-born, 14 sick-room in, 314 Inflammation of biliary ducts, 222 of portal vein, 222 Influenza, 273 causes, 273 definition, 273 diagnosis, 276 incubation, 273 pathology, 273 symptomatology, 274 treatment, 276 Inguinal region, as aid to diagnosis, 86 enlargement of, 86 swellings in, differential diagnosis of, 478 tumors of, 86 Injuries during birth, 6 to bone, 7 to head, 6 to muscle, 7 Insomnia, 494 Inspection of sick child, 41 Insufflation, direct, in asphyxia, 11 Intestines, of infant, 34 tumors of, 85 Intubation, 257 Intussusception, 555 diagnosis, 556 etiology, 555 prognosis, 556 symptomatology, 555 treatment, 556 Inunctions for premature infants, 5 Inunction test for tuberculosis, 55 Invagination, intestinal, 555 Irritability of temper, as a sign of illness, 57 INDEX. 001 Ischemic paralysis, Volkman's, 484 Ischiorectal abscess, 559 Itch, the, 588 Itch-mite, 589 Jaundice, 220, and see Icterus Joints, swollen, 88 tuberculosis of, 334 Jugular bulb infection, 568 Keratitis, 572 Kernig's sign, 289 method of eliciting, 45, 46 Kidney, amyloid, 461 congestion of, 455 chronic, 455 formation of, 449 large white, 461 passive hyperemia of, 455 tumors of, 85, 465 waxy, 461 Kilmer belt for pertussis, 266 Knee, tuberculous disease of, 338 Koplik's spots, 226 Laboratory feeding. 160 Lacrimal glands of infant, 33 La Grippe, 273 Laryngeal stenosis, 84 stridor, congenital, 357 Laryngismus stridulus, 356 Laryngitis, acute, 353 diagnosticated from laryngismus stridulus, 356 diphtheritic, diagnosticated from acute laryngitis, 354 spasmodic, 353 submucous, 354 Larynx, new growths of, 358 papilloma of, 358 Lavage, 72 Length of infant, 29 premature infant, 3 Leptomeningitis, acute, 518 Leukemia, 403 lymphatic, 404, 406 splenomyelogenous, 404, 406 Leukocytes, 398, 399 number of, 400 Leukocytosis, 398, 401 Leukopenia, 398, 401 Limp, walking with, 87 Lip, hare-, 535 Lips, enlarged, 82 Liver, 219 abscess of, 224 amyloid, 223 cirrhosis of, 224 congestion of, 223 diseases of, 219 enlarged, 85 examination of, 219 fatty, 223 Liver, of infant, 34 Lobar pneumonia, 371 complications, 371 diagnosis, 371 etiology, 371 pathology, 371 physical signs, 371 prognosis, 372 symptomatology, 371 treatment, 372 Lobular pneumonia, 364 Lumbar puncture, in cerebrospinal meningitis, 289, 292 technic of, 52 Lungs, abscess of, 378 diseases of, 359 gangrene of, 378 Lymphadenoma, 418 Lymphocytes, 399 Lymphocytosis, 398, 401 MacEwen's sign, 289 Microglossia, 83 Malaria, 305 differential diagnosis, 308 etiology, 305 pathology, 306 prophylaxis, 308 symptomatology, 307 treatment, 308 Malformations, congenital, 535 of anus, 538 of esophagus, 538 of rectum, 538 Mammary secretions, and see Milk comparative, 95 Marasmus, 439 course, 441 diet in, 442 etiology, 439 medication, 443 pathology, 439 prognosis. 441 symptomatology, 440 treatment, 441 Mast cells, 400 Mastitis of the newly born. 22 Mastoiditis, 567 Masturbation, 476 Measles, 225 complications, 227 definition, 225 eruption, 227 etiology, 225 exanthem, 227 fever, 227 German. 230 incubation, 226 Koplik's spots. 226 pathology, 226 prodromal stage, 226 prognosis, 229 prophylaxis, 229 602 INDEX. Measles, sequelae, 227 treatment, 229 variations, 227 Measurements, physical, 37 relative of infant, 31 of child, 32, 33 Meat broths, to make, 157 Megaloblast, 398, 399 Meningeal apoplexy, during birth, 9 Meningitis, 518 diagnosis, 519 etiology, 518 leptomeningitis, 518 pachymeningitis, 518 symptomatology, 518 treatment, 519 epidemic cerebrospinal, 287 complications, 290 differential diagnosis, 290 etiology, 287 lumbar puncture in, 289, 292 pathology, 287 prognosis, 290 serum treatment, 291 symptomatology, 288 treatment, 291 tuberculous, 327 Meningocele, 544. 546 Mensuration of infants and children, 48 Mental growth of child, 39 Mercurial salts, as disinfectants, 313 Microblast, 398 Microcephalus, 528 Microcyte, 399 Migraine, 493 Miliaria, 585 Miliary tuberculosis, acute, 326 of lungs, 322 Milk, and see Mammary secretions and gruel mixtures, percentage composition of, 143 bacteriology of, 114 bottled, 116 certified, 116 commissions, 116 condensed, 119 cows', 113 crust, 578 evaporated, 119 fat in, to decrease, 172 to increase, 172 grocery, 115 human, normal, 94 inspected, 116 market, 115 composition of, 117 microscopical appearance of, 118 mixtures, percentage, in infant feeding, 136 modified, 129 classification of methods em- ployed, 130 Milk, modified effects of various meth- ods employed, 131 modifier, 150 mother's, disagrees with infant, 103 drugs eliminated in, 103 insufficient, 102 one cow's, 113 pasteurized, 116 peptonized, 159 percentages of fat, in different portions of, 138 sanitary, 116 production of, 115 sterilized, 116 top, 137 percentage of food element in, 141 Mitral obstruction, 391 regurgitation, 391 Modified milk, 129 classification of method, 130 effects of various method, 131 for premature infants, 4 Moles, 576 Mongolian idiocy, 531 diagnosticated from cretinism, 426, 532 Moral growth of child, 39 Morbilli, 225, and see Measles Morbus coxse, 336 Moro test for tuberculosis, 55, 324 Mosquitoes, 305 Motion, disturbances of, 87 Mouth, as aid to diagnosis, 82 breathing in nasal obstruction, 83 diseases of, 181 fissures of, 82 inflammation of, see Stomatitis open, 82 putrid sore, 186 ulcerations of, 82 white, 184 Movements, purposeless involuntary, 88 Multiple neuritis, 503 sclerosis, 509 Mumps, 267 complications, 268 differential diagnosis, 268 etiology, 267 pathology, 267 prognosis, 268 symptomatology, 268 treatment, 268 Murmurs, hemic, 394 Muscles, injuries to, during birth, 7 of infant, 34 paralysis of, 484 Muscular atrophy, idiopathic, 512 dystrophy, 512 Mustard bath, 70 Myelitis, 507 diagnosis, 509 etiology, 507 pathology, 507 INDEX. 603 Myelitis, prognosis, 509 symptomatology, 507 treatment, 509 Myelocytes, 400 Myocarditis, 388 Myopathy, primary, 512 complications, 516 differential diagnosis, 516 etiology, 512 pathology, 513 symptomatology, 514 treatment, 516 types of. 512 Myotonia congenita, 499 Mytonic reaction, of Erb, 499 Myxedema, 424, and see Cretinism Xasal obstruction, mouth breathing in, 83 Nasopharyngeal toilet, the, 71 Nauheim baths, artificial, 71 Neck, as aid to diagnosis, 82 tumors about, 82 Nematodes, 211 Nephritis, 456 acute, 456 causes, 456 complications, 459 definition, 456 diagnosis, 459 pathology, 457 prognosis, 459 symptomatology, 457 synonyms, 456 treatment, 460 desquamative, 456 diffuse, 456 exudative, 456 glomerulo-, 456 parenchymatous, 456 tubular, 456 chronic, 461 causes, 461 complications, 462 definition, 461 diagnosed from cretinism, 428 diagnosis, 462 pathology, 461 prognosis, 463 symptomatology, 462 synonyms, 461 treatment, 463 diffuse, 461 interstitial, 461 parenchymatous, 461 Nerve paralysis, 484 Nerves, peripheral, diseases of, 503 Nervous diseases, general, 482 system, diseases of, 482 Nettle-rash, 585 Neuritis, multiple, 503 course, 504 diagnosis, 503 Neuritis, multiple, etiology, 503 prognosis, 504 symptomatology. 503 pathology, 503 treatment, 504 optic, 574 Nevi, 576 New growths of larynx, 358 Newly-born, and see Infant acute infectious diseases of the, 1 I conjunctivitis of the, 21 dimensions of, 31 diseases of the. 14 fatty degeneration of the. Is hemorrhages of, 87 icterus of, 18 mastitis of, 22 sepsis of the, 14 spontaneous hemorrhages in the, 23 tetanus of, 20 Night terrors, 495 Nipple shield, 107 Noma, 187 Normoblast, 398, 399 Nose, bleeding from, 87. 341 foreign bodies in, 342 Nursery, the. 26 Nursing, and see Breast-feeding contraindications for, 107 not possible, 107 Nutrition, and see Feeding difference of infants incapacity for, 135 of infant, 89, 98 of premature infants, 3 Nutritive periods of life, 90 Nystagmus, 574 Occlusion of esophagus, congenital, 1S9 Ophthalmia neonatorum. 21 Opsonic index, 77 Opsonins, 76 Optic neuritis, 574 Otitis, 566 Otoscopy, 565 Oxyuris vermicularis, 21] Pachymeningitis, 518 Packs, hot, 69, 70 Palate, cleft, 536 Palpation of sick child, 44 Palpitation of heart, 394 Palsies, birth, 8 classification of, 523 infantile cerebral, 522 classification, 523 diagnosis, 525 etiology, 522 pathology, 522 symptoms, 524 treatment, 525 Palsy, Bell's, 505 cerebral. 295 004 INDEX. Palsy, peripheral. 295 spinal. 295 Paludism, 305 Pancreas of infant, 33 Papillitis. 574 Papilloma of larynx, 35S Paralysis, 87, 483 acute atrophic, 292 wasting, 292 central, during birth, 9 cerebral, 483 diphtheritic, 504 Duchenne's, during birth, 8 epidemic, in children, 297 Erb's, during birth, 8 essential, of children, 292 facial, 505 during birth, 8 general characteristics of the vari- ous types, 483 in general, 483 infantile, 292 ischemic, Volkman's, 484 muscle, 484 nerve, 484 postdiphtheritic, 254 pseudo-, 484 spinal, 484 upper-arm, during birth, 8 Paramyoclonus multiplex, 499 Paraphimosis, 472 Paraplegia, spastic, 483, 522 Parasites, animal, 211 found in childhood, 211 Parasitic protozoa, 211 skin diseases, 588 Parotitis, epidemic, 267 Pasteurized milk, 116 Pasteurizer, 164, 165 Pavor nocturnus, 495 Pediculosis, 588 Pediculus capitis, 588 Pemphigus neonatorum, 577 Peptonized milk, 159 Percentage milk mixtures, in infant feeding, 136 Percussion of infants and children, 47 Pericarditis. 395 diagnosis. 396 etiology, 395 pathology, 395 physical signs, 395 prognosis, 396 symptomatology, 395 treatment, 396 Pericardium, diseases of, 395 Perinephritis, 465 Peripheral nerves, diseases of, 503 Peritonitis, acute, 556 diagnosis, 558 in early life, 557 in the new-born. 556 prognosis, 558 Peritonitis, symptomatology, 557 treatment, 559 gonorrheal, 558 pneumococcic, 558 tuberculous, 330 Peritonsillar abscess, 352 Perleche, 184 Pertussis, 263 aerotherapy in, 265 complications, 264 course, 265 diet in, 267 drugs for. 265 etiology, '263 Kilmer belt for, 266 pathology, 263 primary stage of, 264 prognosis, 265 recession of symptoms, 264 spasmodic stage, 264 symptomatology, 263 treatment, 265 Petit mal, 491 Pharyngeal stenosis, 83 tonsil, hypertrophy of, 350 Pharyngitis, acute, 346 in infants, 344 treatment, 346 Phimosis, 472 Photophobia, 573 Physical measurements, 37 Pioscope, 105 Pisek's dressing for umbilical hernia, 16 Plaques, blood. 401 Plates, blood-, 401 Platform scale, for weighing baby, 28 Pleura, diseases of, 359 Pleural cavity, aspiration of, technic of. 54 Pleurisy, 372 dry, 372 serofibrinous, 372 pathology, 372 physical signs, 373 prognosis, 373 symptomatology, 373 treatment, 373 Pneumonia, catarrhal, 364 croupous, 371, and see Lobar pneumonia hypostatic, 370 lobar, 371, and see Lobar pneu- monia lobular, 364 Pneumothorax, 377 Poikilocytosis, 398 Poliomyelitis, anterior, 292 causes, 292 definition, 292 diagnosis, 295 pathology, 293 prognosis, 296 symptomatology, 293 INDEX. 605 Poliomyelitis, treatment, 296 Polynuclears, 399 Polynucleosis, 398 Polypus, rectal, 560 Polyuria, 451 Portal vein, inflammation of, 222 Postdiphtheritic paralysis, 254 Pott's disease, 335 cervical, 335 dorsal, 335 lumbar, 335, 337 Poultice, ice, 69 Practical feeding, 136 basis of, 136 Premature infants, breast milk for, 3 care of, 1 cyanosis in, 5 danger of gavage in, 4 death rate of, 1 factors prejudicial to life of, 1 feeders for, 4 feeding of, 3, 4 icterus in, 5 incubators for, 2, 5 inunctions for, 5 length of, 3 management and care of, 1 modified milk for, 4 nutrition of, 3 subnormal temperature of, 1, 2 temperature of, 1, 2 weight of, 3, 4 Prickly heat, 585 Primary myopathy, 512 Prolapse of anus, 561 of rectum, 561 Proprietary infant foods, 122 classification of, 122 composition of, 123 Proteins, forms of, used in infant feeding, 111 Protozoa, parasitic, 211 Pseudodysphagia, 83 Pseudoleukemia, 418 of infants, 405, 406 Pseudo-paralysis, 87, 484 Psoriasis, 584 Psychotherapy, 66 Ptosis, 573 Pulmonary abscess, 378 collapse, 361 tuberculosis, 324 Pulse, in infancy and childhood, 45 Purpura, 409 fulminans, 411 hemorrhagica, 410 Henoch's, 411 Schonlein's, 411 simplex, 409 Putrid sore mouth, 186 Pyelitis, 463 causes, 463 definition, 463 Pyelitis, diagnosis, 464 pathology, 463 prognosis, 464 symptomatology, 464 thread reaction in, 55 treatment, 464 Pylephlebitis, suppurative, 222 Pyloric spasm, 193 Pylorus, hypertrophy of, congenital, 193 stenosis of, 193 Quinsy sore throat, 352 Rachitic spine, 336 Rachitis, 431 antenatal, 437 congenital. 437 course, 435 diagnosis, 435 deformities in, 434, 436 dietetic treatment of, 436 etiology, 431 hygienic treatment of, 436 medication in, 436 pathology of, 431 prognosis of, 435 symptomatology of, 432 treatment of, 435 Reaction of immunization, 77 Rectal examination of infants and children, 48 feeding, 76 polypus, 560 syringe for infants, 209 Rectum, hemorrhages from, 87 malformations of, 538 obstruction of, 538 prolapse of, 561 Renal calculi, 452 Resistant exercises, 79 Respiratory capacity, exercises for increasing, 79 tract, foreign bodies in, 3S0 upper, diseases of the, 341 Respiration, artificial, methods of, 12 in infancy and childhood, 41 Restless sleep, as a sign of illness Retropharyngeal abscess, 352 Rheumatic fever, 299 Rheumatism, acute articular, 299 complications, 300 differential diagnosis, 301 etiology, 299 drugs for, 302 prognosis, 301 prophylaxis, 302 symptomatology, 300 treatment, 302 Rheumatoids, 304 Rhinitis, acute, 341 Rickets, 431, and see Rachitis diagnosed from cretinism, 42S Rigid extremities, 87 606 INDEX. Ringworm of scalp, 589 of tongue, 181 Ritter's disease, 577 Rotheln, 230 Round worm, 212 Rubella, scarlatiniform, diagnosticated from scarlet fever, 237 Rubeola, 225, 230, and see Measles Salivary glands of infant, 33 Sarcoma, 562 Salt-rheum, 580 Scabies, 588 Scalp, ringworm of, 589 Scarlatina, 231 and see Scarlet fever Scarlet fever, 231 anginal form, 232 complications of, 240 desquamation, 232, 234 desquamative stage, 238 diet in, 239 differential diagnosis, 235 eruptive stage, 238 etiology, 231 incubation, 231 pathology, 231 predesquamative stage, 238 preemptive stage of, 238 prognosis, 238 prophylaxis, 239 rash, 233 sequelae of, 240 serum treatment of, 241 sick-room quarantine, 239 simple form, 231 symptomatic treatment, 240 symptomatology, 231 treatment, 239 Schonlein's purpura, 411 Sclerosis, disseminated, 509 multiple, 509 Scorbutus, 437 aggravated cases, 438 course, 438 dietetic treatment of, 439 diagnosis of, 438 etiology of, 437 mild cases, 437 pathology of, 437 prognosis of, 438 prophylaxis of, 439 symptomatology of, 437 treatment of, 439 Scurvy, infantile, 437 Sebaceous glands of infant, 34 Seborrhea capitis, 578 Secretions, breast, 92 Sepsis of the newly-born, 14 Serum rashes, diagnosed from scarlet fever, 237 Sheet baths, 68 Shingles, 586 Sick child, examination of, 41 blank for, 42 history of, 41 blank for, 42 inspection of, 41 palpation of, 44 to take temperature of, 43 Sick-room, in infectious diseases, 314 Signs of illness in infancy, 57 Sinus thrombosis, infective cerebral, 568 Skin, diseases of, 575 parasitic, 588 Skin test for tuberculosis, 54 Skull of infant, 30, 31 Sleep, amount required, 494 habits of, in infancy, 27 restless, as a sign of illness, 58 Smallpox, 241 complications, 243 definition, 241 etiology, 242 exanthem, 242 incubation, 242 prodromal stage, 242 pathology, 242 prognosis, 244 prophylaxis, 245 sequelae, 243 symptomatology, 242 treatment, 245 variations, 243 Soor, 184 Soothing bath, 70 Sore mouth, putrid, 186 Spasm, pyloric, 193 vesical, 481 Spastic diplegia, 522 extremities, 87 hemiplegia, 522 paraplegia, 483, 522 Specialized foods, 92 Speculum, ear, 565, 566 Spina bifida, 547 Spinal cord, diseases of, 507 inflammation of, see Myelitis Spinal paralysis, 484 Spine, caries of, 335 of infants, 32 rachitic, 336 Spleen, chronic passive congestion of, 417 diseases of, 417 enlarged, 85 enlargement of, 417 inflammation of, 417 Spondylitis, 335 Sponge baths, 68 Spontaneous hemorrhages in the newly- born, 23 Sprue, 184 Sputum, examination of, 51 Squint, 572 Stammering, 501 INDEX. 007 Status lymphaticus, 416 Steam, as a disinfectant, 313 Stenosis, bronchial, 84 laryngeal, 84 of pylorus, 193 pharyngeal, 83 tracheal, 84 Sterilized milk, 116 Sterilizer, for infant food, 165 Sternocleidomastoid, hematoma of, 7 Stillborn infant, 13 Still's disease, 305 Stomacace, 186 Stomach, dilatation of, 192 hemorrhages from, 87 inflammation of, see Gastritis of different milk secreting animals, 96 of infant, 34 tumors of, 85 washing, 72 Stomatitis, aphthous, 183 catarrhal, 182 follicular, 183 gangrenous, 187 herpetic, 183 maculo-fibrinous, 183 mycotic, 184 parasitic, 184 simple, 182 ulcerative, 186 vesicular, 183 Stools, 196 character of, as a sign of illness, 59 examination of, 166, 197 of artificially fed infants, 197 Strabismus, 572, 574 Stridor, congenital infantile, 357 laryngeal, 357 Strophulus, 585 Stuttering, 501 St. Vitus' dance, 486, and see Chorea Stye, 572 Subdural puncture, technic of, 52 Subphrenic abscess, 381 Substitute feeding, 110 difficulties of, 110 material used in, 113 principles of, 110 Suggestion, in treatment of disease, 66 Sulphurous acid, as a disinfectant, 313 Summer complaint, 200 diarrhea, 200 Surgical diseases, 549 Swallowing, as aid to diagnosis, 83 Swellings in inguinal region, differential diagnosis of, 478 of extremities, 88 Sydenham's chorea, 486 Syndactylism, 544 Syphilis, 277 acquired 286 Syphilis, cause, 277 congenital, 277, and see Syphilis, hereditary definition, 277 hereditary, 277 Colles' law, 278 definition, 277 diagnosis, 282 method of transmission, 277 pathology, 278 prognosis, 284 symptomatology, 279 treatment, 284 late hereditary, 284 Hutchinson's teeth, 285 treatment, 286 Wasserman test for, 56 Syringe, rectal, for infants, 209 Talipes, 541 acquired, 542 calcaneus, 543 congenital, 541 equinus, 542 treatment, 543 valgus, 543 varus, 542 Tape worms, 214 armed, 215 beef, 215 pork, 215 Teeth, abnormalities of, 83 of infant, 34 temporary, care of, 36 permanent, 36 Hutchinson's, 36, 285 Temper, irritability of, as a sign of illness, 57 Temperature of premature infant, 1 to take, 43 Tenia mediocanellata, 214, 215 saginata, 214, 215 solium, 214, 215 Testicle, undescended, 477 Testicles of infant, 34 Tetanilla, 496, and see Tetany Tetanus neonatorum, 20 Tetany, 496 differential diagnosis, 498 etiology, 496 prognosis, 498 symptomatology, 496 treatment, 49S Tetter, 580 Therapeutics, general, 60 Thomsen's disease, 499 Thoracic tuberculosis, 321 Thoracentesis, 375 Thread reaction in pyelitis, 55 Thread worms, 211 Throat, examination of, in infants, 343, 345 608 INDEX. Thrombosis, sinus, infective cerebral, 568 Tuberculosis, tests for, eye test, 54 Thrush, 184 inunction test, 55 Thymic asthma, 357 Moro test, 55 Thymus, 414 skin test, 54 enlargement of, 414 von Pirquet test, 54 of infant, 34 thoracic, 321 Tics, 500 diagnosis, 322 differential diagnosis, 501 pulmonary lesions, 322 treatment, 501 treatment in general, 338, 339 Tinea favosa, 590 tuberculin test in, 323 tonsurans, 589 Tuberculous adenitis, 318 Toes, webbed, 544 course, 320 Tongue depressors, Chapin's, 343 diagnosis, 320 enlarged, 82 prognosis, 320 fissures of, 82 symptomatology, 318 geographic, 181 treatment, 320 inflammation of, see Glossitis arthritis, 305 ringworm of, 18i bronchopneumonia, 322 ulcers of, 82 disease of hip, 336 Tongue-tie, 535 treatment, 337 Tonsillar hypertrophy, chronic, 349 knee, 338 Tonsil, pharyngeal, hypertrophy of, 350 treatment, 330 Tonsillitis, acute follicular, 347 meningitis, 327 in infants, 344 course, 330 treatment, 346 diagnosis, 330 ulcero-membranous, 348 etiology, 328 Top milk, 137 prognosis, 330 Tracheal stenosis, 84 symptomatology, 328 Trachoma, 571 peritonitis, 330 Transudates, examination of, 53 caseating form, 331 Traveling, infant feeding when, 168 diagnosis, 332 Tracheotomy, 262 fibrous form, 331 Trichina spiralis, 217 miliary form, 331 Tricuspid regurgitation, 393 symptomatology, 332 Trousseau's symptom, in tetany, 498 treatment, 334 Tuberculin test, 54, 323 ulcerative form, 331 Tuberculosis, 316 Tumors about head, 81 acute miliary, 326 about neck, 82 differential diagnosis, 327 malignant, in children, 562 etiology, 326 diagnosis, 563 bone, 334 treatment, 564 and joint tuberculosis, 334 of abdomen, localized, 85 diagnosed from syphilis, 282 of abdominal wall, 86 disease of hip, 336 of brain, 521 of knee, 338 of chest wall, 84 etiology, 316 of inguinal region, 86 joint. 334 of intestines, 85 miliary, of lungs, 322 of kidney, 85, 465 of vertebrae, 335 of stomach, 85 diagnosis, 335 Typhoid fever, 269 treatment, 336 drugs in, 273 prophylaxis, 338 etiology of, 269 pulmonary, 324 feeding in, 272 acute form, 324 hydrotherapy in, 272 etiology, 324 laboratory tests for, 271 physical signs, 325 pathology, 269 chronic, 325 prophylaxis, 271 causes, 326 symptomatology, 270 subacute form, 324 temperature curve in, 270 etiology, 324 treatment, 271, 272 physical signs, 325 tests for, 54 Ulcerations of mouth, 82 Calmette test, 54 of tongue, 82 INDEX. 609 Umbilical hemorrhages, 15 hernia, 17 Pisek's dressing for, 16 region, abnormalities of, 86 vegetations, 16 Uncinaria duodenalis, 216 Undescended testicle, 477 Upper-arm paralysis, during birth, 8 Urethritis, 473 Urine, acetone in, 455 albumin in, 454, and see Albumin- uria blood in, 453 character of, 446 as a sign of illness, 59 diacetic acid in, 455 excess of, 451 hemoglobin in, 453 incontinence of, 468 indican in, 454 in infancy, 445 suppression of, 450, and see Anuria to collect, 445 Urinal, for infants, 445 Urogenital blennorrhea, 474 Uropoietic system, diseases of, 445 Urticaria, 585 Uvula, elongated, 188 Vaccination, 245 description of normal course, 246 method of, 246 value of, 245 variations and complications, 247 when to vaccinate, 246 Vaccine therapy, 76, 77 Vaccinia. 245 Valves of heart, location of, 390 Valvular disease of heart, chronic, 389 aortic, 392 mitral, 391 tricuspid, 393 Varicella, 247 Variola, 241, and see Smallpox Varioloid, 243 Vegetations, umbilical, 16 Vertebrae, tuberculosis of, 335 ' Vesical calculus, 481 spasm, 481 Vincent's angina, 348 Viscera of infant, 33 Vomiting, as a sign of illness, 58 cyclic, 195 periodic, 195 recurrent, 195 Volkman's ischemic paralysis, 484 Von Jaksch Anemia, 405, 406 Von Pirquet test for tuberculosis, 54, 324 Vulvo-vaginitis, 474 treatment, 475 vaccine treatment, 475 Walk, inability to, 87 with limp, 87 Warm baths, 69 Wasserman test for syphilis, 56 Wasting paralysis, acute, 292 Water, in treatment of disease, 68 Weaning and mixed feeding, 107 Webbed fingers, 544 Weighing infant, 28, 167 importance of, 166 Weight of child, 38 of infant, 28 . of premature infant, 3, 4 chart, 49 for infant, 168 Wet-nurse, selection of, 108 Whey, directions for making, 154 and cream mixtures, 154 White mouth, 184 swelling, 338 Whooping-cough, 263 Winckel's disease, 17 Worms, hook, 216 round, 212 tape, 214 thread, 211 Xerodermia, 575 X-rays, use of, 51 Zoster, 586 39 I